Copyright 1991 by the American Psychological Association, Inc. 0022-006X/9I/S3.00
Journal of Consullmg and Clinical Psychology 1991, Vol 59. No 1,88-99
Cognitive Therapy and Pharmacotherapy for Depression Steven D. Hollon Vanderbilt University
Richard C. Shelton and Peter T. Loosen
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Department of Psychiatry, Vanderbilt University
Cognitive therapy (CT) for depression has generated considerable interest in recent years. Comparisons with tricyclic pharmacotherapy in nonbipolar outpatients have suggested that (a) CT may be roughly comparable in the treatment of the acute episode; (b) combined OT-pharmacotherapy does not appear to be clearly superior to either modality (although indications of potential enhancement do exist to justify additional studies with larger samples), and {c) treatment with CT during the acute episode (either alone or with medications) may reduce the risk of subsequent relapse following termination. Nonetheless, for a variety of reasons (e.g., limitations in study design and execution, inadequate design power, and possible differential retention), these conclusions can be considered only suggestive at this time. More than a decade after the publication of the first controlled study involving CT, the approach remains a promising, but not adequately tested, alternative to pharmacotherapy in the treatment of depression.
Cognitive therapy has emerged as one of the most promising innovations for the treatment of depression. Predicated on the notion that at least some forms of depression are the consequence of erroneous beliefs and maladaptive information processing (Beck, 1963,1967.1976), cognitive therapy seeks to produce symptomatic relief by encouraging clients to systematically evaluate the accuracy and nature of their thinking (Beck, 1964,1970; Beck, Rush, Shaw, & Emery, 1979). The various pharmacological and somatic interventions have long been established as the standard of treatment for clinical depression (Klein & Davis, 1969; Morris* Beck, 1974). At the same time, it has been only in the last decade that any evidence has been generated suggesting that psychosocial interventions may be effective in this disorder (Hollon & Beck, 1978). Up through the mid-1970s, the typical finding from a series of controlled psychotherapy-pharmacotherapy comparisons was that psychotherapy was no more effective than pill-placebo and less effective than active medications in the treatment of depressive symptoms (Covi, Lipman, Derogatis, Smith, & Pattison, 1974; Friedman, 1975; Klerman, DiMascio, Weissman, Prusoff, & Paykel, 1974). In the late 1970s, Rush, Beck, Kovacs, and Hollon (1977) published a comparison of cognitive therapy to tricyclic pharmacotherapy in a bona fide clinical population. In that trial, cognitive therapy appeared to outperform imipramine tricyclic pharmacotherapy in the treatment of depressed outpatients. In the years since that initial report, a number of controlled trials have appeared contrasting the two single modalities. In the bulk of these trials, cognitive therapy has fared well, appearing
Preparation of this article was supported by a grant from the Vanderbilt University Research Council to Steven D. Hollon. Correspondence concerning this article should be addressed to Steven D. Hollon, Department of Psychology, Vanderbilt University, Nashville, Tennessee 37240.
to at least match the tricyclic pharmacotherapies in terms of overall efficacy and, perhaps, providing greater protection against the return of symptoms following treatment termination (Hollon & Beck, 1986). Nevertheless, questions can be raised regarding the nature of the samples studied and the adequacy with which pharmacotherapy has been operationalized (Klein, 1989; Meterissian & Bradwejn, 1989). Given that the majority of these trials have not included nonspecific treatment controls (e.g., pill-placebos), it is often not possible to address these concerns in a fully satisfactory fashion. In the review to follow, we examine the following questions: (a) Is cognitive therapy sufficiently effective to warrant consideration as an alternative to tricyclic pharmacotherapy? (b) Does combining cognitive therapy with tricyclic pharmacotherapy provide any advantage over pharmacotherapy alone? and (c) Does cognitive therapy prevent subsequent relapse/recurrence following treatment termination?
