Effectiveness Of Supplementary Cognitive-Behavioral Therapy (CBT) Vs. Pharmacotherapy For Managing Depression

Various Therapies for Managing Depression

Depression refers to a mental ill-health experienced by an individual, that brings a persistent feeling of worthlessness and despair, making that individual to lose joy from his/her daily life. It is one of the serious disorder that interrupts the normal activities of a person, causes pain and ultimately leads to suicide in many cases. Though being one of the most severe cases, depression is a highly curable disorder. It all depends on how early it is diagnosed and treated. According to the World Health Organization, untreated depression causes of over 700,000 suicides across the world every year (Hofmann, and Otto, 2017). The earlier that treatment is started, the more successful it is in preventing the recurrence of depressive disorder. The previous researches on psychoanalysis for depressive disorder have come up with a number of therapies for managing the problem of depression, such as Cognitive Behavioral Therapy, Psychodynamic Therapy, and pharmacotherapy. In this context, this research study aims to examine the effectiveness of Supplementary Cognitive-Behavioral Therapy (CBT) over Pharmacotherapy for managing Depression in patients.

In the recent years, Cognitive Behavioral Therapy (CBT) has become an effective treatment for the patients whose depression has failed to respond towards anti-depressants. CBT works by making clients to learn a series of behavioral and cognitive skills that they can apply on their own. However, the long-term results of using CBT are not known yet. In a constant follow-up process of the CoBalt Trial, the cost-effectiveness and clinical behavioral therapy  has been investigated as an addition to the patients’ normal care routine (Seki et al., 2016). It involved medication for 4-6 years in primary care clients suffering with treatment-resistant depression.

An adequate amount of evidences have  also been found regarding the use of combined treatment for dealing with the issues of major depression, obsessive-compulsive disorder, and panic disorder. The outcomes of the combined treatment were observed twofold as large as those of pharmacotherapy, thus emphasizing upon the experimental advantage of combined treatment. In addition to this, in many circumstances from mild to severe depression, CBT has also been applied successfully as standalone treatment. A range of meta-analysis have been carried out in the past, about the combination of pharmacotherapy and psychotherapy for the patients, and have come up with an benefit over the use of either treatment alone (Park et al., 2017). This benefit was specifically evident mainly in those patients suffering from chronic or extreme recurrent depression, and hospitalized patients.  

Effectiveness of CBT for Treating Treatment-Resistant Depression

From the past clinical researches in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) , it has been found that pharmacotherapy was better than cognitive behavior therapy (CBT) in the severe diagnosis of depressed clients. However, this verdict was neither consistent throughout the sites within the TDCRP nor robust with the findings of other researches. Moreover, many scholars have argued that those other researches were innately inconsistent due to exclusion of pill-placebo controls. Although this had been established that the inclusion of such controls would have enabled flawless interpretation of findings, it was not established that their non-inclusion made those researches uninterruptable. Since many years, CBT has been a feasible alternative to pharmacotherapy for treating the issue of depression in an effective manner, and a successful intervention for the treatment of this serious disorder.

In addition to this, the previous studies have also suggested that the impact of  pharmacotherapy are not interrelated at all, with both of them largely contributing to the results of combined treatment (Trauer et al., 2015). Thus, it has been identified that a combined treatment can be more successful than treatment with CBT or pharmacotherapy alone, in the situations of major depression, OCD, and panic disorder.

The aim of this research paper is to determine the Effectiveness of Supplementary Cognitive-Behavioral Therapy (CBT) over Pharmacotherapy for managing Depressive Diorder.

Design

The researcher has employed various strategies for identifying the appropriate literatures. Four key bibliographical databases are also used by the researcher, that are  PsycInfo, PubMed, Cochrane, and Embase database of randomized trials. For the purpose, the researcher has designed a search string for psychotherapy with text signifying the several types of CBT and psychotherapy treatments. However, in this study, the research was restricted to randomized controlled trials only. Also, the researcher has verified the references of 8 previous meta analysis of treatments of depressive disorder. Randomized trials have been also included wherein the outcomes of treatment with CBT therapy are compared with the outcomes of pharmacotherapy, and a mix of both the therapies in individuals suffering with panic and depressive order (Huguet et al., 2016). Only those literatures in which the research topic has met the diagnostic norms for the disorder as per the diagnostic interview are included in this research, such as the Composite International Diagnostic Interview (CIDI), Mini-International Neuropsychiatric Interview (MINI), and Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). However, the studies on teenagers, children, and inpatients are not included in this study.

