Divergent outcomes in cognitive-behavioral therapy and pharmacotherapy for adult depression
Open accessAbstract
OBJECTIVE: Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. METHOD: Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. RESULTS: About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels. CONCLUSIONS: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
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Those earlier studies also back the conclusions that deterioration is uncommon and that psychotherapy lowers its frequency.
“However, these studies also support the findings that deterioration rates are low and that psychological treatment reduces these rates.”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Vittengl et al., 2016
This study's results agree with an increasing body of meta-analytic evidence that psychological treatments significantly reduce deterioration in patients.
“The results of this study are in line with a growing number of metaanalytic studies showing that psychological treatments result in a significant reduction of deterioration in patients.”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Vittengl et al., 2016
Earlier meta-analytic studies on deterioration were limited to small samples.
“Earlier studies were limited to small samples (Vittengl et al., 2016)”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Vittengl et al., 2016
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- Authors
- Vittengl, J. R., Jarrett, R. B., Weitz, E., Hollon, S. D., Twisk, J., Cristea, I., David, D., DeRubeis, R. J., Dimidjian, S., Dunlop, B. W., Faramarzi, M., Hegerl, U., Kennedy, S. H., Kheirkhah, F., Mergl, R., Miranda, J., Mohr, D. C., Rush, A. J., Segal, Z. V., Siddique, J., Simons, A. D., & Cuijpers, P.
- Affiliations
- Truman State University (US)
- ORCID
- Vittengl, Jeffrey R.
- Jarrett, Robin B.
- Weitz, Erica
- Hollon, Steven D.
- Twisk, Jos
- Cristea, Ioana
- David, Daniel
- DeRubeis, Robert J.
- Dimidjian, Sona
- Dunlop, Boadie W.
- Faramarzi, Mahbobeh
- Hegerl, Ulrich
- Kennedy, Sidney H.
- Kheirkhah, Farzan
- Mergl, Roland
- Miranda, Jeanne
- Mohr, David C.
- Rush, A. John
- Segal, Zindel V.
- Siddique, Juned
- Cuijpers, Pim
- Venue
- American Journal of Psychiatry
- Published
- 2016-05-01
- Volume
- 173
- Issue
- 5
- Pages
- 481-490
- ISSN
- 0002-953X (ISSN-L)
- 1535-7228
- PMC
- PMC4934129
- OpenAlex
- W2252762384
- Cited by
- 97
- References
- 42
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 4 · 2023: 4 · 2022: 7 · 2021: 47 · 2020: 6 · 2019: 9 · 2018: 5 · 2017: 4 · 2016: 4
- FWCI
- 1.09
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Padua Research Archive (University of Padova) (submittedVersion)
- Funders
- Bristol-Myers Squibb
- Eli Lilly and Company
- Pfizer
- AstraZeneca
- GlaxoSmithKline
- Vanderbilt University
- University of Pennsylvania
- Emory University
- Northwestern University
- University of Texas Southwestern Medical Center
- University of Notre Dame
- Pennsylvania State University
- Fondation Brain Canada
- Montana State University
- Truman State University
- Universität Trier
- European Commission
- National University of Singapore
- ZonMw
- Vrije Universiteit Amsterdam
- Fonds NutsOhra
- University of Toronto
- Babol University of Medical Sciences
- Servier
- H. Lundbeck A/S
- National Institutes of Health
- St. Jude Medical
- University of California, Los Angeles
- School of Medicine, Emory University
- Feinberg School of Medicine
- Canadian Institutes of Health Research
- National Institute of Mental Health (P20MH090318, R01MH100482, R01MH060713, R34MH095907, R01MH095753, R01MH060998, K02MH001697, MH 01697)
- National Institute on Drug Abuse
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Keywords
- cognitive behavioral therapy, pharmacotherapy, adult depression, major depressive disorder, treatment outcome variability, treatment response, treatment deterioration, attrition, predictors of treatment outcome, moderators of treatment outcome
- MeSH terms
- Adult, Antidepressive Agents, Major Depressive Disorder, Depressive Disorder, Female, Humans, Male, Psychiatric Status Rating Scales, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome, Young Adult
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