Evaluation Of Cbt For Depression

There have now been a number of meta-analytic reviews of the comparative effectiveness of CBT for depression that have clearly demonstrated its effectiveness (e.g., Dobson, 1989; Reinecke et al., 1998; Robinson et al., 1990). These studies show a reduction in symptom severity across treatment by about two-thirds in comparison to pre-treatment depression levels. The meta-analysis of Reinecke et al. (1998) is of interest in that they demonstrated the effectiveness of CBT for the treatment of adolescent depression with effect sizes compared to controls of 1.02 at immediate post-treatment, and continuing at 0.61 at short to medium length follow-up (see Chapter 5). Laidlaw (2001) (see Chapter 19) has summarised the work to date with CBT for depression in older adults, concluding that CBT is probably efficacious, but that more large-scale studies are needed. The American Psychological Association Task Force (see Crits-Cristoph, 1998, for a revised summary) concluded that both CBT and IPT are well-established treatments for adult depression.

However, the results from these studies have been overshadowed by the large-scale National Institute of Mental Health multisite study of CBT, IPT, imipramine, and placebo (Elkin et al., 1989). In this study, 250 patients with major depressive disorder were randomly assigned to one of four treatment types at one of three treatment centres. The immediate post-treatment results showed that, overall, there were no significant differences between any of the treatment types, the surprising comparison being that imipramine was no more effective than placebo. Only on a post hoc division of cases into moderate versus severe levels of depression did some effects emerge for the more severe group, with imipramine being clearly more effective than placebo, and there being some possible benefits for IPT in comparison to placebo. More recent analyses of follow-up over 18 months have again shown surprisingly few significant comparisons, though there was some evidence that CBT was slightly more effective than imipramine or placebo in relation to a range of measures of relapse, need for further treatment, and length of time symptom free (Shea et al., 1992). Perhaps one of the more interesting revelations from this large-scale study has been comment about site differences for the various therapies (e.g., Elkin, 1994); however, a more revealing analysis might be of therapist differences rather than leaving the differences attributed to sites, though, understandably, individual therapists may wish to avoid such direct scrutiny. Perhaps one of the most intriguing of the subsequent analyses of this large dataset has been the recent study by Ablon and Jones (2002). In their analyses of therapy process in transcripts of CBT and IPT sessions, they developed a rating system of the "ideal CBT prototype" and the "ideal IPT prototype". They found, however, that both CBT and IPT corresponded more closely to the CBT prototype rather than the IPT prototype. Moreover, the better the correspondence to the CBT prototype, the better the outcome for both types of therapy. Of course, this finding highlights many issues that have been long discussed about theory versus actual practice in therapy, with findings, such as those going back to Sloane et al. (1975), that expert therapists of different therapy types are more similar to each other than predicted when the content of their therapy sessions is analysed (see Holmes & Bateman, 2002, for a recent summary).

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