Cognitive Therapy Versus Pharmacotherapy In a recent quantitative analysis, Dobson (1989) reviewed eight studies comparing cognitive therapy versus tricyclic pharmacotherapy in the treatment of depressed outpatients and found evidence suggestive of greater efficacy for the former. The average patient treated with cognitive therapy in those trials did better than 70% of the drug-treated patients, with a mean differential effect size (calculated by Cohen's [1977] rfstatistic) of-0.53, ranging from 0.42 to -1.74 (more negative values indicate superiority for cognitive therapy). Although Dobson's conclusion that cognitive therapy is at least comparable, if not superior, to tricyclic pharmacotherapy was appropriately tempered by a recognition of the small number of studies and generally limited sample sizes, it was consistent with similar conclusions drawn in both earlier quantitative (Miller & Herman, 1983) and qualitative reviews, including those of Steven D.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SPECIAL SECTION: COGNITIVE THERAPY/PHARMACOTHERAPY
Hollon (Hollon, 1981; Hollon & Beck, 1986; Hollon & Najavits, 1988). Nonetheless, we think that it may still be premature to draw any strong conclusions on the basis of the existing empirical literature. In particular, we have come to share Klein's (1989) view that the tendency to not include pill-placebo controls (maintained in a double-blind fashion) in this literature has made it difficult to determine whether pharmacotherapy as operationalized was indeed effective for the samples actually studied. The absence of differences between cognitive therapy and pharmacotherapy takes on a different meaning in the context of an observed difference between the latter and a pill-placebo control. In the presence of such a difference, it is clear that the sample as a whole was indeed pharmacologically responsive and that pharmacotherapy was adequately implemented. In its absence, neither can be assumed. Because the logic behind the selection of the tricyclic pharmacotherapies as a reference condition rests on the general perception that they are indeed effective, the failure to establish that efficacy in the particular sample studied renders any subsequent comparison between the two "active" interventions less readily interpretablc. There are two sources of concern. First, not all depressed patients are equally responsive to pharmacotherapy. Klein (1989), for example, has argued that "it is no great trick to select a sample of moderately ill outpatients for whom medication is no better or even worse than placebo, despite nominal diagnosis" (p. 264). Symptom severity and endogenicity are two variables that appear to predict differential response to pharmacotherapy relative to pill-placebo (Bielski & Friedel, 1976; Joyce & Paykel, 1989). If, for example, trials contrasting cognitive therapy with pharmacotherapy have systematically undersampled such patients, then the entire literature might well have underestimated the efficacy of pharmacotherapy on the average. This is not to say that all patients studied must (or will) be pharmacologically responsive, but the inclusion of a pill-placebo control provides an independent basis for the specification of precisely such differential responsivity. Saying that cognitive therapy does not differ from pharmacotherapy among patients who are pharmacologically nonresponsive is quite a different matter from saying it does not differ among those who are. Thus, the failure to include pill-placebo controls has limited the certainty with which results from the respective trials can be generalized. The second source of concern has to do with the adequacy with which pharmacotherapy has been operationalized in the respective studies. Meterissian and Bradwejn (1989) have argued that optimal pharmacotherapy should meet at least five conditions: (a) doses need to exceed some minimum (e.g., at least 250-300 mg/day for imipramine or its equivalent for other medications); (b) patients should be kept at maximum dosage for at least 4-6 weeks; (c) serum medication levels should be monitored to ensure compliance and absorption, with levels in excess of 200 ng/ml required for imipramine and between 50 and 150 ng/ml required for nortriptyline, the only two antidepressant medications for which effective plasma levels have been established; (d) pharmacotherapists should be adequately trained and experienced with that modality; and (e) patients not responding to an adequate trial of medication (as defined above) should either be switched to a different medication (pref-
89
