Tuesday, 30 April 2013

Cognitive Behavioural Therapy as an Adjunct to Pharmacotherapy for Primary Care Based Patients with Treatment Resistant Depression

Lancet, Early Online Publication, December 7, 2012 doi:10.1016/S0140-6736(12)61552-9

Also available online in the Lancet is the result of the CoBaLt trial which was a trial of cognitive behaviour therapy in people who had failed to respond to antidepressants in primary care in England. Failure to respond to antidepressants is the norm with only a third of people responding fully to antidepressants. The authors recruited 469 patients into the trial with 235 randomized to usual care and 234 to cognitive behaviour therapy plus usual care. To get into the trial participants had to have been on antidepressants for longer than six weeks, have a BDI score greater than 13, be aged 18-75 and meet ICD 10 criteria for depression.

Most people in the trial had received treatment for depression for over a year. One year after starting the trial 95 participants in the intervention group (46%) met criteria for response versus 46 (22%) in the usual care group. This means that about four people need to be treated with CBT for 12 to 18 sessions to get one extra person better after one year compared to usual care. One of the most noticeable aspects of this trial is that it demonstrated the acceptability of psychological treatments with 99% of patients invited for baseline assessment agreeing to participate. This is in contrast to the flawed STAR*D trial where only a quarter of participants were willing to be randomised to CBT.

The context for this trial is the introduction of IAPT in England where IAPT stands for “improving access to psychological therapies” which is a £ 500 million project to train providers in cognitive behaviour therapy for depression and anxiety. This is an attempt to address the difficulty that clinicians always encounter when recommending CBT in that there is limited access to CBT therapists.
One obvious way to alleviate this is to massively increase the number of CBT therapists which is what they are doing in England. However criticisms of IAPT are that:
  • it treats people who previously would not have had treatment and who would have got better without any intervention (just the passage of time);

  • IAPT workers do not manage risk so anyone who is remotely suicidal gets booted up the system paradoxically increasing waiting times in mental health service;

  • the system is protocol driven with little flexibility; and

  • there is no system for the introduction of new therapies (that is therapies other than CBT).
Another way to manage the lack of CBT resources is to provide computerised therapies with mental health coaches to help people progress through them. We are planning on trying the second approach in Ottawa but a few more therapists would not go amiss – one approach would be to use consumer peers who get brief training in CBT but close supervision from fully trained therapists.

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