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Cognitive Behavioral Analysis System of Psychotherapy as group psychotherapy for chronically depressed inpatients: a naturalistic multicenter feasibility trial

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Abstract

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a relatively new approach in the treatment of chronic depression (CD). Adapted as group psychotherapy for inpatients, CBASP is attracting increasing attention. In this naturalistic multicenter trial, we investigated its feasibility after 10 sessions of CBASP group therapy over a treatment time of at least 5 to a maximum of 10 weeks. Treatment outcome was additionally assessed. Across four centers, 116 inpatients with CD (DSM-IV-TR) attended CBASP group psychotherapy. Feasibility was focused on acceptance, and evaluated for patients and therapists after five (t1) and ten sessions (t2) of group psychotherapy. Observer- and self-rating scales (Hamilton Depression Rating Scale—24 items, HDRS24; Beck Depression Inventory-II, BDI-II; World Health Organization Quality of Life assessment, WHOQOL-BREF) were applied before group psychotherapy (t0) and at t2. Dropouts were low (10.3%). Patients’ evaluation improved significantly from t1 to t2 with a medium effect size (d = 0.60). Most of the patients stated that the group had enriched their treatment (75.3%), that the size (74.3%) and duration (72.5%) were ‘optimal’ and 37.3% wished for a higher frequency. Patients gave CBASP group psychotherapy an overall grade of 2 (‘good’). Therapists’ evaluation was positive throughout, except for size of the group. Outcome scores of HDRS24, BDI-II, and WHOQOL-BREF were significantly reduced from t0 to t2 with medium to large effect sizes (d = 1.48; d = 1.11; d = 0.67). In this naturalistic open-label trial, CBASP, when applied as inpatient group psychotherapy, was well accepted by patients and therapists. The results point towards a clinically meaningful effect of inpatient treatment with CBASP group psychotherapy on depression and quality of life. Other potential factors that could have promoted symptom change were discussed. A future controlled study could investigate the safety and efficacy of CBASP group psychotherapy for inpatients.

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Notes

  1. We received the PEF (n = 101) of almost all patients completing the 10 group sessions. However, we had a smaller sample after 5 sessions (t1) as we handed out the questionnaires and did not receive them back or failed to follow up on this. This left 70 for comparison of t1 and t2.

  2. We had to exclude patients in study center 3, because the study center deviated from the protocol and failed to let the questionnaire being filled out at t2.

  3. All effect sizes of studies were recalculated if necessary using the formula M2 − M1⁄ SDpooled, where SDpooled = √((SD 21  + SD 22 )/2) to allow for direct comparisons.

  4. The study by Brakemeier et al. (2015) followed 70 patients in the 12-weeks inpatient program at the Department of Psychiatry and Psychotherapy at the University of Freiburg. Of these 44 patients were also recruited for this study, but time points of assessment were different.

References

  1. Satyanarayana S, Enns MW, Cox BJ, Sareen J (2009) Prevalence and correlates of chronic depression in the Canadian community health survey: mental health and well-being. Can J Psychiatry 54:389–398

    Article  Google Scholar 

  2. Arnow BA, Constantino MJ (2003) Effectiveness of psychotherapy and combination treatment for chronic depression. J Clin Psychol 59:893–905

    Article  Google Scholar 

  3. Klein DN (2008) Dysthymia and chronic depression. In: Craighead WE, Miklowitz DJ, Craighead LW (eds) Psychopathology: history, diagnosis, and empirical foundations. Wiley, Hoboken, pp 329–365

    Google Scholar 

  4. Murphy JA, Byrne GJ (2012) Prevalence and correlates of the proposed DSM-5 diagnosis of chronic depressive disorder. J Affect Disord 139:172–180

    Article  Google Scholar 

  5. McCullough JP Jr (2000) Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (CBASP). Guilford Press, New York

    Google Scholar 

  6. Piaget J (1926) The language and thought of the child (Original work published in French in 1923). Harcourt, Brace, New York

  7. Piaget J (1981) Intelligence and affectivity: their relationship during child development (trans and ed A Brown & C E Kaegi). Annual Reviews, Oxford

  8. Kiesler DJ (1983) The 1982 interpersonal circle: a taxonomy for complementarity in human transactions. Psychol Rev 90:185–214

