PsychologicalReporh, 1992, 70, 803-807.
O Psyd~olog~cal Reports 1992
PRESCRIBING THERAPY FOR DEPRESSION: T H E ROLE O F LEARNED RESOURCEFULNESS, A FAILURE TO REPLICATE ' RICHARD D. WETZEL, GEORGE E. MURPHY, ROBERT M. CARNEY, PAMELA WHITWORTH, MARY ANN KNESEVICH Washington Universib School of Medicine Summary.-Work in 1985 by Simons, Lustman, Wetzel, and Murphy showed that a patient's score on Rosenbaum's self-control scale predicted differential response to treatments for depression, with a high score predicting a good outcome with talking therapy and a low score a good outcome with drug therapy. This study of 37 patients did not replicate those findings. Using the same paradigm, we predicted response correctly 7 times and incorrectly 16 times, a clear failure. A valid method for choosing the best treatment for a patient with major depression remains to be found.
A test that would allow one to select the best treatment for a patient with a specific psychiatric disorder would be quite useful and result in great cost savings. Simons, Lustman, Wetzel, and Murphy (1985) reported on the use of the Self-control Scale (Rosenbaum, 1980) in a larger study involving 70 patients in 12 weeks of therapy (Murphy, Simons, Wetzel, & Lustman, 1984). Subjects were assigned to one of four treatments; cognitive behavior therapy alone (n = 19), tricyclic antidepressants alone (n = 16), both treatments combined (n = 17), or cognitive behavioral treatment and placebo (n = 18). The Self-control Scale was added to the evaluation battery after the first 14 patients had been entered into the study, so those 14 did not complete the scale prior to treatment. AU subjects assigned to either cognitive behavioral treatment or antidepressant medication took the Self-control Scale prior to treatment. Patients in all treatments improved significantly over time. No one treatment had a higher success rate than the others. To optimize comparisons, only patients receiving single treatments were compared. Simons, et al. used a median split ( 5 - 7 ) to classify self-control scores as high (>-7) or low. There was a significant interaction between scores on the Self-control Scale, treatment, and treatment response. Patients receiving cognitive behavioral treatment alone who had high scores on the Self-control Scale were very likely to respond well to treatment. Those who had low scores on the Self-control Scale did not do well. The opposite interaction was observed with patients receiving only a tricyclic antidepressant. Only those with hlgh Self-control Scale scores did badly; those with low Self-control Scale scores did quite well. Scores on the Self-control Scale were 'This study was sup orted by NIMH Grant No. MH32756. Address correspondence and reprint requests to ~ic!ard D. Wetzel, Ph.D., Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Avenue, St. Louis, Missouri 63110.
804
R. D. WETZEL. ETAL.
unrelated to outcome unless the treatment assignment was considered. I t seemed possible that the Self-control Scale might-be used to select the treatment of choice for depressed patients. The present account tests the reproducibility of those earlier findings in a second study. Murphy, Carney, Knesevich, Wetzel, and Whitworth (unpublished manuscript) evaluated relaxation therapy as an attention control for cognitive behavioral treatment and antidepressant therapy. The design of t h s study differed from the 1984 study in a number of respects. The length of therapy was increased from 12 weeks to 16 weeks. The minimum score of depression required to enter the 1992 study was lowered from a Beck depression score (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) of 20 to a score of 14 and from a depression scale score (Hamilton, 1969) of 16 to a score of 10. This requirement was lowered to increase comparability to standard clinical practice and hence to increase generali~abilit~. -
~
Subjects Thirty-seven subjects were randomly assigned to receive one of three treatments for a period up to 16 weeks (cognitive behavioral treatment = 11, relaxation training = 14, antidepressant medication = 12). The 11 randomly assigned to cognitive therapy included 10 w h t e and one black persons. Three were men and eight were women. Two were single, seven married, one separated and one divorced.Their average age was 38.8 12.0 yr. Mean education was 15.5 3.0 yr. The 12 assigned to antidepressant medication were all white. Seven were men and five were women. The mean age was 37.6 yr. ( * 11.5). They had completed 15.3 1.9 yr. of schooling. The two groups &d not differ significantly on any variables. The 11 patients assigned to cognitive behavioral treatment and the 12 assigned to antidepressant medication completed the Self-control Scale prior to the initiation of treatment.
*
*
Instruments The Self-control Scale is a 36-item scale which asks the patient to estimate the extent to which the patient attempts to manage reactions to problems, life events, and emotions. A lower score indicates less frequent attempts to manage oneself. Scores could range from -108 to + 108 (-3 to + 3 on 36 items). Outcome was assessed by the use of the Beck Depression Inventory (Beck, et al., 1961) and the Hamilton Depression Inventory. The Beck Depression Inventory is a 21-item scale, measuring self-reported severity of symptoms on a scale from 0 to 3. The total score can range from 0 to 63 (Beck, et al., 1961). Patients whose final Beck Depression score was below 10 were considered to be treatment successes, those 10 or above as failures.
PRESCRIBING THERAPY FOR DEPRESSION
805
Statistical Analysis All statistical analyses were performed with version 6.04 of the Statistical Analysis System for personal computers (SAS Institute, 1985).
