Differential
Relapse Following Cognitive Therapy and Pharmacotherapy for Depression
Mark D. Evans, PhD; Steven D. Hollon, PhD; Robert J. DeRubeis, PhD; Joan M. Piasecki, William M. Grove, PhD; Michael J. Garvey, MD; Vicente B. Tuason, MD, FRCPC \s=b\ Patients successfully treated during a 3-month period with either imipramine hydrochloride pharmacotherapy, cognitive therapy, or combined cognitive-pharmacotherapy were monitored during a 2-year posttreatment follow-up period. Half of the patients treated with pharmacotherapy alone continued to receive study medications for the first year of the follow-up. All other patients discontinued treatment at the end of the acute treatment phase. Patients treated with cognitive therapy (either alone or in combination with medication) evidenced less than half the rate of relapse shown by patients in the medication\p=m-\on continuation condition, and their rate did not differ from that of patients provided with continuation medication. It appears that providing cognitive therapy during acute treatment prevents relapse. Whether this preventive effect extends to recurrence remains to be determined.
PhD;
will experience multiple episodes, the capacity of an inter¬ prevent the return of symptoms after treatment as important as its ability to treat the cur¬ be least at may
vention to rent
episode.5
Can cognitive therapy reduce subsequent risk? Recent studies suggest that it might.6 In a series of naturalistic follow-ups of controlled treatment trials, patients who had been treated with cognitive therapy showed approxi¬ mately half the rate of posttreatment relapse than did pa¬ tients who had been treated pharmacologically.7"9 Nonetheless, these findings cannot be considered con¬ clusive.6 Samples have typically been small, nonresponders have sometimes been included,8 ascertainment of See also
774.
(Arch Gen Psychiatry. 1992;49:802-808) of the psychosocial interventions have long argued that psychotherapy provides stable gains that survive the termination of treatment and reduce subse¬ quent risk.1 Although ongoing continuation and mainte¬ nance medication are known to reduce risk,2-3 there is no evidence that pharmacotherapy confers any protection against the return of symptoms after treatment has been terminated.4 Since the majority of depressed individuals
Advocates
Accepted for publication June 18, 1992. From the Department of Psychology, University of Minnesota, Minneapolis (Drs Evans, Hollon, DeRubeis, and Grove), and Department of Psychiatry, St Paul (Minn)\p=m-\RamseyMedical Center (Drs Piasecki,
Garvey, and Tuason).
Dr Hollon is
now
with the
Department of
Psychology, Vanderbilt University, Nashville, Tenn; Dr DeRubeis, with the Department of Psychology, University of Pennsylvania, Philadelphia; Dr Piasecki, with the Department of Psychiatry, University of Col-
orado Health Sciences Center, Denver; Dr Garvey, with the Department of Veterans Affairs and the Department of Psychiatry, University of Iowa College of Medicine, Iowa City; and Dr Tuason, with the Department of Veterans Affairs Medical Center and the Department of Psychiatry, University of New Mexico, Albuquerque. Read in part before the 141st Annual Meeting of the American Psychiatric Association, Montreal, Quebec, May 12, 1988. Reprint requests to Department of Psychology, Vanderbilt University, 306 Wilson Hall, Nashville, TN 37240 (Dr Hollon).
