Jeffrey R Vittengl1, Robin B Jarrett1, Erica Weitz1, Steven D Hollon1, Jos Twisk1, Ioana Cristea1, Daniel David1, Robert J DeRubeis1, Sona Dimidjian1, Boadie W Dunlop1, Mahbobeh Faramarzi1, Ulrich Hegerl1, Sidney H Kennedy1, Farzan Kheirkhah1, Roland Mergl1, Jeanne Miranda1, David C Mohr1, A John Rush1, Zindel V Segal1, Juned Siddique1, Anne D Simons1, Pim Cuijpers1. 1. From the Department of Psychology, Truman State University, Kirksville, Mo.; the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas; the Department of Clinical Psychology and the EMGO Institute for Health and Care Research, VU University Amsterdam, the Netherlands; the Department of Psychology, Vanderbilt University, Nashville, Tenn.; the Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj, Romania; the Department of Psychology, University of Pennsylvania, Philadelphia; the Department of Psychology and Neuroscience, University of Colorado, Boulder; the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta; the Fatemeh Zahra Infertility and Reproductive Health Research Center and the Department of Psychiatry, Babol University of Medical Sciences, Babol, Iran; the Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany; the Department of Psychiatry, Faculty of Medicine, University of Toronto; the Department of Psychology, University of Toronto-Scarborough; the Health Services Research Center, Neuropsychiatric Institute, University of California, Los Angeles; the Department of Preventive Medicine and the Center for Behavioral Intervention Technologies, Feinberg School of Medicine, Northwestern University, Chicago; the Duke-National University of Singapore Graduate Medical School, Singapore; and the Department of Psychology, University of Notre Dame, Notre Dame, Ind.
Abstract
OBJECTIVE: Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. METHOD: Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. RESULTS: About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels. CONCLUSIONS: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
OBJECTIVE: Although the average depressedpatient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. METHOD: Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. RESULTS: About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels. CONCLUSIONS: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
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