    Article  Google Scholar 

  9. Bandura A (1977) Social learning theory. Prentice-Hall, Oxford

    Google Scholar 

  10. Skinner BF (1969) Contingencies of reinforcement. Appleton-Century-Crofts, East Norwalk

    Google Scholar 

  11. Pavlov IP (1927) Conditioned reflexes: an investigation of the physiological activity of the cerebral cortex. Oxford University Press, Oxford

    Google Scholar 

  12. Seligman MEP (1975) Helplessness: on depression, development, and death. W H Freeman/Times Books/Henry Holt & Co, New York

    Google Scholar 

  13. Keller MB, McCullough JP, Klein DN, Arnow B, Dunner DL, Gelenberg AJ, Markowitz JC, Nemeroff CB, Russell JM, Thase ME, Trivedi MH, Zajecka J (2000) A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New Engl J Med 342:1462–1470

    Article  CAS  Google Scholar 

  14. Nemeroff CB, Heim CM, Thase ME, Klein DN, Rush AJ, Schatzberg AF, Ninan PT, McCullough JP Jr, Weiss PM, Dunner DL, Rothbaum BO, Kornstein S, Keitner G, Keller MB (2003) Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA 100:14293–14296

    Article  CAS  Google Scholar 

  15. Negt P, Brakemeier E-L, Michalack J, Winter L, Bleich S, Kahl KG (2016) The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain Behav 6(8):00486

    Article  Google Scholar 

  16. Schramm E, Kriston L, Zobel I, Bailer J, Wambach K, Backenstrass M, Klein JP, Schoepf D, Schnell K, Gumz A, Bausch P, Fangmeier T, Meister R, Berger M, Hautzinger M, Härter M (2017) Effect of disorder-specific vs nonspecific psychotherapy for chronic depression: a randomized clinical trial. JAMA Psychiatry 74(3):233–242

    Article  Google Scholar 

  17. Michalak J, Schultze M, Heidenreich T, Schramm E (2015) A randomized controlled trial on the efficacy of mindfulness-based cognitive therapy and a group version of cognitive behavioral analysis system of psychotherapy for chronically depressed patients. J Consult Clin Psychol 83(5):951–963

    Article  Google Scholar 

  18. Jobst A, Brakemeier E-L, Buchheim A, Caspar F, Cuijpers P, Ebmeier KP, Falkai P, Jan van der Gaag R, Gaebel W, Herpertz S, Kurimay T, Sabaß L, Schnell K, Schramm E, Torrent C, Wasserman D, Wiersma J, Padberg F (2016) European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe. Eur Psychiatry 33:18–36

    Article  CAS  Google Scholar 

  19. Schramm E, Brakemeier E-L, Fangmeier R (2012) CBASP in Gruppen: Das Kurzmanual. [CBASP in groups: The short manual.]. Schattauer, Stuttgart

  20. Brakemeier E-L, Normann C (2012) Praxisbuch CBASP: Behandlung chronischer Depression. Beltz, Weinheim

    Google Scholar 

  21. Brakemeier E-L, Radtke M, Engel V, Zimmermann J, Tuschen-Caffier B, Hautzinger M, Schramm E, Berger M, Normann C (2015) Overcoming treatment resistance in chronic depression: a pilot study on outcome and feasibility of the cognitive behavioral analysis system of psychotherapy as an inpatient treatment program. Psychother Psychosom 84(1):51–56

    Article  Google Scholar 

  22. Gilmer WS, Trivedi MH, Rush AJ, Wisniewski SR, Luther J, Howland RH, Yohanna D, Khan A, Alpert J (2005) Factors associated with chronic depressive episodes: a preliminary report from the STAR-D project. Acta Psychiatr Scand 112:425–433

    Article  CAS  Google Scholar 

  23. Klein DN, Schwartz JE, Rose S, Leader JB (2000) Five-year course and outcome of dysthymic disorder. A prospective, naturalistic follow-up study. Am J Psychiatry 157:931–939

    Article  CAS  Google Scholar 

  24. Klein DN, Shankman SA, Rose S (2008) Dysthymic disorder and double depression: prediction of 10-year course trajectories and outcomes. J Psychiatr Res 42:408–415

    Article  Google Scholar 

  25. Burlingame GM, Fuhriman A, Mosier J (2003) The differential effectiveness of group psychotherapy: a meta-analytic perspective. Group Dyn Theory Res Pract 7:3–12

    Article  Google Scholar 

  26. Cuijpers P, van Straten A, Warmerdam L (2008) Are individual and group treatments equally effective in the treatment of depression in adults? A meta-analysis. Eur J Psychiatry 22:38–51