relapse view7
has sometimes relied
or
on
retrospective
chart
re¬
infrequent (biannual) réévaluations,9 and defini¬
relapse have typically included return to treat¬ ment, even if it occurred in the absence of documentable distress. Finally, given that patients included in the follow-ups typically represented only a fraction of those initially assigned (patients must both complete and re¬ tions of
spond to treatment to be included), it is possible that cognitive therapy's apparent preventive effect results from an artifact. If pharmacotherapy is more likely than cognitive therapy to retain high-risk patients, then acute treatment could
serve as a "differential sieve" that sys¬ biases the groups entering the follow-up. (We are indebted to an anonymous reviewer for sug¬ gesting and naming this possibility.) In this article, we describe a 2-year follow-up of de¬ pressed outpatients treated in a controlled comparison of imipramine pharmacotherapy vs cognitive therapy, both singly and together. Our primary interest was in deter¬ mining whether cognitive therapy prevents relapse after successful treatment. We also hoped to compare it with ongoing continuation medication, the current standard of treatment. Our study was designed before the publication of the naturalistic follow-ups just reviewed, and it shares many of the limitations of those earlier trials. Nonetheless,
tematically
Downloaded From: http://archpsyc.jamanetwork.com/ by a Michigan State University User on 06/09/2015
we hoped to improve on the previous naturalistic designs by reporting results separately for treatment responders, by assessing relapse on a frequent and prospective basis, and by differentiating return of symptoms from premature
return to treatment.
PATIENTS AND METHODS Patients The initial sample consisted of 107 nonbipolar, nonpsychotic depressed outpatients requesting treatment for depression. Full details of the patient selection criteria and screening procedures are presented in a companion article.10 In brief, each patient met Research Diagnostic Criteria (RDC)11 for major depressive disor¬ der, unipolar type, and did not meet criteria for any of several ex¬ clusionary diagnoses, including lifetime designations of bipolar affective disorder, schizophrenia, organic brain syndrome, somatization disorder, antisocial personality, or schizotypal features (two or more), or recent designations (within the last year) of al¬ coholism or drug use disorder. Also excluded were patients meeting any of the RDC anxiety-related disorders if that disorder was predominant over and not strictly coterminous with the cur¬ rent episode of depression.
Details of treatment assignment and treatment execution dur¬ ing the acute treatment phase are provided elsewhere.1" In brief, patients were randomly assigned to 12 weeks of treatment with an experienced pharmacotherapist and/or cognitive therapist. Treatment conditions included (1) imipramine hydrochloride pharmacotherapy with posttreatment continuation, (2) imi¬ pramine pharmacotherapy without posttreatment continuation, (3) cognitive therapy, and (4) combined cognitive-pharmacotherapy. Of the 107 patients assigned to treatment, 64 completed the 12-week active treatment protocol, whereas the remaining 43 failed to complete treatment (five patients did not begin treat¬ ment, 29 dropped out of treatment after beginning, and nine were "withdrawn" from treatment due to severe complications, in¬ cluding two patients who died as a consequence of suicide attempts). Among the 64 treatment completers, those 50 patients who evidenced at least a partial clinical response were deemed sufficiently remitted to warrant graduation into the posttreatment follow-up. Partial response was defined as a posttreatment Beck Depression Inventory (BDI)12 score of 15 or less. This criterion was adopted to be consistent with the earlier report by Kovacs and colleagues,8 the only published follow-up involving cognitive therapy available when the current study was initiated. Rates of at least partial response were high (75% or greater) and not significantly different across the conditions. Thirty-nine patients evidenced a full clinical response (posttreatment BDI score, s9), while 11 evidenced a partial response (BDI score, 10 to 15). These 50 patients constitute the primary sample reported
in the current article. Treatment was terminated for these pa¬ tients (except those assigned to the continuation medication con¬ dition) at the point of entry into the follow-up. (The remaining 14 nonresponders were encouraged to continue in treatment; most had medication added or changed, or had psychotherapy added to their pharmacotherapy regimen.) Although treatment termination decisions were made solely on the basis of posttreatment BDI scores, posttreatment ratings were also available on the clinician-rated Hamilton Rating Scale for Depression (HRSD).13 On the HRSD, partial response was defined as a score between 7 and 11, whereas full response was defined as a score of 6 or less. Thirty-seven patients met the criterion for full response, 10 for partial response, and 16 for nonresponse on the HRSD. (One completer, a full responder on the BDI, did not provide a posttreatment HRSD score.) In general, overlap be¬ tween the two measures was strong (r=.74, P
Relapse Following Cognitive Therapy and Pharmacotherapy for Depression
Mark D. Evans, PhD; Steven D. Hollon, PhD; Robert J. DeRubeis, PhD; Joan M. Piasecki, William M. Grove, PhD; Michael J. Garvey, MD; Vicente B. Tuason, MD, FRCPC \s=b\ Patients successfully treated during a 3-month period with either imipramine hydrochloride pharmacotherapy, cognitive therapy, or combined cognitive-pharmacotherapy were monitored during a 2-year posttreatment follow-up period. Half of the patients treated with pharmacotherapy alone continued to receive study medications for the first year of the follow-up. All other patients discontinued treatment at the end of the acute treatment phase. Patients treated with cognitive therapy (either alone or in combination with medication) evidenced less than half the rate of relapse shown by patients in the medication\p=m-\on continuation condition, and their rate did not differ from that of patients provided with continuation medication. It appears that providing cognitive therapy during acute treatment prevents relapse. Whether this preventive effect extends to recurrence remains to be determined.
