Psychotherapy Brown Bag

Treating chronic depression: A comparison of CBASP and interpersonal psychotherapy

by Michael D. Anestis, M.S.

A large portion of my early clinical training focused on the cognitive behavioral analysis system of psychotherapy (CBASP), a form of psychotherapy deveoped specifically for the treatment of chronic depression.  We have detailed the nature of this treatment before and I have truly enjoyed utilizing it in sessions, but I'm always on the lookout for new studies examining its efficacy and/or effectiveness, as the evidence base for this treatment is not as strong as I would like.  Yesterday, I came across a new study just published in the Journal of Affective Disorders by Elisabeth Schramm and colleagues (2011) that compared CBASP and interpersonal psychotherapy (IPT) in the treatment of early-onset chronic depression and I'd like to summarize the results for you in an effort to add to our earlier discussion of the treatment.  The study provides an important addition to the literature, as it compares CBASP to another empirically supported active treatment rather than waitlists of psychopharmacology.

In this particular study, all participants were between the ages of 18 and 65 and met DSM-IV criteria for one of the following diagnoses, as determined through semi-structured diagnostic interviews:

• Current episode of chronic depression
• Depression superimposed on pre-existing dysthymia
• Recurrent depression without full interepisode recovery in a patient with current depression and a total duration of at least two years
• Dysthymia

Additionally, the authors were specifically interesting in early onset chronic depression, so all participants needed to have experienced their first depressive episode prior to age 21.  All participants needed to present with a score of at least 16 on the Hamilton Rating Scale for Depression (HRSD, Hamilton, 1967).  Unfortunately (in my opinion), participants were excluded if they were at acute risk for suicide, although this is a common occurrance in treatment research.

The authors randomized 30 patients to 22 sessions of either CBASP or IPT and sessions were delivered over a period of 16 weeks.  Participants were assessed at baseline, at the end of treatment, and at a twelve month follow-up, allowing not only for an examination of the impact of treatment when therapy was still fresh in the patients' minds, but also of the longer term impact of each form of therapy.

During the course of treatment, patients in the CBASP group exhibited a significant decrease in clinician-rated depression symptoms (23.00 to 11.21), whereas the patients in the IPT group did not demonstrate a statistically significant drop (23.27 to 18.87).  That being said, the post-treatment scores in the two groups (11.21 vs 18.87) were not statistically different from one another.  In order for the authors to detect significant differences like this, they would really need more patients in each group (this is the issue of statistical power); however, we can not say for sure that, had there been more patients, the results would have been the same and the difference would be significant.  The authors also administered a measure of self-reported depression symptoms.  Both the CBASP (25.43 to 10.79) and the IPT (28.47 to 21.27) groups exhibited sigificant drops in their scores on this measure (Beck Depression Inventory; BDI).  With respect to self-reported depression symptoms, improvement in the CBAST group was significantly greater than in the IPT group.

At the end of treatment, the response rate in the CBASP group (64.3%) was significantly greater than the rate in the IPT group (26.7%).  Similarly, remission rates in the CBASP group (57.1%) was higher than the rates in the IPT group (20.0%).  Both groups improved in the global assessment of functioning (GAF), with no significant differences between the two groups on that outcome.

A year after treatment ended, patients were assessed again.  75.9% of the total sample (57% of CBASP, 93% of IPT) participated in the follow-up assessment.  At 12-month follow-up, both groups demonstrated significant decreases in symptoms and CBASP no longer outperformed IPT on self-reported depression symptoms, although it did outperform IPT on an assessment of general adaptation.

So what does all of this mean?  In the end, the results immediately post-treatment favor CBASP, but by 12-month follow-up, the results appear to be essentially equal.  This is not particularly surprising, as studies examining IPT versus CBT for particular diagnoses (e.g., bulimia nervosa) have presented similar patterns: CBT results in quicker improvement, but IPT catches up over time.  In the end, this is good news.  Both treatments resulted in improvements despite being extremely different from one another.  Both treatments are manualized and evidence-based, but CBASP is substantially more structured than is IPT.  As such, patients have an opportunity to choose from two very different approaches if they present with chronic depression.