    Article  Google Scholar 

  27. McDermut W, Miller IW, Brown RA (2001) The efficacy of group psychotherapy for depression: a meta-analysis and review of the empirical research. Clin Psychol Sci Pract 8:98–116

    Article  Google Scholar 

  28. Kösters M, Burlingame GM, Nachtigall C, Strauss B (2006) A meta-analytic review of the effectiveness of inpatient group psychotherapy. Group Dyn Theory Res Pract 10:146–163

    Article  Google Scholar 

  29. Burlingame GM, MacKenzie KR, Strauss B (2004) Small group treatment: evidence for effectiveness and mechanisms of change. In: Lambert MJ (ed) Bergin and Garfield’s handbook of psychotherapy and behavior change. Wiley, Hoboken, pp 647–696

    Google Scholar 

  30. Nietzel MT, Russell RL, Hemmings KA, Gretter ML (1987) Clinical significance of psychotherapy for unipolar depression: a meta-analytic approach to social comparison. J Consult Clin Psych 55:156–161

    Article  CAS  Google Scholar 

  31. Tucker M, Oei TPS (2007) Is group more cost effective than individual cognitive behaviour therapy? The evidence is not solid yet. Behav Cogn Psychoth 35:77–91

    Article  Google Scholar 

  32. Tschuschke V (2004) Gruppenpsychotherapie: die unbekannte und benachteiligte psychotherapeutische Behandlungsoption. Psychotherapeut 49:101–109

    Article  Google Scholar 

  33. Strauß B (1992) Empirische Untersuchungen zur stationären Gruppenpsychotherapie. Gruppenpsychotherapie und Gruppendynamik 28:125–149

    Google Scholar 

  34. Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, Bakken S, Kaplan CP, Squiers L, Fabrizio C, Fernandez M (2009) How we design feasibility studies. Am J Prev Med 36(5):452–457

    Article  Google Scholar 

  35. American Psychiatric Association (APA) (2001) Diagnostic and statistical manual of mental disorders, 4th edn. APA, Washington

    Google Scholar 

  36. McCullough JP Jr, Schramm E, Penberthy JK (2015) CBASP as a distinctive treatment for persistent depressive disorder. Routledge Press, London

    Google Scholar 

  37. Kiesler DJ (1996) Contemporary interpersonal theory and research: Personality, psychopathology, and psychotherapy. Wiley, Oxford

    Google Scholar 

  38. DGPPN, BÄK, KBV, AWMF, AkdÄ, BPtK, BApK, DAGSHG, DEGAM, DGPM, DGPs, DGRW (ed) (2009) für die Leitliniengruppe Unipolare Depression. S3-Leitlinie/Nationale Versorgungsleitlinie Unipolare Depression-Kurzfassung, Erste Auflage (German National Health Policy guideline for unipolar depression. 1st ed). DGPPN, ÄZQ, AWMF, Berlin, Düsseldorf

  39. Fydrich T, Renneberg B, Schmitz B, Wittchen H-U (1997) SKID-II. Strukturiertes Klinisches Interview für DSM-IV. Achse II: Persönlichkeitsstörungen Interviewheft. Hogrefe, Göttingen

    Google Scholar 

  40. Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, Stokes J, Handelsman L, Medrano M, Desmond D, Zule W (2003) Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl 27:169–190

    Article  Google Scholar 

  41. Bernstein DP, Fink L (1998) Childhood Trauma Questionnaire: a retrospective self-report (CTQ). NCS Pearson, San Antonio

    Google Scholar 

  42. Klinitzke G, Romppel M, Häuser W, Brähler E, Glaesmer H (2012) Die deutsche Version des Childhood Trauma Questionnaire (CTQ): psychometrische Eigenschaften in einer bevölkerungsrepräsentativen Stichprobe. Psychother Psychosom Med 62:47–51

    Article  Google Scholar 

  43. Vieweg T, Trabert W (2002) Psychoedukation in der Depressionsbehandlung ein psychoedukatives Gruppenprogramm im Rahmen stationärer Psychotherapie. Verhaltenstherapie Verhaltensmedizin 23:479–497

    Google Scholar 

  44. Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56–61

    Article  CAS  Google Scholar 

  45. CIPS (1986) Hamilton-depressions-Skala. Fremdbeurteilungs-Skala (Hamilton Psychiatric Rating Scale for Depression). Internationale Skalen für Psychiatrie, 3rd edn. Beltz, Weinheim

