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Cognitive Behavioral Analysis System of Psychotherapy and Brief Supportive Psychotherapy for Augmentation of Antidepressant Nonresponse in Chronic DepressionThe REVAMP Trial
James H. Kocsis, MD;
Alan J. Gelenberg, MD;
Barbara O. Rothbaum, PhD;
Daniel N. Klein, PhD;
Madhukar H. Trivedi, MD;
Rachel Manber, PhD;
Martin B. Keller, MD;
Andrew C. Leon, PhD;
Steven R. Wisniewski, PhD;
Bruce A. Arnow, PhD;
John C. Markowitz, MD;
Michael E. Thase, MD; for the REVAMP Investigators
Arch Gen Psychiatry. 2009;66(11):1178-1188.
Context Previous studies have found that few chronically depressed patients remit with antidepressant medications alone.
Objective To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial.
Design This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone.
Setting Eight academic sites.
Participants Chronically depressed patients with a current DSM-IV–defined major depressive episode and persistent depressive symptoms for more than 2 years.
Interventions Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs).
Main Outcome Measures Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores.
Results In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores.
Conclusions Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing.
Trial Registration clinicaltrials.gov Identifier: NCT00057551
Author Affiliations: Departments of Psychiatry, Weill Cornell Medical College, New York, New York (Drs Kocsis, Leon, and Markowitz); University of Wisconsin, and Healthcare Technology Systems, Inc, Madison, Wisconsin (Dr Gelenberg); Emory University School of Medicine, Atlanta, Georgia (Dr Rothbaum); The University of Texas Southwestern Medical Center, Dallas (Dr Trivedi); Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Wisniewski), and University of Pennsylvania School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (Dr Thase); Department of Psychology, Stony Brook University, Stony Brook, New York (Dr Klein); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Drs Manber and Arnow); and Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island (Dr Keller).
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