RESUMO
BACKGROUND: Minimal efficacy differences have been found between cognitive behavioral therapy (CBT) and psychodynamic therapies for depression, but little is known about patient characteristics that might moderate differential treatment effects. We aimed to generate hypotheses regarding such potential prescriptive factors. METHOD: We conducted post-hoc model-based recursive partitioning analyses alongside a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy (SPSP). Severely depressed patients received additional antidepressant medication. We included 233 adults seeking treatment for a major depressive episode in psychiatric outpatient clinics, who completed post-treatment assessment. Post-treatment mean Hamilton Depression Rating Scale scores constituted the main outcome measure. RESULTS: While treatment differences (CBT v. SPSP) were minimal in the total sample of patients (d = 0.04), model-based recursive partitioning indicated differential treatment efficacy in certain subgroups of patients. SPSP was found more efficacious among moderately depressed patients receiving psychotherapy only who showed low baseline co-morbid anxiety levels (d = -0.40) and among severely depressed patients receiving psychotherapy and antidepressant medication who reported a duration of the depressive episode of ⩾1 year (d = -0.31), while CBT was found more efficacious for such patients reporting a duration <1 year (d = 0.83). CONCLUSIONS: Our findings are observational and need validation before they can be used to guide treatment selection, but suggest that knowledge of prescriptive factors can help improve the efficacy of psychotherapy for depression. Depressive episode duration and co-morbid anxiety level should be included as stratification variables in future randomized clinical trials comparing CBT and psychodynamic therapy.
Assuntos
Antidepressivos/uso terapêutico , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo Maior/terapia , Psicoterapia Psicodinâmica/métodos , Adulto , Ansiedade/psicologia , Terapia Combinada , Transtorno Depressivo Maior/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicoterapia Breve , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Regressão , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Insufficient response to monotreatment for depression is a common phenomenon in clinical practice. Even so, evidence indicating how to proceed in such cases is sparse. METHODS: This study looks at the second phase of a sequential treatment algorithm, in which 103 outpatients with moderately severe depression were initially randomized to either short-term supportive psychodynamic therapy (PDT) or antidepressants. Patients who reported less than 30% symptom improvement after 8 weeks were offered combined treatment. Outcome measures were the Hamilton Depression Rating Scale (HAM-D), the Clinical Global Impression of Severity and Improvement, the SCL-90 depression subscale and the EuroQOL questionnaire. RESULTS: Despite being nonresponsive, about 40% of patients preferred to continue with monotherapy. At treatment termination, patients initially randomized to PDT had improved more than those initially receiving antidepressants, as indicated by the HAM-D and the EuroQOL, independently of whether the addition was accepted or not. CONCLUSIONS: Starting with psychotherapy may be preferable in mildly and moderately depressed outpatients. For patients who receive either PDT or antidepressants, combined therapy after early nonresponse seems to be helpful. Nevertheless, this sequential strategy is not always preferred by patients.
Assuntos
Antidepressivos/uso terapêutico , Terapia Combinada/métodos , Transtorno Depressivo/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Psicoterapia , Adulto , Algoritmos , Assistência Ambulatorial , Análise de Variância , Transtorno Depressivo/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Escalas de Graduação Psiquiátrica , Índice de Gravidade de Doença , Adulto JovemRESUMO
OBJECTIVE: To examine the efficacy and speed of action of short-term psychodynamic supportive psychotherapy (SPSP) in comparison to pharmacotherapy (PhT) in the acute treatment of depression. METHOD: This study reported on the first 8 weeks of a treatment algorithm for depression. 70 patients with a depressive episode according to DSM-IV were randomized to PhT, 71 patients were randomized to SPSP. The acceptability of the psychotherapy was greater than pharmacotherapy. RESULTS: At the end of the first 8 weeks of treatment, attrition rates were similar in both conditions. PhT-patients were better off at 4 weeks according to two of the four measures The superiority of PhT was clearer on the self-report than on the independent measure. CONCLUSIONS: There are signs that the benefits of PhT over SPSP--where detected--are short-lived and cover mostly the first month of treatment. The progression of these patients through the rest of their treatments, and afterwards, will be reported in further contributions.
Assuntos
Algoritmos , Antidepressivos/uso terapêutico , Transtorno Depressivo Maior/psicologia , Transtorno Depressivo Maior/terapia , Psicoterapia/métodos , Adolescente , Adulto , Idoso , Terapia Combinada , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Comorbidity of depressive and personality disorder occurs frequently, in literature percentages of around 50 to nearly 80 percent are found. Also in the Mentrum depression study on which this article is grounded, high percentages of around 66% were found. There is no equivocal treatment method of choice in literature, and opinions differ as to whether personality pathology has an adverse influence on the efficacy of the treatment for depression. AIM: To compare the results of pharmacotherapy and combined therapy in the treatment of depressive disorders in patients with and without comorbid personality disorder. METHOD: A 6 month randomised clinical trial of antidepressants and combined therapy in ambulatory patients with major depressive disorder and a baseline score of at least 14 points on the 17-item Hamilton Rating Scale for Depression. Pharmacotherapy follows three subsequent steps in case of intolerance/inefficacy: fluoxetine, amitriptyline and moclobemide. In addition combination therapy includes 16 short-term sessions of psychodynamic supportive psychotherapy. Possible personality pathology is assessed by means of the 'Vragenlijst Kenmerken Persoonlijkheid' (a self report version of the International Personality Disorder Examination). Analyses of (co) variance and chi-squared tests were applied to assess the differences in both treatment conditions in the group with and without personality pathology. RESULTS: Combined therapy was significantly more effective than pharmacotherapy for depressed patients with personality disorders. For depressed patients without personality disorders, combined therapy was not more effective than pharmacotherapy alone. CONCLUSION: The combination of psychotherapy and pharmacotherapy seems to be the treatment of choice for depressed patients with comorbid personality pathology.
