Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression

The REVAMP trial

James H. Kocsis, Alan J. Gelenberg, Barbara O. Rothbaum, Daniel N. Klein, Madhukar H. Trivedi, Rachel Manber, Martin B. Keller, Andrew C. Leon, Steven R. Wisniewski, Bruce A. Arnow, John C. Markowitz, Michael E. Thase

Research output: Contribution to journalArticle

128 Citations (Scopus)

Abstract

Context: Previous studies have found that few chronically depressed patients remit with antidepressant medications alone. Objective: To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial. Design: This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone. Setting: Eight academic sites. Participants: Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years. Interventions: Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs). Main Outcome Measures: Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores. Results: In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores. Conclusions: Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing. Trial Registration: clinicaltrials.gov Identifier: NCT00057551.

Original languageEnglish (US)
Pages (from-to)1178-1188
Number of pages11
JournalArchives of General Psychiatry
Volume66
Issue number11
DOIs
StatePublished - Nov 2009

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Brief Psychotherapy
Psychotherapy
Antidepressive Agents
Depression
Drug Therapy
Diagnostic and Statistical Manual of Mental Disorders
Therapeutics
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Psychiatry and Mental health

Cite this

Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression : The REVAMP trial. / Kocsis, James H.; Gelenberg, Alan J.; Rothbaum, Barbara O.; Klein, Daniel N.; Trivedi, Madhukar H.; Manber, Rachel; Keller, Martin B.; Leon, Andrew C.; Wisniewski, Steven R.; Arnow, Bruce A.; Markowitz, John C.; Thase, Michael E.

In: Archives of General Psychiatry, Vol. 66, No. 11, 11.2009, p. 1178-1188.

Research output: Contribution to journalArticle

Kocsis, James H. ; Gelenberg, Alan J. ; Rothbaum, Barbara O. ; Klein, Daniel N. ; Trivedi, Madhukar H. ; Manber, Rachel ; Keller, Martin B. ; Leon, Andrew C. ; Wisniewski, Steven R. ; Arnow, Bruce A. ; Markowitz, John C. ; Thase, Michael E. / Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression : The REVAMP trial. In: Archives of General Psychiatry. 2009 ; Vol. 66, No. 11. pp. 1178-1188.
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abstract = "Context: Previous studies have found that few chronically depressed patients remit with antidepressant medications alone. Objective: To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial. Design: This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone. Setting: Eight academic sites. Participants: Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years. Interventions: Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs). Main Outcome Measures: Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores. Results: In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0{\%}), partial response (22.5{\%}), and nonresponse (62.5{\%}) or in changes on HAM-D scores. Conclusions: Although 37.5{\%} of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing. Trial Registration: clinicaltrials.gov Identifier: NCT00057551.",
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AU - Rothbaum, Barbara O.

AU - Klein, Daniel N.

AU - Trivedi, Madhukar H.

AU - Manber, Rachel

AU - Keller, Martin B.

AU - Leon, Andrew C.

AU - Wisniewski, Steven R.

AU - Arnow, Bruce A.

AU - Markowitz, John C.

AU - Thase, Michael E.

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N2 - Context: Previous studies have found that few chronically depressed patients remit with antidepressant medications alone. Objective: To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial. Design: This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone. Setting: Eight academic sites. Participants: Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years. Interventions: Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs). Main Outcome Measures: Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores. Results: In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores. Conclusions: Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing. Trial Registration: clinicaltrials.gov Identifier: NCT00057551.

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