Novel, Self-Help Therapy May Improve Depressive Symptoms

Yael Waknine

November 22, 2011

November 22, 2011 — The addition of a novel self-help treatment to standard therapy can significantly improve depressive symptoms in as little as 8 weeks, new research suggests.

Investigators at the University of Exeter and the Devon Partnership National Health Service (NHS) Trust in the United Kingdom found that concreteness training (CNT) significantly reduced symptoms of depression from severe to mild within the first 2 months, and had a durable effect of up to 6 months.

"[The study] indicates that a relatively brief guided self-help treatment provided with limited therapeutic contact can improve treatment as usual for depression in primary care. This is important because this is where most depression presents itself, but where there is not sufficient resource for individual therapy. Thus, this intervention provides a means to make an effective psychological intervention widely available for little cost," principal investigator Edward Watkins, PhD, told Medscape Medical News.

The study was published online November 16 in Psychological Medicine.

Daily Exercises

CNT is designed to shift the depressed patient's cognition away from unhelpful abstract thinking that leads them to dwell on negative thoughts (rumination) and develop negative conclusions (overgeneralization).

For the study, which represents the first formal test of CNT in the United Kingdom, investigators randomly assigned 121 depressed patients to receive treatment as usual (TAU), TAU + CNT, or TAU + relaxation training (RT).

About 50% of patients were receiving ongoing antidepressant medication: 75% selective serotonin reuptake inhibitors, 11.7% serotonin norepinephrine reuptake inhibitors, and 8.3% tricyclics.

The CNT intervention was originally performed with a therapist and then continued alone with an audio CD. It consisted of a daily exercise in which patients identified a mild to moderately upsetting recent event and then worked through standardized steps that helped them think of the event in a more concrete manner.

Mental imagery was used to focus on sensory details during the event, and the context in which it occurred, after which the circumstances of the event were investigated, including warning signs and actions that could have been used to change the outcome. Future steps and behaviors were then examined.

Reduced Negative Thinking

Results at 8 weeks showed that CNT/TAU was significantly more effective than TAU alone for reducing symptoms of depression and anxiety, as evaluated using the Hamilton Rating Scale for Depression (intention to treat [ITT], P = .006; per protocol [PP], P < .0001), Beck Depression Inventory II measure (P < .0001 for ITT and PP), the Patient Health Questionnaire (P < .0001 for ITT and PP), and Generalized Anxiety Disorder 7 scale (ITT, P = .001; PP, P < .0001).

Although no significant differences were found between the CNT/TAU and RT/TAU groups (P > .05 for all PP and ITT measures but 1), only CNT decreased the negative thinking associated with depression.

Patients in the CNT/TAU group experienced significant decreases in depressive rumination, as measured using the 22-item Ruminative Response scale of the Response Styles Questionnaire (ITT, P = .006; PP, P = .004), and negative overgeneralization, as evaluated with a shortened version of the Attributional Style Questionnaire, in which 4 hypothetical situations (2 positive, 2 negative) were used to assess thinking (ITT, P = .028; PP, P = .016).

For those patients who practiced CNT long enough for it to become a habit, CNT reduced symptoms of depression more than RT (P = .02), an effect that was maintained after 3 and 6 months.

"This treatment utilized a novel delivery method, repeated use of audio CDs supported by telephone, and there is scope to provide these materials via smartphone or Internet, [representing a] potential for this treatment to be delivered by nontraditional means in a way that can reach more people than face-to-face therapy without being limited by geography, timing, or cost," said Dr. Watkins.

"The fact that the CT solely focused on shifting thinking style indicates that a specific and targeted approach to thinking in depression can by itself be of benefit, which is consistent with some theoretical accounts and indicates the clinical value of...focusing in on processes like rumination and overgeneralization."

Positive Message

Commenting on the study findings for Medscape Medical News, Joseph F. Goldberg, MD, who was not involved in the research, said: "The conceptual backdrop for this undertaking is laudable and encouraging, and may help more sufferers from depression to identify their condition and seek help."

Dr. Goldberg, who is associate clinical professor, Mount Sinai School of Medicine, New York City, and director of the Affective Disorders Research Program at Sliver Hill Hospital in New Canaan, Connecticut, noted that the described technique is not particularly new and can be found in existing self-help workbooks based on cognitive therapy.

He also noted that the study has several limitations, including the fact that it did not evaluate whether CNT corrected dysfunctional attitudes or altered cognitive schemas in a manner likely to produce enduring change.

It also did not assess whether the observed benefits were unique, or instead represented a synergy between formal treatment and cognitively inspired self-help CNT exercises, as half of the patients were receiving antidepressant medication. In addition, no comparison was made with a group of patients receiving psychotherapy only.

Dr. Watkins agrees to some extent. "In terms of self-help treatments, CNT was put together as a guided self-help package that included coaching and support from a postgraduate-level psychologist, based on evidence that self-help works better in depression when there is someone to support and motivate the person with depression," he said.

"We therefore don't know how well it would work as a solely unguided self-help treatment. We suspect that, if presented in the right way, it would be beneficial, and we are currently exploring how to adapt the materials to be used as a self-help book without any therapist instruction," he added.

The study also did not address more severe forms of depression, such as melancholia, psychotic depression, agitated depression, comorbid depression, or bipolar depression, said Dr. Goldberg. He noted that these conditions are "common forms of complex illness that account for high rates of poor response to traditional treatments."

Still, the message is positive.

"These findings should underscore the usefulness of cognitively based approaches to treating depression, but should not be viewed as an alternative to formal treatment," said Dr. Goldberg.

The research team is now calling for larger efficacy trials to assess the feasibility of CNT as part of the NHS' treatments for depression.

The study was funded by a Medical Research Council Experimental Medicine Grant to Dr. Watkins. Dr. Goldberg has disclosed that he has served on the speaker's bureau of Abbott Laboratories, Astra Zeneca, Eli Lilly, GlaxoSmithKline, and Pfizer; and has served as an advisor or consultant to Eli Lilly and GlaxoSmithKline.

Psychol Med. Published online November 15, 2011. Abstract