Assuntos
Antidepressivos/uso terapêutico , Transtorno Depressivo/terapia , Transtornos da Personalidade/terapia , Psicoterapia/métodos , Adolescente , Adulto , Terapia Combinada , Comorbidade , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos da Personalidade/tratamento farmacológico , Transtornos da Personalidade/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: A limited number of psychotherapy sessions in combination with medication is preferable to pharmacotherapy only in the treatment of ambulatory patients with major depression. Whether there is a relation between the number of sessions and the efficacy of the treatment is uncertain. METHOD: Randomized clinical trial comparing two treatment conditions in outpatients with major depression. All patients studied had a baseline score of at least 14 points on the 17-item Hamilton Depression Rating Scale. The two conditions consist of 8-session or 16-session Short Psychodynamic Supportive Psychotherapy, both in combination with pharmacotherapy. Efficacy was assessed using the 17-item HDRS, the CGI of Severity and of Improvement, the depression subscale of the SCL-90 and the Quality of Life Depression Scale. RESULTS: The rate of change would seem to indicate that eight sessions are preferable for both moderately and severely depressed patients, although the results converged again at the end. Furthermore, in terms of satisfaction with the number of sessions and drop-out percentages during treatment, no differences were found between the conditions. CONCLUSION: In the light of the outcome analysis (faster remission after fewer sessions), a short version of the psychotherapy treatment in a combined course of treatment seems to be justified.
Assuntos
Transtorno Depressivo Maior/tratamento farmacológico , Fluoxetina/uso terapêutico , Psicoterapia/métodos , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Adolescente , Adulto , Terapia Combinada , Transtorno Depressivo Maior/diagnóstico , Manual Diagnóstico e Estatístico de Transtornos Mentais , Relação Dose-Resposta a Droga , Feminino , Fluoxetina/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Fatores de TempoRESUMO
OBJECTIVE: To compare the efficacy of antidepressants with that of antidepressants plus psychotherapy ("combined therapy") in the treatment of depression. METHODS: 6 month randomised clinical trial of antidepressants (N=84) and combined therapy (N=83) in ambulatory patients with Major Depression and a 17-item HDRS baseline score of at least 14 points. The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline and moclobemide. The combined therapy condition consists, in addition to pharmacotherapy, of 16 sessions of Short Psychodynamic Supportive Psychotherapy. Efficacy is assessed using the 17-item HDRS, the CGI of Severity and of Improvement, the depression subscale of the SCL-90, and the Quality of Life Depression Scale. The data analysis is conducted on three samples: the intention-to-treat sample, the per protocol sample and the observed cases sample. RESULTS: After randomisation, 32% of the patients refused the proposed pharmacotherapy while 13% refused the proposed combined therapy. In 24 weeks, 40% of the patients who started with the pharmacotherapy stopped medication; 22% of those receiving the combined therapy did so. The difference in success rates is statistically significant, favouring combined therapy, in 23%, 31% and 62% of the patients after 8, 16 and 24 weeks of treatment, respectively. At week 24, the mean success rate is 40.7% in the pharmacotherapy group and 59.2% in the combined therapy group. CONCLUSION: Patients found combined treatment significantly more acceptable, they were significantly less likely to drop out of combined therapy and, ultimately, significantly more likely to recover. Combined therapy is preferable to pharmacotherapy in the treatment of ambulatory patients with major depression.
Assuntos
Antidepressivos/uso terapêutico , Transtorno Depressivo/terapia , Psicoterapia , Adolescente , Adulto , Antidepressivos/administração & dosagem , Terapia Combinada , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/tratamento farmacológico , Estudos de Viabilidade , Humanos , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Escalas de Graduação Psiquiátrica , Indução de Remissão , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
Personality disorders are much more common among depressive patients than among normal people. Until now, little research has been conducted into the prevalence of personality disorders among patients with both major depression and dysthymia (double depression). The subject of this study is whether depressive patients with dysthymia have more personality disorders than those with no dysthymia. The Vragenlijst voor Kenmerken van de Persoonlijkheid (a Dutch self-report based on the International Personality Disorder Examination) was completed for 211 outpatients with major depression. Approximately 60% of the patients suffer from one or more personality disorders. Depressive patients with dysthymia differ little from the patients without dysthymia, but patients with dysthymia have more cluster A disorders and are more avoidant. Depressive patients without dysthymia do not differ from the patients with dysthymia in terms of symptoms. Depressive patients with personality disorders have significantly more symptoms than the patients without these disorders. There is no interaction between dysthymia and personality disorder.