erably one like a monoamine oxidase [MAO1] inhibitor that operates through some mechanism other than blocking reuptake) or have their existing medication potentiated by the addition of a second medication (e.g., lithium, tryptophan, or thyroid hormone). Although this last recommendation is somewhat controversial (it is not clear, for example, whether nonresponders to cognitive therapy should be allowed to switch to some other form of psychotherapy), on the whole these criteria appear to be quite reasonable. In their review of the psychotherapy-pharmacotherapy literature for depression, the authors found not a single study that met all five criteria and few that met more than two. The clear implication is that pharmacotherapy has not been adequately implemented in the bulk of these trials. Table 1 presents the randomized controlled trials comparing cognitive therapy with tricyclic pharmacotherapy, either alone or together, in the treatment of clinical depression. Tabled information includes the nature of the sample, the conditions contrasted, various parameters relevant to an evaluation of the adequacy of the respective modalities (for cognitive therapy, we consider the frequency of sessions, duration of treatment, expertise of the therapists, frequency of supervision, and whether the adequacy of execution was explicitly monitored to be among the relevant indices), and indices of treatment outcome. These latter include, when available, pretreatment, posttreatment, and percentage change scores on both the Beck Depression Inventory (BDI: Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the most frequently used self-report measure, and the Hamilton Rating Scale for Depression (HRD; Hamilton, 1960), the most frequently used clinician rating. Percentage change scores (the change in scores from pretreatment to posttreatment expressed as a proportion of pretreatment scores) are presented rather than Cohen's d, inasmuch as the former provide an estimate of the difference between the modalities independent of sample size. Included are five of the eight studies reviewed by Dobson (1989), along with two additional trials not available at the time of that review (Covi & Lipman, 1987; Miller, Norman, Keitner, Bishop, & Dow, 1989; the former involving a community sample screened for diagnosable depression and the latter involving an inpatient sample), and all five of the studies involving cognitive therapy reviewed by Meterissian and Bradwejn (1989). Three additional studies reviewed by Dobson are not included in this table because we consider them to be unrepresentative of either cognitive therapy or tricyclic pharmacotherapy, but they are discussed in some detail in the text to follow. As previously noted, the original Rush et a). (1977) trial was the first study to suggest that a psychosocial intervention might be at least comparable to tricyclic pharmacotherapy in the treatment of depression. In that study, a sample of nonpsychotic, nonbipolar depressed outpatients was found to evidence greater change and less attrition to 12 weeks of cognitive therapy than to a comparable period of imipramine pharmacotherapy. Although this initial report generated considerable interest, it was flawed in several respects. The study was conducted at the center at which cognitive therapy was developed, assessments were not conducted blind to treatment condition, and no plasma monitoring was conducted to evaluate the adequacy
S. HOLLON, R. SHELTON, AND P. LOOSEN
90
3 c
w
1 E
ro
o
«^
tl fc:
ishop, lley, 1981
$ X
II £$,
= 1 SEE -1 Sot-OooH^o cubzuuusu
•3.E a lackburn, Glen, W & Christ
iical Psychology, 47, 818-836.
SPECIAL SECTION: COGNITIVE THERAPY/PHARMACOTHERAPY in depression: Was adequate pharmacotherapy provided? Journal of Clinical Psychopharmacology, 9, 334-339. Miller, I. W, Norman, W H.. Keitner, G. I., Bishop, S. B., & Dow. M. G. (1989). Cognitive-behavioral treatment of depressed inpatients. Behavior Therapy, 20, 25-47.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Miller. R. C, & Berman. J. S. (1983). The efficacy nf cognitive behavior therapies: A quantitative reviewofthe research evidence. Psychological Bulletin, 94. 39-53. Morris, J. B., & Beck, A. T. (1974). The efficacy of antidepressant drugs: A review of research (1958-1972). Archives of lieneral Psychiatry, 30, 667-674. Murphy, G. E., Simons, A. D., Wetzel, R. D., & Lustman. P. J. (1984). Cognitive therapy and pharmacotherapy, singly and together in the treatment of depression. Archives of General Psychiatry, 41, 33-41. Parloff, M. B. (1986). Placebo controls in psychotherapy research: A sine qua non or a placebo for research problems? Journal of Consulting and Clinical Psychology, 54, 79-87. Prien, R. F.,&Caffty, E. M.(I977). Long-term maintenance drug therapy in recurrent affective illness: Current status and issues. Disease.1; of ihe Nervous System. 164. 981-992. Prien, R. E, & Kupfer, D. J. (1986). Continuation drug therapy for major depressive episodes: How long should it be maintained? American Journal of Psychiatry, 143, 18-23. Reynolds, W M., & Coats, K.. 1. (1986). A comparison of cognitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology, 54, 653-660. Rush, A. J., Beck, A. T, Kovacs, M., & Hollon, S. D. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17-37. Seligman, M. E. P., Abramson, L. Y., Semmel, A., & von Baeyer, C. (1979). Depressive attributional style. Journal of Abnormal Psychology, 88. 242-247. Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology. 45. 543-551. Shaw, B. F., & Dobson, K. S. (1988). Competency judgments in the training and evaluation of psychotherapists. Journal of Consulting and Clinical Psychology, 56. 666-672.