  46. Hautzinger M, Keller F, Kühner C (2006) Beck-Depressions-Inventar (BDI-II). Harcourt Test Services, Frankfurt/Main

    Google Scholar 

  47. Angermeyer MC, Kilian R, Matschinger H (2000) WHOQOL-100 und WHOQOL-BREF. Handbuch für die deutsche Version der WHO Instrumente zur Erfassung von Lebensqualität. Hogrefe, Göttingen

  48. Cohen J (1977) Statistical power analysis for the behavioral sciences. Academic, New York

    Google Scholar 

  49. Meng XL, Rosenthal R, Rubin DB (1992) Comparing correlated correlation coefficients. Psychol Bull 111:172–175

    Article  Google Scholar 

  50. Corp IBM (2013) IBM SPSS statistics for windows. IBM Corp, Armonk

    Google Scholar 

  51. Rush AJ, Thase ME (1997) Strategies and tactics in the treatment of chronic depression. J Clin Psych 58:14–22

    Google Scholar 

  52. Gotlib IH, Meltzer SJ (1987) Depression and the perception of social skill in dyadic interaction. Cognit Ther Res 11:41–54

    Article  Google Scholar 

  53. Javna CD (1981) Depressed and non-depressed college students’ interpretations of and memory for feedback about self and others. Unpublished doctoral dissertation, The Ohio State University, Columbus, OH

  54. Pyszczynski T, Holt K, Greenberg J (1987) Depression, self-focused attention, and expectancies for positive and negative future life events for self and others. J Pers Soc Psychol 52:994–1001

    Article  CAS  Google Scholar 

  55. Beck AT (1964) Thinking and depression, II: theory and therapy. Arch Gen Psychiatry 10:561–571

    Article  CAS  Google Scholar 

  56. Cantazaro A, Wei M (2010) Adult attachment, dependence, self-criticism, and depressive symptoms: a test of a mediational model. J Pers 78:1135–1162

    PubMed  Google Scholar 

  57. Feng CY, Chu H, Chen CH, Chang YS, Chen TH, Chou YH, Chang YC, Chou KR (2012) The effect of cognitive behavioral group therapy for depression: a meta-analysis 2000–2010. Worldviews Evid Based Nurs 9:2–17

    Article  Google Scholar 

  58. Schneibel R, Wilbertz G, Scholz C, Becker M, Brakemeier E-L, Bschor T, Zobel I, Schmoll D (2017) Adverse events of group psychotherapy in the in-patient setting—results of a naturalistic trial. Acta Psychiatr Scand 136(3):247–258

    Article  CAS  Google Scholar 

  59. Swan JS, MacVicar R, Christmas D, Durham R, Rauchhaus P, McCullough JP, Matthews K (2014) Cognitive behavioural analysis system of psychotherapy (CBASP) for chronic depression: clinical characteristics and six month clinical outcomes in an open case series. J Affect Disord 162:268–276

    Article  Google Scholar 

  60. Schramm E, Schneider D, Zobel I, van Calker D, Dykierek P, Kech S, Härter M, Berger M (2008) Efficacy of interpersonal psychotherapy plus pharmacotherapy in chronically depressed inpatients. J Affect Disord 109:65–73

    Article  Google Scholar 

  61. Zimmerman M, Martinez JA, Attiullah N, Friedman M, Toba C, Boerescu DA, Rahgeb M (2012) Why do some depressed outpatients who are in remission according to the Hamilton Depression Rating Scale not consider themselves to be in remission? J Clin Psychiatry 73:790–795

    Article  Google Scholar 

  62. Schneibel R, Brakemeier E-L, Wilbertz G, Dykierek P, Zobel I, Schramm E (2012) Sensitivity to detect change and the correlation of clinical factors with the Hamilton Depression Rating Scale and the Beck Depression Inventory in depressed inpatients. Psychiatry Res 198:62–67

    Article  Google Scholar 

  63. Wiersma JE, Van Schaik DJF, Hoogendorn AW, Dekker JJ, Van HL, Schoevers RA, Blom MBJ, Maas K, Smit JH, McCullough JP Jr, Beekman ATF, Van Oppen P (2014) The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial. Psychother Psychosom 83:263–269

    Article  Google Scholar 

  64. Sayegh L, Locke KD, Pistilli D, Penberthy JK, Chachamovich E, McCullough JP Jr, Turecki G (2012) Cognitive behavioural analysis system of psychotherapy for treatment-resistant depression: adaptation to a group modality. Behaviour Change 29:97–108