Population of interest

Benefits of Combined Therapy

In this research, 15 depressed patients have participated in the Cognitive Behavior Therapy,15 patients in pharmacotherapy, and other 10 patients participated in the combined treatment.  Three studies were aimed at major depression issue, and one was aimed at patients having both OCD, and major depression. In addition to this, two studies were aimed at anxiety disorder (one on panic disorder with or without agoraphobia (Cristea et al., 2015). More than half of studies recruited patients from experimental samples, aiming at adults rather than focusing on a more specific population like older people. However, many of the psychotherapies were from the group of CBT, and some were focused on pharmacotherapy, while a were focused on examining other therapies such as psychodynamic therapies. The number of treatment programs were ranged from 3 to 10, with most therapies between 2 to10 sessions.

Sample and sampling approach

The effective sample size was estimated for each comparison between the cognitive behavioural therapy, and pharmacotherapy, along with the combined treatment group. This sample effect size was determined by subtracting the average score of the CBT group from that of the pharmacotherapy group and combined treatment group, thus separating the effect using joint standard deviation. Since some studies had quite small sample size, the researcher rectified the effect size to remove small sample prejudices (Fernandez et al., 2015). It has also been found that the difference between CBT and pharmacotherapy was high particularly in clinical samples in comparison to community recruited samples. Although this difference was only a bit large (p<0.1), it indicated that patients actively taking treatment are likely to benefit more from combined treatment than those who seek for CBT or pharmacotherapy treatment .

Intervention (if applicable)

In this research, CBT intervention has been applied. Cognitive behavioral therapy belongs to the family of interventions that are among the most common and frequently used, and empirically supported treatments for depressive disorder. Also, there exist many diverse specific interventions that differ in their constituent components, with CBT being one of the widely applied practice. However, all such interventions are directly associated with each other. CBT intervention has been used on the belief that maladaptive information system plays a connecting part in the management of depressive disorder (Cuijpers et al., 2016). This ‘cognitive model’ speculates that when maladaptive process is corrected, both severe suffering and the risk for subsequent indicator return are minimized significantly.  In this paper, the researcher has emphasized upon the effectiveness of CBT alone in the treatment of serious stage depression and the avoidance of subsequent symptom return especially in adult populations, with a main focus on the control and intercession of response.

Methodology

Data collection approach

For the purpose of this research, qualitative methods have been used by the researcher because this method is helpful in drawing out the outlooks of prior studied literatures. Qualitative methods enable the people to represent the facts in their own voice without taking confirmation from others or complying with the terms imposed by them. By analyzing the perspectives of participants, the qualitative methods would helped the researcher in increasing the reliability and accuracy of the data being gathered. This method has allowed the researcher to honestly compare his/her own opinion of reality with the results of those which are being reviewed (Fernandez et al., 2015). Also, the qualitative method have proved to be more appropriate during the beginning of the research as the researcher became able to gain a good understanding of the issues for acquiring sample data.  It has involved an investigation of the experiences of health professionals who had met immigrant patients in their services on regular basis. It has also helped the researcher to have a look into the areas where difficulties might occur and how to deal with these while serving mental health services. Moreover, this data collection method has allowed the researcher to discover the wraparound services for patients above 18 years of age suffering serious depressive disorder.

Finally, qualitative methods have been used in this research study for an effective assessment of process,  to explain how an intervention or a clinical program runs. Such methods have provided a useful insight as to why a particular therapy standalone  cannot work to arrive at the intended outcomes or benefits.

Data management and analyses

In this study, data management and analysis was carried out by 2 external reviewers who used an explicit work sheet chosen before the literature search. For the purpose, a consensus conference was conducted with a third investigator to resolve inconsistencies between the 2 reviewers. Data analysis was held from full-text versions of the RCTs, where available. In addition to this, a quality-control practice was also undertaken for the data management by the third researcher for validating all the collected data against the original sources (Milgrom et al., 2015).  Furthermore, the data involving crucial characteristics and effect measures, including the study identity, study design, country,  number of research participants, gender, mean or median age, intervention characteristics, and other relevant outcomes were managed electronically for all literatures.

While designing a clinical therapy treatment study, a number of potential ethical concerns would be taken into account by the researcher. An effective balance would be made between the general ethical and scientific rigor principles, particularly in the areas of use of control group or wait list group, Randomization to treatment, reimbursement for patient involvement, methods of recruiting patients, registering vulnerable individuals like adolescents, children, and other people who can weaken the decision as a result of disorder. In this context, the researcher would take extra care that the rights and dignity of the participants are not hurt during the entire study.