99
Simons, A. D.. Murphy, G. E., Levinc, J. E., & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry, 43. 4349. Steuer, J. L., Mintz, J., Hammen, C. L., Hill, M. A., Jarvik, L. F., McCarley, T, Motoike, P, & Rosen, R. (1984). Cognitive-behavioral and psychodynamic group psychotherapy in treatment of geriatric depression. Journal of Consulting and Clinical Psychology, 52, 180189. Taylor, F. G., & Marshall, W L. (1977). Experimental analysis of a cognitive-behavioral therapy for depression. Cognitive Therapy and Research. 1. 59-72. Teasdale, J. D., Fennell, M. J. V, Hibbert, G. A., & Amies, P. L. (1984). Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry, 144, 400-406. Thompson, L. W, Gallagher, D., & Breckenridge, J.S. (1987). Comparative effectiveness of psychotherapies for depressed elders. Journal of Consulting and Clinical Psychology. 55. 385-390. Vallis, T. M., Shaw, B. F., & Dobson, K. S. (1986). The cognitive therapy scale: Psychometric properties. Journal of Consulting and Clinical Psychology. 54. 381-385. Weissman, A. N., & Beck, A. T. (1978, November). Development and validation of the dysfunctional attitude scale: A preliminary investigation. Paper presented at the annual meeting of the American Educational Research Association, Toronto, Ontario, Canada. Wierzbicki, M., & Bartlett, T. S. (1987). The efficacy of group and individual cognitive therapy for mild depression. Cognitive Therapy and Research, 11, 337-342. Wilson, P. H.,Goldin,J.C.,&Charbonneau-Powis, M. (1983). Comparative efficacy of behavioral and cognitive treatments of depression. Cognitive Therapy and Research, 7, 111 -124. Young, J. E., & Beck, A. T. (1980). Development of an instrument for rating cognitive therapy The Cognitive Therapy Scale. Unpublished manuscript. University of Pennsylvania, Philadelphia. Zis, A. P., & Goodwin, F. K.(1979). Major affective disorder as a recurrent illness: A critical review. Archives of General Psychiatry. 36,835839.
Received February 26,1990 Revision received June 17,1990 Accepted June 27,1990 •
Journal of Consullmg and Clinical Psychology 1991, Vol 59. No 1,88-99
Cognitive Therapy and Pharmacotherapy for Depression Steven D. Hollon Vanderbilt University
Richard C. Shelton and Peter T. Loosen
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Department of Psychiatry, Vanderbilt University
Cognitive therapy (CT) for depression has generated considerable interest in recent years. Comparisons with tricyclic pharmacotherapy in nonbipolar outpatients have suggested that (a) CT may be roughly comparable in the treatment of the acute episode; (b) combined OT-pharmacotherapy does not appear to be clearly superior to either modality (although indications of potential enhancement do exist to justify additional studies with larger samples), and {c) treatment with CT during the acute episode (either alone or with medications) may reduce the risk of subsequent relapse following termination. Nonetheless, for a variety of reasons (e.g., limitations in study design and execution, inadequate design power, and possible differential retention), these conclusions can be considered only suggestive at this time. More than a decade after the publication of the first controlled study involving CT, the approach remains a promising, but not adequately tested, alternative to pharmacotherapy in the treatment of depression.
Cognitive therapy has emerged as one of the most promising innovations for the treatment of depression. Predicated on the notion that at least some forms of depression are the consequence of erroneous beliefs and maladaptive information processing (Beck, 1963,1967.1976), cognitive therapy seeks to produce symptomatic relief by encouraging clients to systematically evaluate the accuracy and nature of their thinking (Beck, 1964,1970; Beck, Rush, Shaw, & Emery, 1979). The various pharmacological and somatic interventions have long been established as the standard of treatment for clinical depression (Klein & Davis, 1969; Morris* Beck, 1974). At the same time, it has been only in the last decade that any evidence has been generated suggesting that psychosocial interventions may be effective in this disorder (Hollon & Beck, 1978). Up through the mid-1970s, the typical finding from a series of controlled psychotherapy-pharmacotherapy comparisons was that psychotherapy was no more effective than pill-placebo and less effective than active medications in the treatment of depressive symptoms (Covi, Lipman, Derogatis, Smith, & Pattison, 1974; Friedman, 1975; Klerman, DiMascio, Weissman, Prusoff, & Paykel, 1974). In the late 1970s, Rush, Beck, Kovacs, and Hollon (1977) published a comparison of cognitive therapy to tricyclic pharmacotherapy in a bona fide clinical population. In that trial, cognitive therapy appeared to outperform imipramine tricyclic pharmacotherapy in the treatment of depressed outpatients. In the years since that initial report, a number of controlled trials have appeared contrasting the two single modalities. In the bulk of these trials, cognitive therapy has fared well, appearing
Preparation of this article was supported by a grant from the Vanderbilt University Research Council to Steven D. Hollon. Correspondence concerning this article should be addressed to Steven D. Hollon, Department of Psychology, Vanderbilt University, Nashville, Tennessee 37240.
