Cognitive Therapy in the Treatment and Prevention of Depression Steven D. Hollon, Ph.D. Vanderbilt University

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Cognitive Therapy in the Treatment and Prevention
of DepressionSteven D. Hollon, Ph.D.Vanderbilt
University
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Cognitive Pharmacotherapy Project Research Team
Penn Vanderbilt Robert J.
DeRubeis, Ph.D. Steven D. Hollon, Ph.D. Jay D.
Amsterdam, M.D. Richard C. Shelton, M.D. Paula
R. Young, Ph.D. Margaret L. Lovett, M.Ed. John
P. OReardon, M.D. Ronald M. Salomon,
M.D. Madeline M. Gladis, Ph.D. Kirsten L. Haman,
Ph.D. Cory P. Newman, Ph.D. Karl N. Jannasch,
Ph.D. Frances Shusman, Ph.D. Sandra Seidel,
M.S.N. Brent B. Freeman, B.A. Richard C. Carson,
Ph.D. Nathaniel R. Herr, B.A. Nana A.
Landenberger, Ph.D. Robert Gallop, Ph.D. Laurel
L. Brown, Ph.D. Aaron T. Beck, M.D.
Jan Fawcett, M.D.
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Support for this research provided by
National Institute of Mental Health GlaxoSmithKli
ne
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From the American Psychiatric Associations
(2000)Practice Guidelines for Major Depressive
Disorder in Adults

• Antidepressant medications should be provided
  for moderate to severe depressive disorders
  unless ECT is planned.
• For example, although some data suggest that
  cognitive behavioral therapy alone may be
  effective for patients with moderate to severe
  major depressive disorder, most such patients
  will require medication.

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Post-treatment HRSD Scores forSeverely Depressed
Patients (Intake HRSD gt 20)
(From DeRubeis et al., 1999, Am J of Psychiatry)
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3 booster sessions
Prior CT (N34)
CT
(N 60)
ADM (N34)
ADM
(N 120)
PLACEBO (N34)
PLACEBO
(N 60)
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Major Entry Criteria

• Principal Diagnosis of Major Depressive Disorder
• Two consecutive (at least one week apart) scores
  of 20 or more on a modified 17-item Hamilton
  Rating Scale for Depression
• No Psychosis or Bipolar Disorder
• No Borderline, Antisocial, or Schizotypal PD
• No marked Substance Abuse or Dependence in
  previous 6 months

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Reasons Interested Patients Were Screened Out of
the Trial
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Characteristics of the Sample
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Demographic Information
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Depressive Subtype and History Information
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Comorbidity I
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Comorbidity II
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Acute Phase
(Single blind)
Not Augmented (59)
R a n d o m i z a t i o n
Augmented (41)
(Triple blind)
0 2 4 6 8 10 12 14 16
Weeks
Un-blinding for pill patients
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Dropouts in First 8 Weeks
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Degrees of Response at 8 Weeks
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Mean HRSD Scores Over 8 Weeks
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Change in Depressive Symptomsfrom Intake to Week
8 (HRSD)
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Dropouts in ADM and CTover 16 Weeks
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Percent Responders (HRSD lt 12) amongAll
Assigned, Across Sites
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Degrees of Response after 16 Weeks
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Percent Response (HRSD lt 12) by Site (16 Weeks)
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Mean HRSD Scores Over 16 Weeks, by Site
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Mean HRSD Scores Over 16 Weeks, by Site
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Relative HRSD Change (Slopes) of ADM vs. CT from
Intake to Week 16, by Site
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Sample Characteristics on Potential Predictors of
Response
Demographics History/Subtype Age
4012 Ever Hospitalized 19 Female
59 Chronic 50 Minority 18 Recurrent 75
Married 33 Melancholic 31 Employed
82 Atypical 15 Axis I Comorbidity
(73) Axis II Comorbidity (47) PTSD 17
Cluster A 3 GAD 13 Cluster B
4 Panic Dis. 13 Avoidant 18 Eating
Dis. 17 OCPD 15 Subs. Use 36 PD
NOS 16 Predicts response across ADM and CT
(Prognostic) Predicts differential response to
ADM vs. CT (Prescriptive)
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Chronicity Predicts Poor Response (Prognostic)
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Being Unemployed Predicts Poor Response
(Prognostic)
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Cluster A Predicts Poor Response (Prognostic)
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PTSD Predicts Poor Response(Prognostic)
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GAD Predicts Differential Response (Prescriptive)
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3 booster sessions
Prior CT (N34)
CT
(N 60)
ADM (N34)
ADM
(N 120)
PLACEBO (N34)
PLACEBO
(N 60)
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Intake Characteristics of Patients Who Graduated
into the Continuation Phase
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Demographic Characteristics of Patients Who
Graduated into the Continuation Phase