RESULTS The reduction in the Beck Depression Inventory mean score and Hamilton Depression Scale mean score required to enter this study allowed a significant reduction in mean Beck Depression Inventory on evaluation from 29.30 6.02 in the 1984 study to 25.11 6.58 in the 1992 study ( ~ ~ 0 . 0 5 ) and on mean Hamilton depression rating from 19.9 4.0 in the 1984 study to 15.7 4.4 in the 1992 study (p
O Psyd~olog~cal Reports 1992
PRESCRIBING THERAPY FOR DEPRESSION: T H E ROLE O F LEARNED RESOURCEFULNESS, A FAILURE TO REPLICATE ' RICHARD D. WETZEL, GEORGE E. MURPHY, ROBERT M. CARNEY, PAMELA WHITWORTH, MARY ANN KNESEVICH Washington Universib School of Medicine Summary.-Work in 1985 by Simons, Lustman, Wetzel, and Murphy showed that a patient's score on Rosenbaum's self-control scale predicted differential response to treatments for depression, with a high score predicting a good outcome with talking therapy and a low score a good outcome with drug therapy. This study of 37 patients did not replicate those findings. Using the same paradigm, we predicted response correctly 7 times and incorrectly 16 times, a clear failure. A valid method for choosing the best treatment for a patient with major depression remains to be found.
A test that would allow one to select the best treatment for a patient with a specific psychiatric disorder would be quite useful and result in great cost savings. Simons, Lustman, Wetzel, and Murphy (1985) reported on the use of the Self-control Scale (Rosenbaum, 1980) in a larger study involving 70 patients in 12 weeks of therapy (Murphy, Simons, Wetzel, & Lustman, 1984). Subjects were assigned to one of four treatments; cognitive behavior therapy alone (n = 19), tricyclic antidepressants alone (n = 16), both treatments combined (n = 17), or cognitive behavioral treatment and placebo (n = 18). The Self-control Scale was added to the evaluation battery after the first 14 patients had been entered into the study, so those 14 did not complete the scale prior to treatment. AU subjects assigned to either cognitive behavioral treatment or antidepressant medication took the Self-control Scale prior to treatment. Patients in all treatments improved significantly over time. No one treatment had a higher success rate than the others. To optimize comparisons, only patients receiving single treatments were compared. Simons, et al. used a median split ( 5 - 7 ) to classify self-control scores as high (>-7) or low. There was a significant interaction between scores on the Self-control Scale, treatment, and treatment response. Patients receiving cognitive behavioral treatment alone who had high scores on the Self-control Scale were very likely to respond well to treatment. Those who had low scores on the Self-control Scale did not do well. The opposite interaction was observed with patients receiving only a tricyclic antidepressant. Only those with hlgh Self-control Scale scores did badly; those with low Self-control Scale scores did quite well. Scores on the Self-control Scale were 'This study was sup orted by NIMH Grant No. MH32756. Address correspondence and reprint requests to ~ic!ard D. Wetzel, Ph.D., Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Avenue, St. Louis, Missouri 63110.
804
R. D. WETZEL. ETAL.
unrelated to outcome unless the treatment assignment was considered. I t seemed possible that the Self-control Scale might-be used to select the treatment of choice for depressed patients. The present account tests the reproducibility of those earlier findings in a second study. Murphy, Carney, Knesevich, Wetzel, and Whitworth (unpublished manuscript) evaluated relaxation therapy as an attention control for cognitive behavioral treatment and antidepressant therapy. The design of t h s study differed from the 1984 study in a number of respects. The length of therapy was increased from 12 weeks to 16 weeks. The minimum score of depression required to enter the 1992 study was lowered from a Beck depression score (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) of 20 to a score of 14 and from a depression scale score (Hamilton, 1969) of 16 to a score of 10. This requirement was lowered to increase comparability to standard clinical practice and hence to increase generali~abilit~. -
~
Subjects Thirty-seven subjects were randomly assigned to receive one of three treatments for a period up to 16 weeks (cognitive behavioral treatment = 11, relaxation training = 14, antidepressant medication = 12). The 11 randomly assigned to cognitive therapy included 10 w h t e and one black persons. Three were men and eight were women. Two were single, seven married, one separated and one divorced.Their average age was 38.8 12.0 yr. Mean education was 15.5 3.0 yr. The 12 assigned to antidepressant medication were all white. Seven were men and five were women. The mean age was 37.6 yr. ( * 11.5). They had completed 15.3 1.9 yr. of schooling. The two groups &d not differ significantly on any variables. The 11 patients assigned to cognitive behavioral treatment and the 12 assigned to antidepressant medication completed the Self-control Scale prior to the initiation of treatment.
*
*
Instruments The Self-control Scale is a 36-item scale which asks the patient to estimate the extent to which the patient attempts to manage reactions to problems, life events, and emotions. A lower score indicates less frequent attempts to manage oneself. Scores could range from -108 to + 108 (-3 to + 3 on 36 items). Outcome was assessed by the use of the Beck Depression Inventory (Beck, et al., 1961) and the Hamilton Depression Inventory. The Beck Depression Inventory is a 21-item scale, measuring self-reported severity of symptoms on a scale from 0 to 3. The total score can range from 0 to 63 (Beck, et al., 1961). Patients whose final Beck Depression score was below 10 were considered to be treatment successes, those 10 or above as failures.
PRESCRIBING THERAPY FOR DEPRESSION
805
Statistical Analysis All statistical analyses were performed with version 6.04 of the Statistical Analysis System for personal computers (SAS Institute, 1985).
RESULTS The reduction in the Beck Depression Inventory mean score and Hamilton Depression Scale mean score required to enter this study allowed a significant reduction in mean Beck Depression Inventory on evaluation from 29.30 6.02 in the 1984 study to 25.11 6.58 in the 1992 study ( ~ ~ 0 . 0 5 ) and on mean Hamilton depression rating from 19.9 4.0 in the 1984 study to 15.7 4.4 in the 1992 study (p