to at least match the tricyclic pharmacotherapies in terms of overall efficacy and, perhaps, providing greater protection against the return of symptoms following treatment termination (Hollon & Beck, 1986). Nevertheless, questions can be raised regarding the nature of the samples studied and the adequacy with which pharmacotherapy has been operationalized (Klein, 1989; Meterissian & Bradwejn, 1989). Given that the majority of these trials have not included nonspecific treatment controls (e.g., pill-placebos), it is often not possible to address these concerns in a fully satisfactory fashion. In the review to follow, we examine the following questions: (a) Is cognitive therapy sufficiently effective to warrant consideration as an alternative to tricyclic pharmacotherapy? (b) Does combining cognitive therapy with tricyclic pharmacotherapy provide any advantage over pharmacotherapy alone? and (c) Does cognitive therapy prevent subsequent relapse/recurrence following treatment termination?
Cognitive Therapy Versus Pharmacotherapy In a recent quantitative analysis, Dobson (1989) reviewed eight studies comparing cognitive therapy versus tricyclic pharmacotherapy in the treatment of depressed outpatients and found evidence suggestive of greater efficacy for the former. The average patient treated with cognitive therapy in those trials did better than 70% of the drug-treated patients, with a mean differential effect size (calculated by Cohen's [1977] rfstatistic) of-0.53, ranging from 0.42 to -1.74 (more negative values indicate superiority for cognitive therapy). Although Dobson's conclusion that cognitive therapy is at least comparable, if not superior, to tricyclic pharmacotherapy was appropriately tempered by a recognition of the small number of studies and generally limited sample sizes, it was consistent with similar conclusions drawn in both earlier quantitative (Miller & Herman, 1983) and qualitative reviews, including those of Steven D.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SPECIAL SECTION: COGNITIVE THERAPY/PHARMACOTHERAPY
Hollon (Hollon, 1981; Hollon & Beck, 1986; Hollon & Najavits, 1988). Nonetheless, we think that it may still be premature to draw any strong conclusions on the basis of the existing empirical literature. In particular, we have come to share Klein's (1989) view that the tendency to not include pill-placebo controls (maintained in a double-blind fashion) in this literature has made it difficult to determine whether pharmacotherapy as operationalized was indeed effective for the samples actually studied. The absence of differences between cognitive therapy and pharmacotherapy takes on a different meaning in the context of an observed difference between the latter and a pill-placebo control. In the presence of such a difference, it is clear that the sample as a whole was indeed pharmacologically responsive and that pharmacotherapy was adequately implemented. In its absence, neither can be assumed. Because the logic behind the selection of the tricyclic pharmacotherapies as a reference condition rests on the general perception that they are indeed effective, the failure to establish that efficacy in the particular sample studied renders any subsequent comparison between the two "active" interventions less readily interpretablc. There are two sources of concern. First, not all depressed patients are equally responsive to pharmacotherapy. Klein (1989), for example, has argued that "it is no great trick to select a sample of moderately ill outpatients for whom medication is no better or even worse than placebo, despite nominal diagnosis" (p. 264). Symptom severity and endogenicity are two variables that appear to predict differential response to pharmacotherapy relative to pill-placebo (Bielski & Friedel, 1976; Joyce & Paykel, 1989). If, for example, trials contrasting cognitive therapy with pharmacotherapy have systematically undersampled such patients, then the entire literature might well have underestimated the efficacy of pharmacotherapy on the average. This is not to say that all patients studied must (or will) be pharmacologically responsive, but the inclusion of a pill-placebo control provides an independent basis for the specification of precisely such differential responsivity. Saying that cognitive therapy does not differ from pharmacotherapy among patients who are pharmacologically nonresponsive is quite a different matter from saying it does not differ among those who are. Thus, the failure to include pill-placebo controls has limited the certainty with which results from the respective trials can be