PhD;
will experience multiple episodes, the capacity of an inter¬ prevent the return of symptoms after treatment as important as its ability to treat the cur¬ be least at may
vention to rent
episode.5
Can cognitive therapy reduce subsequent risk? Recent studies suggest that it might.6 In a series of naturalistic follow-ups of controlled treatment trials, patients who had been treated with cognitive therapy showed approxi¬ mately half the rate of posttreatment relapse than did pa¬ tients who had been treated pharmacologically.7"9 Nonetheless, these findings cannot be considered con¬ clusive.6 Samples have typically been small, nonresponders have sometimes been included,8 ascertainment of See also
774.
(Arch Gen Psychiatry. 1992;49:802-808) of the psychosocial interventions have long argued that psychotherapy provides stable gains that survive the termination of treatment and reduce subse¬ quent risk.1 Although ongoing continuation and mainte¬ nance medication are known to reduce risk,2-3 there is no evidence that pharmacotherapy confers any protection against the return of symptoms after treatment has been terminated.4 Since the majority of depressed individuals
Advocates
Accepted for publication June 18, 1992. From the Department of Psychology, University of Minnesota, Minneapolis (Drs Evans, Hollon, DeRubeis, and Grove), and Department of Psychiatry, St Paul (Minn)\p=m-\RamseyMedical Center (Drs Piasecki,
Garvey, and Tuason).
Dr Hollon is
now
with the
Department of
Psychology, Vanderbilt University, Nashville, Tenn; Dr DeRubeis, with the Department of Psychology, University of Pennsylvania, Philadelphia; Dr Piasecki, with the Department of Psychiatry, University of Col-
orado Health Sciences Center, Denver; Dr Garvey, with the Department of Veterans Affairs and the Department of Psychiatry, University of Iowa College of Medicine, Iowa City; and Dr Tuason, with the Department of Veterans Affairs Medical Center and the Department of Psychiatry, University of New Mexico, Albuquerque. Read in part before the 141st Annual Meeting of the American Psychiatric Association, Montreal, Quebec, May 12, 1988. Reprint requests to Department of Psychology, Vanderbilt University, 306 Wilson Hall, Nashville, TN 37240 (Dr Hollon).
