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Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronic Depression

Schramm, E., Kriston, L., Zobel, I., Bailer, J., Wambach, K., …Harter, M. (2017). Effect of disorder-specific vs nonspecific psychotherapy for chronic depression: A randomized clinical trial. JAMA Psychiatry, 74, 233-242.

The lifetime prevalence of chronic depression is somewhere between 3% and 6% of the population. Chronic depression refers to depression that develops into a chronic course of more that 2 years. Compared to those with acute depression (< 2 years depressed), patients with chronic depression experience greater social, physical, and mental impairments. This large randomized controlled trial by Schramm and colleagues assessed the efficacy of the Cognitive Behavioral Analysis System (CBASP) compared to so-called non-specific psychotherapy (NSP), both delivered in 24 sessions. CBASP is a structured therapy that combines cognitive and interpersonal treatments focused on problems solving and learning the effects of one’s own behaviors on others. On the other hand, therapists delivering NSP were limited to reflective listening, empathy, and helping the client feel hopeful. Specific interventions associated with cognitive or interpersonal therapies were prohibited. A total of 262 patients with chronic depression were randomly assigned to receive 24 sessions of either CBASP or NSP. Main outcomes included indicators of “response” to treatment (a 50% reduction in a depression scale score) or “recovery” (a very low score on the scale at the end of treatment). Both CBASP and NSP resulted in a significant decline in depressive symptoms after 48 weeks. The CBASP condition was slightly more effective than simply providing NSP (d = 0.39, NNT = 5). About 38.7% responded to CBASP compared to 24.3% who responded to NSP (OR = 2.02; 95% CI, 1.09-3.73; p = .03; NNT = 5). In terms of remission, 21.8% recovered after CBASP compared to 12.6% in NSP (OR = 3.55; 95% CI, 1.61-7.85; p = .002; NNT = 4). Average drop-out rates were similar between the two treatments at about 22%.

Practice Implications

CBASP represents a highly structured integrative treatment for chronic depression. It did modestly better than NSP in which therapists were prohibited from engaging in any technical intervention. In the end, the longer-term rates of recovery for CBASP were also modest at about 21.8%. On the one hand, chronic depression is notoriously difficult to treat with psychotherapy or medications, so perhaps CBASP will provide relief for some. On the other hand, an average 21.8% recovery rate for CBASP was modest. CBASP was slightly better than providing active listening and empathy alone.

Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.

Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.

Practice Implications

Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.

Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.

Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.

Practice Implications

This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.