generalized. The second source of concern has to do with the adequacy with which pharmacotherapy has been operationalized in the respective studies. Meterissian and Bradwejn (1989) have argued that optimal pharmacotherapy should meet at least five conditions: (a) doses need to exceed some minimum (e.g., at least 250-300 mg/day for imipramine or its equivalent for other medications); (b) patients should be kept at maximum dosage for at least 4-6 weeks; (c) serum medication levels should be monitored to ensure compliance and absorption, with levels in excess of 200 ng/ml required for imipramine and between 50 and 150 ng/ml required for nortriptyline, the only two antidepressant medications for which effective plasma levels have been established; (d) pharmacotherapists should be adequately trained and experienced with that modality; and (e) patients not responding to an adequate trial of medication (as defined above) should either be switched to a different medication (pref-
89
erably one like a monoamine oxidase [MAO1] inhibitor that operates through some mechanism other than blocking reuptake) or have their existing medication potentiated by the addition of a second medication (e.g., lithium, tryptophan, or thyroid hormone). Although this last recommendation is somewhat controversial (it is not clear, for example, whether nonresponders to cognitive therapy should be allowed to switch to some other form of psychotherapy), on the whole these criteria appear to be quite reasonable. In their review of the psychotherapy-pharmacotherapy literature for depression, the authors found not a single study that met all five criteria and few that met more than two. The clear implication is that pharmacotherapy has not been adequately implemented in the bulk of these trials. Table 1 presents the randomized controlled trials comparing cognitive therapy with tricyclic pharmacotherapy, either alone or together, in the treatment of clinical depression. Tabled information includes the nature of the sample, the conditions contrasted, various parameters relevant to an evaluation of the adequacy of the respective modalities (for cognitive therapy, we consider the frequency of sessions, duration of treatment, expertise of the therapists, frequency of supervision, and whether the adequacy of execution was explicitly monitored to be among the relevant indices), and indices of treatment outcome. These latter include, when available, pretreatment, posttreatment, and percentage change scores on both the Beck Depression Inventory (BDI: Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the most frequently used self-report measure, and the Hamilton Rating Scale for Depression (HRD; Hamilton, 1960), the most frequently used clinician rating. Percentage change scores (the change in scores from pretreatment to posttreatment expressed as a proportion of pretreatment scores) are presented rather than Cohen's d, inasmuch as the former provide an estimate of the difference between the modalities independent of sample size. Included are five of the eight studies reviewed by Dobson (1989), along with two additional trials not available at the time of that review (Covi & Lipman, 1987; Miller, Norman, Keitner, Bishop, & Dow, 1989; the former involving a community sample screened for diagnosable depression and the latter involving an inpatient sample), and all five of the studies involving cognitive therapy reviewed by Meterissian and Bradwejn (1989). Three additional studies reviewed by Dobson are not included in this table because we consider them to be unrepresentative of either cognitive therapy or tricyclic pharmacotherapy, but they are discussed in some detail in the text to follow. As previously noted, the original Rush et a). (1977) trial was the first study to suggest that a psychosocial intervention might be at least comparable to tricyclic pharmacotherapy in the treatment of depression. In that study, a sample of nonpsychotic, nonbipolar depressed outpatients was found to evidence greater change and less attrition to 12 weeks of cognitive therapy than to a comparable period of imipramine pharmacotherapy. Although this initial report generated considerable interest, it was flawed in several respects. The study was conducted at the center at which cognitive therapy was developed, assessments were not conducted blind to treatment condition, and no plasma monitoring was conducted to evaluate the adequacy
S. HOLLON, R. SHELTON, AND P. LOOSEN
90
3 c
w
1 E
ro
o
«^
tl fc:
ishop, lley, 1981
$ X
II £$,
= 1 SEE -1 Sot-OooH^o cubzuuusu
•3.E a lackburn, Glen, W & Christ
iical Psychology, 47, 818-836.