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If you would like to learn more about the topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

Antidepressant use has increased in the United States while psychotherapy use has decreased: Is this a healthy trend?

by Michael D. Anestis, M.S.

When I am contemplating my next article, I use a variety of resources to aid in my decision making process.  At times, I reflect on things I have read in the past that I think might be interesting.  Other times, I react to something I believe was misrepresented in popular media.  On other occasions, I browse newly released issues of prominent psychological journals and search for interesting findings.  Today, however, my article was prompted by a different resource.  While posting updates for PBB on Twitter yesterday, I noticed a user named BPDinOKC had posted a link to an article declaring that antidepressant use in the United States had spiked dramatically in recent years.  I followed up on this link and read a strong review of the study on the excellent website Psych Central.  I highly recommend following that link if you would like to read a more in depth summary of the findings.

The original source of this finding was a recent study by Mark Olfson and Steven Marcus, published in the current issue of Archives of General Psychiatry.  The authors reported that, between the years of 1996 and 2005, the use of antidepressant medications in the United States doubled from 13.3 million individuals to 27.0 million individuals.  Additionally, amongst individuals receiving antidepressant treatment, co-occurring prescriptions of antipsychotic medications increased whereas the use of psychotherapy declined.  It is not my goal today to go into further detail on these findings - the Psych Central article did a great job of accomplishing that task - but rather to provide some evidence that this trend is not our nation's best path towards decreasing the rates of depression onset and relapse.

Before presenting my evidence, let me preface this article with a bit of a disclaimer.  PBB wholeheartedly supports the use of pharmacological interventions when empirical evidence indicates that it is the best option.  In the case of depression, the focus of today's article, there is compelling evidence that antidepressant medications can be highly beneficial.  In this sense, we are not arguing against the use of medication in the treatment of depression, but rather attempting to clarify the entire picture so that individuals in need of help can more fully understand their options.

So...why did the finding that antidepressant use has doubled while psychotherapy use in that same population has declined prompt me to write an article?  Quite simply, because the evidence does not support the use of antidepressant medication in place of psychotherapy as a long term solution to depression. Below is a quick sampling of studies indicating that certain forms of psychotherapy are at least as effective as antidepressant medication in the treatment of depression:

• Keller and colleagues (2000) compared cognitive behavioral analysis system of psychotherapy (CBASP), nefrazadone (an antidepressant), and the combination of the two for the treatment of depression.  They found that, of those who completed the study, 85% of individuals who received both antidepressant medication and CBASP recovered from depression.  Only 55% of individuals receiving medication only and 52% of individuals receiving CBASP only recovered.

• DeRubeis and colleagues (2005) reported that, at 16 weeks, individuals receiving cognitive therapy (CT) had recovered from depression at the same rate (58%) as individuals receiving antidepressant medication.

• Dimidjian and colleagues (2006) found that behavioral activation was just as effective as antidepressant medication in the treatment of depression and both were superior to CT.

• Faramarzi and colleagues (2008) reported that cognitive behavioral therapy (CBT) was more effective than antidepressant mediation in treating depression in infertile women.

• Melvin and colleagues (2006) found that CBT was more effective than antidepressant medication in the treatment of depression, and that the combination of the two offered not significant benefits over CBT alone.

The above mentioned findings, on their own, are fairly compelling, but this is only the beginning of the story.  What these findings show is that, when an individual presents with depression, both antidepressant medication and various forms of CBT can effectively treat acute symptoms.  These findings, however, do not address the degree to which either approach to treatment prevents symptoms from coming back after treatment is over. 

Depression is, by nature, episodic.  In other words, it tends to flare up, recede, flare up again, and so on.  As such, simply being able to diminish symptoms is not enough.  Effective care must also prevent those same symptoms from reoccurring once treatment is over.  One way to do this would be to remain in treatment forever.  This is the approach taken by practitioners who prescribe antidepressant medications with no intention of ever discontinuing use for that patient.  Is this the best approach though?  The evidence says "no."  Below is another sampling of studies, this time with a focus on the degree to which various treatments prevent relapse:

• Bockting and colleagues (2005) found that including CT sessions after remission in clients treated with antidepressant medication significantly reduced rates of relapse at 2-year follow-up.  This was particularly true for individuals with a history of five or more prior depressive episodes, as relapse rates in this group decreased from 72% to 46%.
  

