Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review

Zakhour, Stephanie; Nardi, Antonio E.; Levitan, Michelle; Appolinario, Jose Carlos

doi:10.1590/2237-6089-2019-0033

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Trends in Psychiatry and Psychotherapy

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Sumário

Review Article • Trends Psychiatry Psychother. 42 (1) • Jan-Mar 2020 • https://doi.org/10.1590/2237-6089-2019-0033 copy

Cognitive-behavioral therapy for treatment-resistant depression in adults and adolescents: a systematic review

Terapia cognitivo-comportamental para depressão resistente ao tratamento em adultos e adolescentes: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To conduct a systematic review of literature on use and efficacy of cognitive-behavioral therapy (CBT) for treatment of treatment-resistant depression in adults and adolescents.

Methods

We performed a systematic review according to the Prisma Guidelines of literature indexed on the PubMed, SciELO, Psychiatry Online, Scopus, PsycArticles, Science Direct and the Journal of Medical Case Reports databases. Randomized controlled trials, open studies and case reports were included in the review.

Results

The searches returned a total of 1,580 articles, published from 1985 to 2017. After applying the inclusion criteria, 17 articles were selected, their complete texts were read and 8 were included in this review. Four of these studies were randomized controlled trials with adults, one of which covered a post-study follow-up period; two were randomized controlled trials with adolescents, one of which presented follow-up data; one was an open study; and one was a case report. The studies provide good quality and robust evidence on the topic addressed.

Conclusions

A combination of CBT with pharmacotherapy for treatment-resistant patients shows a decrease in depressive symptoms. CBT can be an effective type of therapy for adults and adolescents with treatment-resistant depression.

Cognitive-behavioral therapy; major depressive disorder; treatment-resistant depressive disorder

First author	Year of publication	Study design	Intervention	Frequency and duration of intervention	Session length	Duration of follow-up	Instruments	Main findings
Brent³	2008	RCT	TAU, CBT	12 weeks	TAU: 30-60 minutes CBT: 60-90 minutes	6 and 12 weeks	CDRS-R, BDI, SIQ-Jr, CGI-I, CGAS	CBT plus a switch to either medication regimen showed a higher response rate (54.8%) than a medication switch alone (40.5%) and there was no difference in response rate between venlafaxine and a second SSRI.
Nakagawa⁶	2017	RCT	TAU, Individual CBT	16 sessions + 4 additional sessions	50 minutes	12 months	GRID-HDRS, QIDS-SR, HPQ	Patients with TRD may benefit from supplementing TAU with CBT.
Wiles¹⁰	2013	RCT	TAU, Individual CBT	12 sessions + 6 additional sessions	50-60 minutes	12 months	BDI, ICD-10	CBT + TAU was effective for reducing depressive symptoms and improving quality of life in patients with TRD.
Wiles¹¹	2016	Follow-Up RCT	TAU, Individual CBT	12 sessions + 6 additional sessions	50-60 minutes	3-5 years	BDI, SF-12, PHQ-9, GAD-7, EQ-5D-5L	The CBT intervention reduced depressive symptoms and improved quality of life over an average of 46 months.
Lopez¹²	2014	RCT	TAU, Individual CBT	18 sessions	NM	IAI	BDI, QIDS	Participants showed a more rapid reduction in depressive symptoms over time and more CBT participants reached full symptom remission.
Emslie¹³	2010	RCT	TAU, CBT	12 weeks	TAU: 30-60 minutes CBT: 60-90 minutes	24 weeks	CDRS-R, BDI, CGAS, CGIS, BHS, SIQ-Jr, CBQ-A, DUS-U, DUS-I	Of the 334 adolescents, only 261 participants (78.1%) were included in the 24-week assessment and 20% did not complete the assessment. The results showed that only 38.9% of 334 adolescents on the TORDIA trial achieved remission by 24 weeks.
Miller¹⁴	1985	Open trial	TAU, CBT, SST	28 sessions over a period averaging 22 weeks	NM	IAI	BDI, HDRS	4 of the 6 patients exhibited complete improvement on measures of depression symptomatology.
Bannan¹⁵	2005	Case report	Venlafaxine, CBT	12 sessions (CBT) 375 mg daily (venlafaxine)	NM	IAI	BDI, BHI, BAI	Clear improvements on assessments of mood and hopelessness and in social and occupational functioning.