p lt .05
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Depressive Subtype and History Information
Patients Who Graduated into the Continuation
Phasevs. Those Who Did Not

p lt .05
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Comorbidity I Patients Who Graduated into the
Continuation Phasevs. Those Who Did Not

p lt .05
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Comorbidity IIPatients Who Graduated into the
Continuation Phasevs. Those Who Did Not

p lt .05
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75
60
19
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Relative Risk of Relapse During Continuation
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Sample Characteristics on Potential Predictors of
Relapse
Demographics History/Subtype Age
4012 Early Onset 49 Female
58 Dysthymic 34 Minority
13 Recurrent 75 Married
37 Melancholic 34 Employed
89 Atypical 24 Axis I Comorbidity
(69) Axis II Comorbidity (49) PTSD 10
Cluster A 1 GAD 11 Cluster B
1 Panic Dis. 12 Avoidant 18 Eating
Dis. 18 OCPD 13 Subs. Use 31 PD
NOS 19 Predicts risk for relapse
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Attributional Styles as a Function of Treatment
Condition (CPT II)


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ASQ and Relapse as a Function of Treatment
Condition
R2.18
R2.05
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Sustained Improvementfor All Assigned to
Treatment
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Cumulative Direct Costs of ADM and CT
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Sustained Improvement Rates by Site
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Treatment Response as a Function of Site and
Gender
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Response to CT as a Function of PTSD by Site
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Therapist Competence as a Function of Experience
in the Trial (Vandy)
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Response to Treatmentas a Function of Time in
Trial
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Weekly Paxil Dosage By Site
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Weekly Paroxetine Dosage by Site and Augmentation
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Response to Treatment as a Function of Ordinal
Rank within Group (Vandy)
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Response to Treatment as a Function of Ordinal
Rank within Group (Penn)
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Response, Remission, Recovery, Relapse,
Recurrence Chronicityadapted from Kupfer
Frank 2001
Relapse
Recurrence
Response
Normalcy
Incompleterecovery
progressionto disorder
Severity
Symptoms
X
Syndrome
Chronicity
16 wks
12 mo
12 mo
Treatment phases
Acute
Maintenance
Continuation
Time
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25 ITT
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Continuation
Followup
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CPT III
Maintenance/Follow-up (36 months)
Acute Treatment (3-12 months)
Continuation (6-18 months)
ADM and CT (N225)
ADM (N90)
(monthly/ quarterly)
(twice weekly/weekly)
(monthly)
No ADM (N90)
1st R a n d o m i z a t i
o n
2nd R a n d o m i z a
t i o n
Response
Recurrence
Relapse
ADM (N225)
ADM (N90)
(monthly/ quarterly)
(monthly)
(weekly/biweekly)
No ADM (N90)
Remission
Recovery
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Medication Sequence
SNRI
MAOI
TCA
SNRI or SSRI
Augment
Augment
Augment
Augment
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Using Longitudinal Data to Disentangle Cause from
Consequence
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Post-treatment HRSD Scores forSeverely Depressed
Patients (Intake HRSD gt 20)
(From DeRubeis et al., 1999, Am J of Psychiatry)
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Attributional Styles as a Function of Treatment
Condition (CPT II)


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ASQ and Relapse as a Function of Treatment
Condition
R2.18
R2.05
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