• Dobson and colleagues (2008) reported that, at 1-year follow-up, individuals who had received behavioral activation or CT or who were still taking antidepressant medication had relapsed at a significantly lower rate than individuals who had discontinued antidepressant use.  This same result was found at 2-year follow-up as well.

• Hollon and colleagues (2006) found that individuals withdrawn from CT were less likely to relapse (30.8%) than were individuals withdrawn from treatment with antidepressants (76.2%).  Additionally, individuals who had completed CT and were withdrawn from treatment following remission were no more likely to relapse than were individuals who continued to take antidepressant medications after remission.

This is only a small sampling of research on this point, but they are consistent with other results and these findings are the key in this entire debate.  Many individuals who argue for the use of antidepressant medication instead of CBT or its various alternative forms and components (e.g., CBASP, behavioral activation) maintain that symptom reduction occurs more quickly with antidepressants than in psychosocial approaches and, as such, is more cost effective.  The problem with this argument, however, is that an extremely high percentage of individuals treated with antidepressants relapse once they discontinue the use of their medication.  So, they either have to pay for medication permanently, which is in no way cost effective, or they can pay a smaller amount for acute treatment and face a substantial risk of relapse.  CBT, on the other hand, offers a short term (often 12-20, 1-hour weekly sessions) treatment that substantially reduces the risk or relapse without requiring ongoing treatment after remission.  That, in the long term, is significantly more cost-effective.

Again, it is important to point out here that I am not arguing against the use of antidepressants.  The evidence for their utility in treatment depression as well as other mental illnesses (e.g., obsessive-compulsive disorder) is strong.  The point, rather, is that antidepressants are no more effective than several psychotherapeutic approaches at reducing symptoms and are, in fact, worse than those approaches at preventing relapse.  As such, a trend towards increased antidepressant use and decreased psychotherapy use is not an overall positive development. 

It is great that more people are seeking treatment.  This indicates that the stigma of mental illness is decreasing and effective care is becoming more accessible.  At the same time, this trend indicates that many clinicians and individuals suffering from depression are unaware of all of their options for treatment and that many clinicians - particularly in primary care settings - are not providing consumers with their most effective paths towards sustained health.

If you would like to learn more about cognitive behavioral therapy, CBASP, or depression, we recommend the following resources, all of which are available through our online store:

Cognitive Therapy of Depression - Aaron Beck, M.D.

Feeling Good: The New Mood Therapy Revised and Updated - David Burns, M.D.

Treatment Plans and Interventions for Depression and Anxiety Disorders - Robert Leahy, Ph.D.

Cognitive Therapy Techniques: A Practitioner's Guide - Robert Leahy, Ph.D.

Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP) - James McCollough, Ph.D.

Patient's Manual for CBASP - James McCollough, Ph.D.

Handbook of Depression, Second Edition - Ian Gotlib, Ph.D. and Constance Hammen, Ph.D.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

CBASP: How to treat chronic depression

by Michael D. Anestis, M.S.

For a beginning therapist, it is not at all uncommon to walk into the therapy room with the fear that you will not remember what you are supposed to do - that you will forget the manual entirely, make things up as you go along, and fail to help your client's symptoms improve.  This rarely actually happens, mind you, but like any negative automatic thought, its validity is not proportionate to its power.  In my first days of training, I was fortunate in this respect, as my initial supervision taught me a therapeutic intervention known as Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000).  In this article, I will discuss the emerging evidence that CBASP, created by James McCullough of Virgina Commonwealth University, is an effective psychotherapeutic approach, particularly for chronic depression, but first I want to explain the steps involved in the process.
    CBASP is easily the most highly structured approach I have learned.  The entire intervention revolves around worksheets that are aimed to discuss the client's interpretations, behaviors, and desired outcomes in specific, quick interpersonal interactions.  Essentially, this is an exercise in situational analysis and the underlying assumption, quite simply, is that by increasing the frequency with which an individual attains what she wants in situations, mood will improve and depressive symptoms will fade.