relapse view7
has sometimes relied
or
on
retrospective
chart
re¬
infrequent (biannual) réévaluations,9 and defini¬
relapse have typically included return to treat¬ ment, even if it occurred in the absence of documentable distress. Finally, given that patients included in the follow-ups typically represented only a fraction of those initially assigned (patients must both complete and re¬ tions of
spond to treatment to be included), it is possible that cognitive therapy's apparent preventive effect results from an artifact. If pharmacotherapy is more likely than cognitive therapy to retain high-risk patients, then acute treatment could
serve as a "differential sieve" that sys¬ biases the groups entering the follow-up. (We are indebted to an anonymous reviewer for sug¬ gesting and naming this possibility.) In this article, we describe a 2-year follow-up of de¬ pressed outpatients treated in a controlled comparison of imipramine pharmacotherapy vs cognitive therapy, both singly and together. Our primary interest was in deter¬ mining whether cognitive therapy prevents relapse after successful treatment. We also hoped to compare it with ongoing continuation medication, the current standard of treatment. Our study was designed before the publication of the naturalistic follow-ups just reviewed, and it shares many of the limitations of those earlier trials. Nonetheless,
tematically
Downloaded From: http://archpsyc.jamanetwork.com/ by a Michigan State University User on 06/09/2015
we hoped to improve on the previous naturalistic designs by reporting results separately for treatment responders, by assessing relapse on a frequent and prospective basis, and by differentiating return of symptoms from premature
return to treatment.
PATIENTS AND METHODS Patients The initial sample consisted of 107 nonbipolar, nonpsychotic depressed outpatients requesting treatment for depression. Full details of the patient selection criteria and screening procedures are presented in a companion article.10 In brief, each patient met Research Diagnostic Criteria (RDC)11 for major depressive disor¬ der, unipolar type, and did not meet criteria for any of several ex¬ clusionary diagnoses, including lifetime designations of bipolar affective disorder, schizophrenia, organic brain syndrome, somatization disorder, antisocial personality, or schizotypal features (two or more), or recent designations (within the last year) of al¬ coholism or drug use disorder. Also excluded were patients meeting any of the RDC anxiety-related disorders if that disorder was predominant over and not strictly coterminous with the cur¬ rent episode of depression.
Details of treatment assignment and treatment execution dur¬ ing the acute treatment phase are provided elsewhere.1" In brief, patients were randomly assigned to 12 weeks of treatment with an experienced pharmacotherapist and/or cognitive therapist. Treatment conditions included (1) imipramine hydrochloride pharmacotherapy with posttreatment continuation, (2) imi¬ pramine pharmacotherapy without posttreatment continuation, (3) cognitive therapy, and (4) combined cognitive-pharmacotherapy. Of the 107 patients assigned to treatment, 64 completed the 12-week active treatment protocol, whereas the remaining 43 failed to complete treatment (five patients did not begin treat¬ ment, 29 dropped out of treatment after beginning, and nine were "withdrawn" from treatment due to severe complications, in¬ cluding two patients who died as a consequence of suicide attempts). Among the 64 treatment completers, those 50 patients who evidenced at least a partial clinical response were deemed sufficiently remitted to warrant graduation into the posttreatment follow-up. Partial response was defined as a posttreatment Beck Depression Inventory (BDI)12 score of 15 or less. This criterion was adopted to be consistent with the earlier report by Kovacs and colleagues,8 the only published follow-up involving cognitive therapy available when the current study was initiated. Rates of at least partial response were high (75% or greater) and not significantly different across the conditions. Thirty-nine patients evidenced a full clinical response (posttreatment BDI score, s9), while 11 evidenced a partial response (BDI score, 10 to 15). These 50 patients constitute the primary sample reported
in the current article. Treatment was terminated for these pa¬ tients (except those assigned to the continuation medication con¬ dition) at the point of entry into the follow-up. (The remaining 14 nonresponders were encouraged to continue in treatment; most had medication added or changed, or had psychotherapy added to their pharmacotherapy regimen.) Although treatment termination decisions were made solely on the basis of posttreatment BDI scores, posttreatment ratings were also available on the clinician-rated Hamilton Rating Scale for Depression (HRSD).13 On the HRSD, partial response was defined as a score between 7 and 11, whereas full response was defined as a score of 6 or less. Thirty-seven patients met the criterion for full response, 10 for partial response, and 16 for nonresponse on the HRSD. (One completer, a full responder on the BDI, did not provide a posttreatment HRSD score.) In general, overlap be¬ tween the two measures was strong (r=.74, P
