Treatment Comparison of Cbt and Ssri in Depression

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Procedures

Ethics approval will be attained from the relevant institutional ‘Human Ethics Review Committee’ and informed content obtained from participants. After referral from doctor, participants will be advised of the study’s purpose and their UMDD severity levels independently confirmed using HRSD17. Eligible participants will be randomly allocated using a computerised random generator providing a randomised double-blind sample for maintenance program with CBT+placebo (n=50) or CBT+SSRI (Fluoxetine 20mg) (n=50). A stratified treatment allocation will be used according to three levels of severity of depression (Blackburn, Bishop, Glen, Whalley, & Christie, 1981), using HRSD17: mild (8-16), moderate (17-23) and severe (≥24) to ensure treatment groups are the same for depression severity.

CBT will be administered by a psychiatrist across both treatment conditions similar to Stangier et al. (2013), with one, 60min session very 4 weeks for 52 weeks, totalling 13 sessions (Klein et al., 2004). Fluoxetine (20mg) will be taken once daily, by CBT+SSRI condition, and monitored for side effects, other condition will be administered a sugar pill of same appearance. Participants will be assessed using HRSD17 every second CBT session by psychiatrist, to monitor for depressive episodes requiring acute treatment.

Results

Raw data will be analysed using SPSS (v.22). Scores from each item of HRSD are totalled to acquire a total measure of depression for each participant. The group mean is obtained for each treatment group. The combined CBT+SSRI groups total score is expected to be lower on the HRDS17 than the CBT+placebo group after a one year maintenance program.

Discussion

This study will aim to test the impact of treatment type on severity of depression symptoms in UMDD. It is hypothesised that the CBT+SSRI treatment group will have greater occurrence of remission compare to the CBT+placebo treatment group.

This study will show increased occurrence of remission and reduced severity of depression symptoms in combined treatment condition of CBT+SSRI, concluding that the combined therapy has greater efficacy than mono-psychotherapy. Because previous studies have found combined treatment to be more effective than mono-psychotherapy (Craighead & Dunlop, 2014; Frank et al., 1990) with a reduction from 50% to 27% at 12 months following a combined maintenance treatment program (Jarrett et al., 1998). This is likely resulting from there being a greater percentage of patients in the combined treatment condition who will respond to treatment compared to the mono-psychotherapy condition (Craighead & Dunlop, 2014). As some patients respond solely to ADM, others only to psychotherapy with some to either and others to neither (Schatzberg et al., 2005). Thus accumulating patients that respond to the individual monotherapies and those that respond to either, this results in superior incidences of remission in the combined treatment group (Craighead & Dunlop, 2014). Additionally combined psychotherapy and pharmacotherapy produces quicker results than psychotherapy alone (Craighead & Dunlop, 2014) which typically takes longer to have an effect on depression symptoms.

A lack of remission in the CBT+SSRI treatment group may be related to the low dose of the SSRI drug fluoxetine. In the current study only 20mg of fluoxetine was administered, however previous research has found that some patients require an increased dose of 40mg to achieve remission (M. Fava et al., 2002; Perlis et al., 2002; Targum, 2014). Thus, the non-significant result may be due to under-dosing in this study.

The proposed study has some limitations. There is an absence of a control condition and an ADM-only condition, thus limiting the results to UMDD patients being treated with combined CBT+SSRI. Also the individual specific benefit is unable to be attributed to the ADM, CBT or the combination. Additionally this study was only 12-months duration. This may not have been long enough to see increases in major depressive episodes or a true representation of successful remission. Future research should include comparison with AMD alone to investigate each monotherapies efficacy and examine participants over a greater duration, 18-24 months, to ensure longer time period between episodes is covered. Nevertheless these results may provide evidence that UMDD patients would benefit more using a combined CBT+SSRI maintenance treatment program, when remission is the objective. New UMDD patients should be fully informed on treatment options and there benefits and constraints.

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References

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Blackburn, I. M., Bishop, S., Glen, A., Whalley, L., & Christie, J. (1981). The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. The British Journal of Psychiatry, 139(3), 181-189. doi:10.1192/bjp.139.3.181

Craighead, W. E., & Dunlop, B. W. (2014). Combination psychotherapy and antidepressant medication treatment for depression: for whom, when, and how. Annual review of psychology, 65, 267-300. Retrieved from doi:10.1146/annurev.psych.121208.131653

Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry, 13(1), 56-67. Retrieved from doi:10.1002/wps.20089

Fava, G. A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., & Grandi, S. (2014). Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. American Journal of Psychiatry. doi:10.1176/ajp.161.10.1872

Fava, M., Schmidt, M. E., Zhang, S., Gonzales, J., Raute, N. J., & Judge, R. (2002). Treatment approaches to major depressive disorder relapse. Psychotherapy and psychosomatics, 71(4), 195-199. doi:10.1159/000063644

Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J., . . . Whiteford, H. A. (2013). Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Medicine, 10(11), e1001547. Retrieved from doi:10.1371/journal.pmed.1001547

Frank, E., Kupfer, D. J., Perel, J. M., Cornes, C., Jarrett, D. B., Mallinger,

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