German investigators test new approach for chronic depression

In a recent issue of Psychotherapy and Psychosomatics a group of German investigators headed by Eva Brakemeier has performed a pilot study to test a new approach for chronic depression.

This study demonstrates that the inpatient cognitive behavioral analysis system of psychotherapy (CBASP) program can be considered as a promising and feasible treatment option that produces a good outcome for chronically depressed patients with high comorbidity in the short and long term. Future randomized controlled studies should examine whether this intensive CBASP program is more effective than standard psychiatric interventions or CBASP outpatient treatment.

Cognitive behavioral analysis system of psychotherapy (CBASP) was initially developed as an outpatient treatment for chronic depression. It integrates cognitive-emotional, behavioral, interpersonal, and psychodynamic theories and strategies by addressing directly the specific psychopathology of chronic depression. Given the high degree of suicidality, comorbidity, and therapy resistance in chronic depression, however, many of these patients require inpatient treatment.

In this study, the investigators report on a first specialized program for chronic depression adapting CBASP to an inpatient setting and evaluate the feasibility and short- as well as long-term outcome of it. The new CBASP group therapy focuses on a modified approach for conducting situation analysis and on Kiesler's circle training with the extensive use of role playing and shaping. The entire treatment team was trained in CBASP; regular workshops and weekly supervisions for both the team and the individual therapists were conducted. Specific CBASP elements were implemented in other accompanying treatments such as nurse encounters, physiotherapy, music therapy, and occupational group therapy. A patient support group was established to avoid relapse after discharge. Patients received optimized pharmacotherapy in addition to the CBASP program in compliance with current national and international guidelines for depression treatment.

Ten inpatients with severe chronic depression according to DSM-IV were included in this pilot study. The SCID I and II were used for diagnosis. Early trauma and life events were assessed by using the Childhood Trauma Questionnaire (CTQ). Follow-up data were collected 6 months after discharge. Concerning feasibility, all patients completed the treatment. The CBASP concept proved to be feasible and there were no major difficulties integrating the concept into the daily clinical routine.

The 24-item version of the Hamilton Depression Rating Scale (HAMD) served as the primary outcome measure and the Beck Depression Inventory (BDI) as the secondary measure. T tests for paired samples revealed significant improvements and large effect sizes in the primary outcome HAMD-24 (p = 0.000) and in the BDI (p = 0.002). Treatment response was defined a priori as a reduction in symptom severity of at least 50% on the HAMD, and remission was defined as a score of 10 or less on the HAMD scale.

Six out of the 10 patients were classified as responders and 4 of these fulfilled the remission criterion. Exploratory analyses revealed that the nonresponders had a significantly higher number of personality disorders (p = 0.038). Finally, the 6-month naturalistic follow-up assessments were completed by 9 out of the 10 patients. Outpatient psychotherapy was continued by 6 patients (CBASP: 3, cognitive-behavioral therapy:2, schema therapy: 1), 9 patients were still on pharmacotherapy, and 6 patients regularly attended the CBASP support group. The findings on short- and long-term outcomes as well as on feasibility of the inpatient CBASP program are promising.

However, in this study response rates were lower than those in outpatient CBASP studies. This might be a consequence of the inclusion of a more severely ill patient sample with high comorbidity, long duration of the episode, and high levels of therapy resistance. Concerning follow-up data, it is remarkable that the patients who remitted remained in remission over 6 months, that all patients had improved satisfaction with psychosocial domains, and that only 1 patient relapsed.