A modular add-on approach for patients with comorbid depression and a history of childhood maltreatment
Clinical Psychiatry, Psychotherapy, Child and Adolescent Psychiatry
Final Report Abstract
In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms of depression, and a high rate of comorbid disorders. Personalized treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and common factors like early childhood maltreatment may lead to better outcomes. A Modular Psychotherapy (MoPT) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoPT has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalized approaches. In a randomized controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbid diagnoses and childhood maltreatment are treated in 20 individual sessions with MoPT or standard Cognitive Behavioral Therapy (CBT) for depression. The three modules of MoPT focus on deficits in RDoC domains associated with early childhood maltreatment: the systems of negative valence, social processes, and arousal. According to a specific questionnaire-based treatment algorithm, elements from Cognitive Behavioral Analysis System of Psychotherapy (CBASP), Mentalization-Based Psychotherapy (MBT) and/or Mindfulness (MBCT) are integrated for a personalized modular procedure. CBT was intentionally chosen as control condition to assess effect estimates for a subsequent confirmatory trial with a strong comparator for a rigorous evaluation and high generalizability to the clinical reality. According to the treatment algorithm, approximately one quarter of patients (28.5%) received one additional module, nearly half received two additional modules (48.6%), and approximately one quarter (22.9%) received all three additional modules. Despite strong prepost-effects in reducing depression severity in both treatments arms, there were no significant differences between treatments in the primary endpoint (HRSD-24-score at posttreatment). While comparable response rates in both approaches occurred, the remission rate was more than twice as high in MoPT compared to CBT (29.4% vs. 11.4%). Overall, the raw value means and their confidence intervals might suggest superiority of MoPT, but no statistical significance was reached probably due to the limited sample size of this trial. Regarding feasibility, neither therapists, trainers nor supervisors expressed any concerns or concerns about the feasibility of Modular Psychotherapy. According to the treatment documentation, there was a higher therapist satisfaction and only half as much adverse events in patients treated with MoPT compared to CBT probably associated with the more personalized procedure in MoPT. However, MoPT therapist also reported more time problems on average having to integrate up to three additional modules in the therapy process. Despite randomization, there were moderate baseline differences between the treatment groups that might have influenced the results to the disadvantage of MoPT. This should be investigated in further sensitivity analyses accounting for this. This trial provides ample proof of the feasibility of an algorithm-based modular psychotherapy approach for patients with depression, comorbid diagnoses and childhood maltreatment. In this feasibility sample, MoPT was equally efficacious as CBT in reducing clinician-rated depression severity within twenty sessions. Remission rates as well as raw value means and their confidence intervals might suggest superiority of MoPT. Therefore, a multicenter confirmation trial with a sufficient sample size and statistical power is needed to assess potential between-treatment differences.
Publications
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Modular-based psychotherapy (MoBa) versus cognitive–behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial. BMJ Open, 12(7), e057672.
Elsaesser, Moritz; Herpertz, Sabine; Piosczyk, Hannah; Jenkner, Carolin; Hautzinger, Martin & Schramm, Elisabeth
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Modulare Psychotherapie: Ein Mechanismus-basiertes, personalisiertes Vorgehen. Klett-Cotta
Herpertz, S. C. & Schramm, E. (Eds.)
