Treatment outcomes in depression: reducing drop-out rates in cognitive therapy

Abstract

SUMMARYAlthough cognitive therapy is a promising treatment for depression, high drop-out rates and, conversely, the specific elements that make the intervention effective continue to puzzle practising clinicians. This article discusses both therapistrelated factors (including competence and competencies) and patient-related factors (such as engagement in therapy and external logistical problems with attendance) that are related to drop-out and suggests practical ways to address them and improve outcomes. It examines cognitive and behavioural elements of manualised cognitive therapy and discusses findings relating to cognitive-behavioural therapy (CBT) in particular. LEARNING OBJECTIVES• Understand factors associated with high dropout rates in the cognitive therapy of depression and ways to reduce them • Learn about treatment integrity in cognitive therapy of depression and its relationship to the clinical outcome • Identify specific cognitive therapy techniques associated with patients' improvement in depressionDepression, or major depressive disorder (MDD), is defined in DSM-5 as an illness that affects mood, thinking and behaviour and it is characterised by feelings of sadness and loss of interest in previously pleasurable activities (American Psychiatric Association 2013). It is a potentially chronic condition and DSM-5 includes new diagnostic conceptualisations of the illness: the new diagnostic criteria for depressive disorders assume that most individuals with chronic depression or MDD will fulfil the criteria for dysthymia, so chronic depression and dysthymia have been merged into the diagnostic category of persistent depressive disorders (PDD). Nevertheless, not all individuals with chronic depression/MDD will meet the diagnostic criteria for PDD (American Psychiatric Association 2013; Uher 2014). People who have experienced MDD have a high risk of relapse during the first 6 months after symptom remission. Those who have been prescribed antidepressant medication are therefore advised to continue the antidepressant for at least 6 months after remission. In a study comparing relapse rates following successful treatment with medication or cognitive therapy, Hollon et al (2005) found that 70% of those who had responded to antidepressants relapsed within 12 months of medication withdrawal, whereas only 31% of responders to cognitive therapy relapsed during that period. The authors thus concluded that cognitive therapy had more enduring results than antidepressants in MDD treatment and relapse prevention. A metaanalysis by Cuijpers et al (2013) that compared the treatment efficacy of psychotherapies and pharmacotherapy found that cognitive-behavioural therapy (CBT) plus medication was slightly better than CBT alone. This suggests the need for more studies to clarify the effects of addition of antidepressants to cognitive therapy and CBT. Cognitive therapy for depressionCognitive therapy as a component of CBT uses cognitive restructuring techniques to change the individual's negative and maladaptive thinking. C...

Therapists’ experiences with providing guided internet-delivered cognitive behavioral therapy for patients with mild and moderate depression: a thematic analysis

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