Initial severity of depression and efficacy of cognitive–behavioural therapy: Individual-participant data meta-analysis of pill-placebo-controlled trials

Furukawa, Toshi A; Weitz, Erica; Tanaka, Shiro; Hollon, Steven D.; Hofmann, Stefan G.; Andersson, Gerhard; Twisk, Jos W. R.; DeRubeis, Robert J.; Dimidjian, Sona; Hegerl, Ulrich; Mergl, Roland; Jarrett, Robin B.; Vittengl, Jeffrey R.; Watanabe, Norio; Cuijpers, Pim

doi:10.1192/bjp.bp.116.187773

Cited by 59 publications

(46 citation statements)

References 36 publications

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“…Unfortunately, only two studies examined combined treatment versus psychotherapy alone among patients with severe depression, so we cannot be certain whether combined treatment is superior for these people. Individual patient data meta‐analyses have suggested that baseline depression severity does not moderate the efficacy of CBT versus antidepressant treatment, or CBT over pill placebo. This supports the notion that combined treatment should be the first option for moderate and probably also severe depression.…”

Section: Discussionmentioning

confidence: 70%

A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

et al. 2020

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No network meta‐analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long‐term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop‐out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment‐resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random‐effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta‐analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14‐1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14‐1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92‐1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05‐1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02‐1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment‐resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long‐term effects of treatments (including cost‐effectiveness), on the impact of specific pharmacological and non‐pharmacological approaches, and on the effects in specific populations of patients.

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Section: Discussionmentioning

confidence: 70%

A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

et al. 2020

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“…For example, having an anxiety disorder, which was likely associated with coming from the studies in the sample that addressed anxiety disorders, had a much stronger predictive value for non-responder. Similarly, Furukawa et al (2017) found that rate of improvement did not interact with baseline severity in an individual patient data meta-analysis of CBT for depression versus pill-placebo (n=509), and that result does not share the same potential sources of bias. Bower et al (2013) is an individual patient-data meta-analysis.…”

Section: Baseline Severity As a Predictor Of Treatment Outcomementioning

confidence: 96%

Predicting treatment failure in regular care Internet-Delivered Cognitive Behavior Therapy for depression and anxiety using only weekly symptom measures.

Forsell

Isacsson

Blom

et al. 2020

Journal of Consulting and Clinical Psychology

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To my family Josefin, Selma and Oskar. Not only did they put up with me during the entire PhD journey, but they also spent the last two weeks of it in quarantine with me because of the coronavirus pandemic of 2020.ABSTRACT Background: Internet-delivered Cognitive Behavior Therapy (ICBT) is efficacious for a number of psychiatric disorders and can be successfully implemented in routine psychiatric care. Still, only about half of patients experience a good enough treatment outcome. Using data from the early part of treatment to identify patients with high risk of not benefitting from it, and target them with additional resources to prevent the predicted failure is a potential way forward. We call this an Adaptive Treatment Strategy, and a very important part of it is the ability to predict the outcome for a specific patient. Aims:To establish a proof of concept for an Adaptive Treatment Strategy in ICBT, and explore outcome prediction further by evaluating the accuracy of an empirically supported classification algorithm, the time point in treatment when acceptable accuracy can be reached, and the accuracy of ICBT-therapists' own predictions. Preliminary benchmarks regarding the clinical usefulness of prediction will be established. Studies:Four studies were performed: Study I was a randomized controlled trial (RCT; n=251) where patients' risk of treatment Failure (Red=high risk of failure, Green=low risk) was predicted during week 4 out of 9 in ICBT for Insomnia. Red patients (n=102) were then randomized to either continuing with standard treatment (n=51) or having their treatment individually adapted (n=51). In Study II, the classification algorithm from Study I was evaluated in terms of classification accuracy and the contribution of the different predictors used. In Study III, data from 4310 regular care ICBT-patients having received treatment for either Depression, Social anxiety disorder or Panic disorder were analyzed in a series of multiple regression models using weekly observations of the primary symptom measure as predictors to classify risk of Failure. As a contrast, Study IV examines ICBT therapists' own predictions on both categorical and continuous treatment outcomes, as they made predictions for each of their patients (n=897) during week 4 in the same three treatments as in Study III. Results:The RCT was successful in that Red patients receiving Adapted treatment improved significantly more than Red patients receiving standard treatment, and their odds of failure were nearly cut in half. Green patients did better than Red patients, indicating that the accuracy of the classification algorithm was clinically useful. Study II showed that the balanced accuracy of the classifier was 67% and that only 11 of 21 predictors correlated significantly with Failure. Notable predictors were symptom levels as well as different markers of treatment engagement. Study III and IV showed that acceptable predictions could be made halfway through treatment using only symptom scores and basic statistics, and that ICBT-...

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“…The treatment significance of severity has been studied in several different ways. There are controlled studies, effectiveness studies, pooled analyses, and meta‐analyses examining the impact of severity on particular treatments, comparing treatments across a range of severity, comparing medication and placebo across a range of severity, comparing psychotherapy and control groups across a range of severity, comparing treatments amongst severely depressed patients, and examining whether severity predicts short‐term outcome, treatment resistance, longer‐term outcome, and relapse.…”

Section: Severity Of Depressionmentioning

confidence: 99%

The severity of psychiatric disorders

2018

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The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

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Initial severity of depression and efficacy of cognitive–behavioural therapy: Individual-participant data meta-analysis of pill-placebo-controlled trials

Cited by 59 publications

References 36 publications

A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

Predicting treatment failure in regular care Internet-Delivered Cognitive Behavior Therapy for depression and anxiety using only weekly symptom measures.

The severity of psychiatric disorders

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