SPECIAL SECTION: COGNITIVE THERAPY/PHARMACOTHERAPY in depression: Was adequate pharmacotherapy provided? Journal of Clinical Psychopharmacology, 9, 334-339. Miller, I. W, Norman, W H.. Keitner, G. I., Bishop, S. B., & Dow. M. G. (1989). Cognitive-behavioral treatment of depressed inpatients. Behavior Therapy, 20, 25-47.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Miller. R. C, & Berman. J. S. (1983). The efficacy nf cognitive behavior therapies: A quantitative reviewofthe research evidence. Psychological Bulletin, 94. 39-53. Morris, J. B., & Beck, A. T. (1974). The efficacy of antidepressant drugs: A review of research (1958-1972). Archives of lieneral Psychiatry, 30, 667-674. Murphy, G. E., Simons, A. D., Wetzel, R. D., & Lustman. P. J. (1984). Cognitive therapy and pharmacotherapy, singly and together in the treatment of depression. Archives of General Psychiatry, 41, 33-41. Parloff, M. B. (1986). Placebo controls in psychotherapy research: A sine qua non or a placebo for research problems? Journal of Consulting and Clinical Psychology, 54, 79-87. Prien, R. F.,&Caffty, E. M.(I977). Long-term maintenance drug therapy in recurrent affective illness: Current status and issues. Disease.1; of ihe Nervous System. 164. 981-992. Prien, R. E, & Kupfer, D. J. (1986). Continuation drug therapy for major depressive episodes: How long should it be maintained? American Journal of Psychiatry, 143, 18-23. Reynolds, W M., & Coats, K.. 1. (1986). A comparison of cognitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology, 54, 653-660. Rush, A. J., Beck, A. T, Kovacs, M., & Hollon, S. D. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17-37. Seligman, M. E. P., Abramson, L. Y., Semmel, A., & von Baeyer, C. (1979). Depressive attributional style. Journal of Abnormal Psychology, 88. 242-247. Shaw, B. F. (1977). Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology. 45. 543-551. Shaw, B. F., & Dobson, K. S. (1988). Competency judgments in the training and evaluation of psychotherapists. Journal of Consulting and Clinical Psychology, 56. 666-672.
99
Simons, A. D.. Murphy, G. E., Levinc, J. E., & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry, 43. 4349. Steuer, J. L., Mintz, J., Hammen, C. L., Hill, M. A., Jarvik, L. F., McCarley, T, Motoike, P, & Rosen, R. (1984). Cognitive-behavioral and psychodynamic group psychotherapy in treatment of geriatric depression. Journal of Consulting and Clinical Psychology, 52, 180189. Taylor, F. G., & Marshall, W L. (1977). Experimental analysis of a cognitive-behavioral therapy for depression. Cognitive Therapy and Research. 1. 59-72. Teasdale, J. D., Fennell, M. J. V, Hibbert, G. A., & Amies, P. L. (1984). Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry, 144, 400-406. Thompson, L. W, Gallagher, D., & Breckenridge, J.S. (1987). Comparative effectiveness of psychotherapies for depressed elders. Journal of Consulting and Clinical Psychology. 55. 385-390. Vallis, T. M., Shaw, B. F., & Dobson, K. S. (1986). The cognitive therapy scale: Psychometric properties. Journal of Consulting and Clinical Psychology. 54. 381-385. Weissman, A. N., & Beck, A. T. (1978, November). Development and validation of the dysfunctional attitude scale: A preliminary investigation. Paper presented at the annual meeting of the American Educational Research Association, Toronto, Ontario, Canada. Wierzbicki, M., & Bartlett, T. S. (1987). The efficacy of group and individual cognitive therapy for mild depression. Cognitive Therapy and Research, 11, 337-342. Wilson, P. H.,Goldin,J.C.,&Charbonneau-Powis, M. (1983). Comparative efficacy of behavioral and cognitive treatments of depression. Cognitive Therapy and Research, 7, 111 -124. Young, J. E., & Beck, A. T. (1980). Development of an instrument for rating cognitive therapy The Cognitive Therapy Scale. Unpublished manuscript. University of Pennsylvania, Philadelphia. Zis, A. P., & Goodwin, F. K.(1979). Major affective disorder as a recurrent illness: A critical review. Archives of General Psychiatry. 36,835839.
Received February 26,1990 Revision received June 17,1990 Accepted June 27,1990 •