Structure of CBASP - Step-by-Step Description

Step 1 - Select an interaction from the previous week.  The situation should be short, lasting minutes rather than hours.  Describe this situation in factual terms (no interpretations of meaning) in no more than three or four sentences.

• Clients often resist focusing on such a small slice of time.  After all, situations relate to one another and problematic patterns have emerged in their lives.  The importance of doing so, however, is to help the client change specific thoughts and behaviors.  Not everything can be changed at once, but developing a pattern of recognizing specific ways to change can lead to general change across situations.
• Clients also often struggle to speak only in factual terms.  Saying "he treated me poorly" does not work here.  Instead, the client should say "I gave cashier a $20 bill and he only gave me change for $10."  The second example still involves poor treatment, but it provides detailed facts the client and therapist can work with later on in the worksheet.

Step 2 - What was your interpretation of the situation?

• Here, the client is instructed to write down three or four automatic thoughts that she experienced during the course of the specific situation.  It is important not to include thoughts prior to or after the situation.
• Examples of interpretations experienced during an interaction could be "she hates me," "I'm horrible at this, "why do I always fail?" or "he's a jerk."

Step 3 - What were your behaviors?

• Here again, the client is instructed to list several examples.  Behaviors include eye contact, tone of voice, delay in response, body language, and what was said during the course of the interaction.
• The client is encouraged to be thorough here.  For example, the phrase "I believe you" can mean different things if an individuals waits 10 seconds in silence before saying it, says it while rolling his eyes, or smiles while saying it.  The details will inform later steps in the worksheet.

Step 4 - Desired outcome - What did you want to happen in this situation?

• This may be the most difficult step in CBASP.  Desired outcomes are limited to things that the client can actually control.  In other words, the desired outcome can not be something that is physically impossible.  Even more importantly, the desired outcome can not be something that the client wanted somebody else to think, do, or feel. 
• It is perfectly natural to desire other people to feel or do things, but CBASP teaches the principle that, even if a situation is navigated perfectly, other individuals may respond poorly.  As such, a desired outcome could be "I wanted to do everything in my power to increase the chance that he would agree with me," but it can not be "I wanted him to agree with me."
• This is often frustrating for the client.  At times, he may even believe that he is being blamed for all that goes wrong.  This is not the case, however.  Instead, the client is being taught to simply focus on things over which he has control so that things outside of his control no longer make him feel as though he has done something wrong.

Step 5 - Actual outcome - What actually happened?

• Here, the client briefly explains what actually happened and declares whether or not this was consistent with her desired outcome.

Step 6 - Remediation

• During the remediation phase of CBASP, the client and therapist review each interpretation and behavior listed on the worksheet and determine whether it was helpful or hurtful with respect to increasing the likelihood that the client would obtain her desired outcome in that situation.
• For interpretations and behaviors that were helpful towards obtaining the desired outcome, time is spent discussing why it was helpful, what led the client to choose an adaptive behavior, and what the client might do to increase the likelihood that she will use this same approach in future situations.
• For interpretations and behaviors that were hurtful towards obtaining the desired outcome, helpful alternative approaches are designed.  This is a particularly useful exercise, as hurtful patterns are quickly recognized and the client thus practices changing bad habits that have become obstacles in his attempts to attain desired outcomes.

Some clients become skilled at this approach quite quickly while, for others, it takes more time.  Regardless of the speed of skill acquisition, CBASP involves a significant amount of homework.  Clients are given numerous worksheets and told to fill them out as often as possible, immediately following the situations they choose.  The closer to the actual occurrence the better.  This is true for two reasons: the situation is remembered more accurately and the benefits of alternative approaches are reinforced because the worksheet often creates an increase in positive affect and/or a decrease in negative affect when filled out close enough to the event that the client is still upset.  During sessions, the client and therapist will go over one or more of the worksheets completed throughout the week, discussing any difficulties the client encountered, training further in particular skills, and reinforcing the efforts of the client.

