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Summary of “J. Mccullough, Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP) (New York: Guilford Press, 2000)”

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When one introduces a new psychotherapy model to professional colleagues, one must do 3 things: (a) define the patient for whom the program has been developed; (b) describe how the model addresses the problems of the patient, which entails some description of the techniques; and (c) present any efficacy data that are available that justify the usefulness of the new program with the target population.

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Many readers, particularly those who have more of a psychoanalytic orientation, will be surprised to learn that in CBASP the therapist is encouraged to become personally involved with the patient in a disciplined way to modify the patient's behaviour. Much of the book is concerned with technique. Situational analysis is a key component and is intended to exacerbate psychopathology in the therapy session, with a view to increasing the probability of behavioural change. A Coping Survey Questionnaire (p. 107) is part of this technique as well. Included in the book's appendices are various other assessment forms (e.g., Therapist Prompts for Administering Situational Analysis; this form might also be useful for recording systematic observations and information in other therapies.) There are also rating scales for adherence, for evaluating the quality of the interpersonal relationship and for rating therapists. This book will likely be essential for anyone wanting to practise CBASP. The aims of the therapy include guiding patients to improve their cognitive and emotional function to mitigate and improve the consequences of their behaviours; learning new skills and coping mechanisms is part of this process

Much of this is shared with other systems of brief psychotherapy. Reports of effectiveness in clinical trials cannot be equated with establishing the theoretical concepts of the therapy or substantiating the origins of the disorder and its psychopathology. Chronic depression in its various forms is a common and disabling disorder, with a high rate of relapse and relatively poor response to treatment. A number of studies suggest that a combination of antidepressant medication with brief (10–20 sessions) psychotherapy, is superior to either psychotherapy or medication alone, yet the availability of therapists adequately trained in the techniques of brief psychotherapy is quite limited. If this book increases that number, patients will have been well served.

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When patients do not respond adequately to antidepressant medications, clinicians generally adopt one of 3 strategies: switching medication, augmentation with adjunctive medication, or adding psychotherapy

There is a growing literature on the first two strategies, including work specific to chronic depression. Few data address the third option, even though it may be among the most common. Although most studies have failed to demonstrate decisive advantages for combined medication and psychotherapy over monotherapy in acute major depressive disorder (MDD) or dysthymic disorder, one large study found combination treatment significantly more efficacious than either medication or psychotherapy alone in chronic depression. Combination treatment is more expensive, at least acutely, than medication alone. Therefore, the most fiscally conservative strategy may be a stepwise approach: initially treat chronic depression with antidepressant medication, and add adjunctive psychotherapy for patients who have a poor or partial response. Recent data suggest that this may be a useful alternative to further courses of pharmacotherapy for MDD. The value of combining both strategies (ie, changing pharmacotherapy and adding psychotherapy) has not been studied. We therefore formulated the present study believing that augmentation with psychotherapy might play an important role in treating chronically depressed patients because chronic depression is less likely to respond to medication than is acute MDD, suggesting a greater need for adjunctive treatment strategies, and because patients with chronic depression exhibit greater psychosocial and interpersonal deficits than do patients with acute MDD, problems that psychotherapy may address (Thase ME, Rush AJ., 1995). Because a previous study by our group found that the cognitive behavioral analysis system of psychotherapy (CBASP)had a significant additive effect on chronic depression when combined with the antidepressant nefazodone hydrochloride and appeared to be an effective switch option when nefazodone alone was ineffective,we chose this psychotherapy for the present trial (Miller IW, Keitner GI, 1998).

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To summarize, the number of studies examining the effects of psychotherapy on chronically depressed patients is very small, while chronic depression affects a large group of patients in secondary care and this subgroup is notable for poorer subjective well being and impaired social and occupational functioning compared to non-chronically depressed patients. Research into the effectiveness of CBASP can make an important contribution to the improvement of care for chronically depressed patients. According to the results of Keller et al., 73% of these patients can be effectively treated if CBASP is combined with antidepressant medication

CBASP can also be an alternative for patients who are not motivated for or refractory to pharmacological treatment. Furthermore, CBASP could also be effective as a maintenance treatment.

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Miller IW, Keitner GI, Schatzberg AF, Klein DN, Thase ME, Rush AJ, Markowitz JC, Schlager DS, Kornstein SG, Davis SM, Harrison WM, Keller MB. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry. 1998

Judd LL, Akiskal HS, Paulus MP. The role and clinical significance of subsyndromal depressive symptoms (SSD) in unipolar major depressive disorder. J Affect Disord. 1997;45(1–2):5–18.

Paykel ES, Ramana R, Cooper Z, Hayhurst H, Kerr J, Barocka A. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25(6):1171–1180.

Cornwall PL, Scott J. Partial remission in depressive disorders. Acta Psychiatr Scand. 1997;95(4):265–271.

Thase ME, Rush AJ. Treatment-resistant depression. In: Bloom FE, Kupfer DJ, editors. Psychopharmacology: The Fourth Generation of Progress. New York, NY: Raven Press; 1995. pp. 1081–1097

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