Data Management and Analysis

In addition to this, an informed consent of the people would be obtained by the researcher in the language that is properly understood by those people, before conducting the study or providing any therapy or counseling services to them either personally or other kind of communication. However, the consent of individuals would not be required in case the research activity is compulsory by any government regulation or statue, or as otherwise mentioned in the Ethics Code. Moreover, the researcher would take the reasonable steps in order to prevent the research participants from any potential harm, and to reduce the level of risk where it can be unavoidable but foreseeable.

Furthermore, the researcher would cooperate with other professionals as well when appropriate and indicated, for the purpose of serving the clients in an effective way. In this regard the clinical professionals would stop using the therapy if it becomes clear that the clients no longer require the therapy, or is being negatively affected by the treatment, or is not likely to get any benefit. Also, the researcher would not come into several relationships could reasonably be predictable to
weaken the researchers’ impartiality, capability, or effectiveness in carrying out his or her activities as a psychologist, or otherwise risks exploitation to the individual with whom the professional association is built.

Research Activity	Month	1	2	3	4	5	6	7	8	9	10	11	12
Proposal development
Proposal submission
HREC
Governance
Site preparation
Participant recruitment
Data collection
Data management / analyses
Report writing
Report for HREC / governance

Explanatory notes on timeline

The above research timeline shows that the development of research proposal took about one month. The proposal submission took another one month as the review and approval of the proposal from the applicable health authority was time consuming. It took around two months to construct the site where the research activities were carried out. Next, the research participants were recruited and their consent was taken ethically (Milgrom et al., 2015). This took another one month for the researcher. Since the data collection method was qualitative, it took one month to search out and evaluate the previous studies and literatures on effective therapy for dealing with depression. Data management and analysis took one month as it was performed by the third party. Finally, the report writing took one month as it included useful but detailed information relevant for the stakeholders.  

Budget Item	Cost ($)
Personnel
Research Analyst                                                       2	100
Research Manager                                                     1	100
Market Researcher                                                     2	100
Data Manager and Analyst                                        2	150
Equipment
Retrospective records (medical data)                          1	50
Laboratory test                                      1	90
Clinical examinations                                                  1	100
Consumables
Masks                                                                          4	40
PET                                                                             2	40
medical gloves                                                            4	30
TOTAL                                                                       20	800

Budget justification

The above research required submission of a budget justification with all the items mentioned in the above table. The research personnel were needed to use the equipments and tools. Retrospective records were required to assess the relationships between biomedical, therapy, and demographic variables, and outcomes measures in patients. Laboratory tests were used for enabling the research professionals to take effective decision making (Ashworth et al., 2015). Clinical examination was done to obtain clinical information. Similarly, the consumables like gloves, and masks were used during the study by the research professionals to prevent or avoid any infection during the processes from patients through nose, mouth and hands.

From the above health research on determining the effectiveness of CBT for reducing depressive disorder, I have learnt that CBT in general are as successful as psychotherapy in major depression, and this decision holds true for both mild and extreme forms of MDD. On the contrary, pharmacotherapy produces better results in case of dysthymia. However, I have also reflected that the combination of CBT and pharmacotherapy is somewhat more efficacious than psychotherapy.  A significant drop of patients has been observed from psychotherapy due to the side effects. However,  some degree of prevention needs to be adopted by the psychiatrist  in treating depressive disorder.

References

Ashworth, D.K., Sletten, T.L., Junge, M., Simpson, K., Clarke, D., Cunnington, D. and Rajaratnam, S.M. (2015) A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression, Journal of counseling psychology, 62(2), p.115. 

Cristea, I.A., Huibers, M.J., David, D., Hollon, S.D., Andersson, G. and Cuijpers, P. (2015) The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: A meta-analysis, Clinical Psychology Review, 42, pp.62-71. 

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M. and Huibers, M.J. (2016) How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta?analytic update of the evidence, World Psychiatry, 15(3), pp.245-258. 

Fernandez, E., Salem, D., Swift, J.K. and Ramtahal, N. (2015) Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators, Journal of Consulting and Clinical Psychology, 83(6), p.1108. 

Hofmann, S.G. and Otto, M.W. (2017) Cognitive Behavioral Therapy for Social Anxiety Disorder: Evidence-Based and Disorder Specific Treatment Techniques. UK: Routledge. 

Huguet, A., Rao, S., McGrath, P.J., Wozney, L., Wheaton, M., Conrod, J. and Rozario, S. (2016) A systematic review of cognitive behavioral therapy and behavioral activation apps for depression, PLoS One, 11(5), p.e0154248.