Empirical evidence for the utility of CBASP

A variety of studies have examined the utility of CBASP as a therapeutic intervention.  The most heavily cited study of CBASP, conducted by Keller and colleagues (2000), was a clinical trial comparing CBASP, nefazodone (an antidepressant medication), and combination treatment (CBASP and nefazodone) in the treatment of chronic depression.  519 participants completed the study - a 12-week acute intervention - with significant effects for all three conditions.  55% of individuals in the nefazodone condition exhibited significant reduction in depressive symptoms as measured by the Hamilton Depression Scale (HAM-D; Hamilton, 1967) compared to 52% of individuals in the CBASP condition.  Importantly, 85% of individuals who received a combination of nefazodone and CBASP exhibited significant reduction of depressive symptoms.  What is most stunning about these impressive findings is that the participants had been chronically depressed, a course that is often resistant to treatment.
    Building off of the Keller et al (2000) findings, Schatzberg and colleagues (2005) found that, for individuals who do not respond to nefazodone, switching to CBASP results in significant clinical improvement.  Similarly, for individuals who do not respond to CBASP, switching to nefazodone results in significant clinical improvement.  Klein et al (2004) found that CBASP is an effective maintenance treatment.  In this study, participants took part in 16-20 sessions during the course of a 12-week treatment period and six sessions during a 16-week continuation period.  Participants in the maintenance condition then received an additional 13 sessions during a 52-week maintenance period.  Results indicated that participants in the maintenance condition experienced a greater average reduction in depressive symptoms and were less likely to relapse.
    Cukrowicz and Joiner (2007) created a computer protocol based upon CBASP and tested its utility in a sample of undergraduates.  They compared the effects of the CBASP computer protocol to the effects of simply providing education on the nature of depression and anxiety and found that, while both education alone and education with CBASP significantly reduced depressive and anxiety symptoms, the computer CBASP condition experienced greater levels of improvement.  Importantly, only individuals with sub-clinical levels of depression and anxiety were included in the study, so further research is needed to determine the potential utility of a computer-based CBASP intervention in clinical populations, but these results are highly promising.   
    Interestingly, in light of Friday's article on therapeutic alliance, Santiago and colleagues (2005) found that therapeutic alliance and the ability to use the skills taught in CBASP both independently contributed to decreases in depressive symptoms.  Arnow and colleague (2007) compared individuals in CBASP alone, nefazodone alone, and combination treatment on dropout rate and found that individuals in the combined treatment were significantly less likely to drop out of treatment than were individuals in the medication only group and did not differ in their dropout rate compared to individuals in the CBASP only group.  For individuals receiving only CBASP, a poor therapeutic alliance predicted premature dropout (and early response to treatment did not). 
    Additional theoretical work has been done on CBASP as well.  Sperry (2005) provided a case example of CBASP in individual and couples counseling as a method to improve communication on medical issues.  Additionally, Sperry (2007) provided a case example of the utility of CBASP in managing spiritual issues that can arise during the course of therapy (e.g., "God hates me").  Future empirical testing of these ideas is necessary before conclusions can be drawn regarding the utility of CBASP in these particular domains, but this early work provides an interesting foundation.

Conclusions

    CBASP, which is essentially a highly structured, interpersonally focused version of cognitive behavioral therapy (CBT), appears to be an effective intervention for depression, particularly for individuals who have experienced chronic symptoms.  The treatment teaches clients to see each interaction as separate, thus diminishing the tendency to ruminate about the ways in which each imperfection relates to other imperfections in life.  Additionally, the treatment emphasizes desired outcomes that lie within the control of the client and the development of helpful alternatives to interpretations and behaviors that decrease the likelihood of clients attaining such desired outcomes.
    As a therapist, I admire CBASP for its structure and its ability to efficiently convey important ideas.  As a researcher, I admire the emerging empirical evidence that CBASP is not only effective, but demonstrates its effects in a population that is often treatment resistant.

If you would like to learn more about CBASP, a variety of resources are available.  We recommend the following:

Hard Copy Books:

Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach To Psychotherapy
Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
Patient's Manual for CBASP
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)

Kindle:
Treating Chronic Depression with Disciplined Personal Involvement: Cognitive Behavioral Analysis System of Psychotherapy (CBASP)

Additional resources are available through our online store.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University