	Brent³	Nakagawa⁷	Wiles¹²	Lopez¹³
Description of subjects
1. Diagnostic method and inclusion/exclusion criteria	2	2	2	1
2. Documentation/demonstration of reliability of diagnostic methodology	1	1	2	0
3. Description of relevant comorbidities	2	2	2	1
4. Description of numbers of subjects screened, included, and excluded	2	2	2	2
Definition and delivery of treatment
5. Treatment(s) (including control/comparison groups) are sufficiently described or referenced to allow for replication	2	2	2	2
6. The treatment being studied is treatment delivered	2	2	2	2
7. Therapist training and level of experience in the treatment(s) under investigation	2	2	2	2
8. Therapist supervision while treatment is being provided	2	1	2	2
9. Description of concurrent treatments allowed and administered	2	1	1	0
Outcome measures
10. Validated outcome measure(s)	2	2	2	2
11. Primary outcome measure(s) specified in advance	2	2	2	0
12. Outcome assessment by raters blinded to treatment group and with established reliability	2	0	0	0
13. Discussion of safety and adverse events during study treatment(s)	2	0	0	0
14. Assessment of long-term post-termination outcome	1	1	1	1
Data analysis
15. Intent-to-treat method for data analysis, primary outcome	2	2	2	0
16. Description of dropouts and withdrawals	2	2	2	1
17. Appropriate statistical tests	2	2	2	1
18. Adequate sample size	2	2	1	1
19. Appropriate consideration of therapist and site effects	2	1	1	1
Treatment assignment
20. A priori relevant hypotheses that justify comparison group(s)	2	1	2	1
21. Comparison group(s) from same population and time frame as experimental group	2	2	2	2
22. Randomized assignment to treatment groups	2	2	2	2
Overall quality of study
23. Balance of allegiance to types of treatment by practitioners	2	1	1	1
24. Conclusions justified by sample, measures, and data analysis	2	2	2	2
25. Omnibus rating	7	5	6	5

	Wiles¹⁴	Emslie¹⁶
Description of subjects
1. Diagnostic method and inclusion/exclusion criteria	2	2
2. Documentation/demonstration of reliability of diagnostic methodology	2	1
3. Description of relevant comorbidities	2	2
4. Description of numbers of subjects screened, included, and excluded	2	2
Definition and delivery of treatment
5. Treatment(s) (including control/comparison groups) are sufficiently described or referenced to allow for replication	2	2
6. The treatment being studied is treatment delivered	2	2
7. Therapist training and level of experience in the treatment(s) under investigation	2	2
8. Therapist supervision while treatment is being provided	2	2
9. Description of concurrent treatments allowed and administered	1	2
Outcome measures
10. Validated outcome measure(s)	2	1
11. Primary outcome measure(s) specified in advance	2	2
12. Outcome assessment by raters blinded to treatment group and with established reliability	0	1
13. Discussion of safety and adverse events during study treatment(s)	0	2
14. Assessment of long-term post-termination outcome	1	1
Data analysis
15. Intent-to-treat method for data analysis, primary outcome	2	2
16. Description of dropouts and withdrawals	2	2
17. Appropriate statistical tests	1	1
18. Adequate sample size	1	2
19. Appropriate consideration of therapist and site effects	1	2
Treatment assignment
20. A priori relevant hypotheses that justify comparison group(s)	2	2
21. Comparison group(s) from same population and time frame as experimental group	2	2
22. Randomized assignment to treatment groups	2	2
Overall quality of study
23. Balance of allegiance to types of treatment by practitioners	1	2
24. Conclusions justified by sample, measures, and data analysis	2	2
25. Omnibus rating	6	7

Associação de Psiquiatria do Rio Grande do Sul Av. Ipiranga, 5311/202, 90610-001 Porto Alegre RS/ Brasil, Tel./Fax: (55 51) 3024 4846 - Porto Alegre - RS - Brazil
E-mail: trends@aprs.org.br

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[1] Correspondence: Stephanie Zakhour. Ambulatório de Depressão Resistente ao Tratamento (DeReTrat) Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ) Av. Vencelaus Brás, 71, Campus da Praia Vermelha 22290-140 - Rio de Janeiro, RJ - Brazil Tel.: + 55 (21) 964426645 E-mail: stephaniezakhour@hotmail.com