    Article  Google Scholar 

  65. Angermeyer MC, Holzinger A, Matschinger H, Stenger-Wenzke K (2002) Depression and quality of life: results of a follow-up study. Int J Soc Psychiatr 48:189–199

    Article  CAS  Google Scholar 

  66. McCullough JP Jr (2006) Chronic depression and the cognitive behavioral analysis system of psychotherapy. In: Stricker G, Gold J (eds) A casebook of psychotherapy integration. American Psychological Association, Washington, pp 137–151

    Chapter  Google Scholar 

  67. Jüni P, Altman DG, Egger M (2001) Assessing the quality of controlled clinical trials. BMJ 323:42–46

    Article  Google Scholar 

  68. Higgins JPT, Altman DG, Sterne JAC (eds) (2011) Chapter 8: assessing risk of bias in included studies. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). The Cochrane Collaboration. www.handbook.cochrane.org

  69. de Groot S, Rijnsburger AJ, Versteegh MM, Heymans JM, Kleijnen S, Redekop WK, Verstijnen IM (2015) Which factors may determine the necessary and feasible type of effectiveness evidence? A mixed methods approach to develop an instrument to help coverage decision-makers. BMJ Open 5(7):e007241

    Article  Google Scholar 

  70. Blome Ch, Augustin M (2015) Measuring change in quality of life: bias in prospective and retrospective evaluation. Value Health 18(1):110–115

    Article  Google Scholar 

  71. Fastame MC, Penna MP (2012) Does social desirability confound the assessment of self-reported measures of well-being and metacognitive efficiency in young and older adults? Clin Gerontol 35(3):239–256

    Article  Google Scholar 

  72. Jadad AR, Enkin MW (2007) Randomized controlled trials: questions, answers, and musings, 2nd edn. Blackwell Publishing Ltd, Oxford

    Book  Google Scholar 

  73. Yalom ID, Leszcz M (2005) The theory and practice of group psychotherapy, 5th edn. Basic Books, New York

    Google Scholar 

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Acknowledgements

We thank all patients who participated in this study and all CBASP therapists and co-therapists delivering the group psychotherapy in the four study centers. In addition, we thank the psychologists, Franziska Welker and Charlotte Wink, who provided support for the study. We thank also Gislene Wolfart, Dr Couns Psych, Oxford Mind & Body, for editing assistance with the manuscript.

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Authors and Affiliations

  1. Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany

    Lena Sabaß, Frank Padberg & Andrea Jobst

  2. School of Psychology, Hochschule Fresenius, University of Applied Sciences, Munich, Germany

    Lena Sabaß

  3. Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

    Claus Normann & Vera Engel

  4. Department of Psychiatry and Psychotherapy, Philipps-University, Marburg, Germany

    Carsten Konrad & Kristina Helmle

  5. Agaplesion Diakonieklinikum, Rotenburg, Germany

    Carsten Konrad

  6. AMEOS Clinic Dr. Heines Bremen, Bremen, Germany

    Andrew Worlitz

  7. Philipps-University Marburg, Marburg, Germany

    Eva-Lotta Brakemeier

  8. Psychologische Hochschule Berlin, Berlin, Germany

    Eva-Lotta Brakemeier

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  1. Lena Sabaß
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  9. Eva-Lotta Brakemeier
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Correspondence to Lena Sabaß.

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Conflict of interest

F.P. received speakers’ honoraria from Mag&More GmbH and neuroCare GmbH, Germany, as well as research support from Brainsway Inc., Israel. C.K. received fees for an educational program from Aristo Pharma, Janssen-Cilag, Lilly, MagVenture, Servier, and Trommsdorff as well as travel support and speakers’ honoraria from Aristo Pharma, Janssen-Cilag, Lundbeck and Servier. V.E. reported receiving honoraria for workshops on CBASP. E.-L.B. reported receiving book royalties and honoraria for workshops and presentations relating to CBASP. There are no other financial interests in relation to this article.

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Sabaß, L., Padberg, F., Normann, C. et al. Cognitive Behavioral Analysis System of Psychotherapy as group psychotherapy for chronically depressed inpatients: a naturalistic multicenter feasibility trial. Eur Arch Psychiatry Clin Neurosci 268, 783–796 (2018). https://doi.org/10.1007/s00406-017-0843-5

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