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Objective: Mindfulness-based cognitive therapy (MBCT) has recently been proposed as a treatment
option for chronic depression. The cognitive behavioral analysis system of psychotherapy (CBASP) is the
only approach specifically developed to date for the treatment of chronically depressed patients. The
efficacy of MBCT plus treatment-as-usual (TAU), and CBASP (group version) plus TAU, was compared
to TAU alone in a prospective, bicenter, randomized controlled trial. Method: One hundred and six
patients with a current DSM–IV defined major depressive episode and persistent depressive symptoms for
more than 2 years were randomized to TAU only (N ⫽ 35), or to TAU with additional 8-week group
therapy of either 8 sessions of MBCT (n ⫽ 36) or CBASP (n ⫽ 35). The primary outcome measure was
the Hamilton Depression Rating Scale (24-item HAM-D, Hamilton, 1967) at the end of treatment.
Secondary outcome measures were the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996)
and measures of social functioning and quality of life. Results: In the overall sample as well as at 1
treatment site, MBCT was no more effective than TAU in reducing depressive symptoms, although it was
significantly superior to TAU at the other treatment site. CBASP was significantly more effective than
TAU in reducing depressive symptoms in the overall sample and at both treatment sites. Both treatments
had only small to medium effects on social functioning and quality of life. Conclusions: Further studies
should inquire whether the superiority of CBASP in this trial might be explained by the more active,
problem-solving, and interpersonal focus of CBASP.
Major depressive disorder (MDD) is among the most prevalent 2011), a substantial minority of approximately 20 –26.5% of patients
psychiatric conditions and places enormous burdens on individuals, develop chronic courses characterized by significant depressive
their families, and on society (Richards, 2011; Murray et al., 2012). symptoms lasting for at least 2 years (Gilmer et al., 2005; Satyanaray-
Besides high rates of relapse/recurrence after remission or recovery ana, Enns, Cox, & Sareen, 2009). Among patients treated in mental
(Frank et al., 1990; Kupfer et al., 1992; Holtzheimer & Mayberg, health care facilities, 47% suffer from some form of chronic depres-
This article was published Online First August 10, 2015. We are grateful to the patients who participated in the trial and the
Johannes Michalak, Department of Psychology and Psychotherapy, research assistants at the two treatment sites; we especially want to thank
Witten/Herdecke University; Martin Schultze, Department of Methods and Eval- the study therapists Ruth Fangmeier, Anne Katrin Külz, Marc Loewer,
uation, Free University of Berlin; Thomas Heidenreich, Department of Psychology Petra Meibert, and Tobias Rathleff. Moreover, we thank the LWL-Klinik
for Social Work and Nursing, Esslingen University of Applied Sciences; Elisabeth Dortmund and the Kliniken Essen-Mitte for their support.
Schramm, Department of Psychiatry and Psychotherapy, University Medical Cen- Correspondence concerning this article should be addressed to Jo-
ter Freiburg. hannes Michalak, Witten/Herdecke University, Alfred-Herrhausen-
This trial was registered (NCT01065311) and was funded by the German Straße 50, D-58448 Witten, Germany. E-mail: johannes.michalak@uni-
Science Foundation (DFG: Mi 700/4 –1). wh.de
951
952 MICHALAK, SCHULTZE, HEIDENREICH, AND SCHRAMM
sion (Torpey & Klein, 2008). The lifetime prevalence of chronic ability to step out of mind states characterized by ruminative
depression in the population ranges between 2.7% and 4.6% (Murphy negative thinking. Besides increases in mindfulness skills, research
& Byrne, 2012; Satyanarayana et al., 2009; Young, Klap, Shoai, & on mechanisms of change has shown that the effects of MBCT are
Wells, 2008); rates depend on the inclusion/exclusion of individuals mediated by enhanced self-compassion (Neff, 2003), the ability to
with dysthymic disorder. relate to oneself with kindness when encountering pain and per-
Research has shown substantial differences between chronic and sonal shortcomings (Kuyken et al., 2010).
nonchronic forms of MDD (Murphy & Byrne, 2012), which led to the Results of three smaller or uncontrolled studies have suggested
inclusion of a new diagnosis of persistent depressive disorder in the that chronically depressed patients benefit from MBCT (Barnhofer
fifth edition of the Diagnostic and Statistical Manual of Mental et al., 2009; Eisendrath et al., 2008; Kenny & Williams, 2007);
Disorders (DSM–5; American Psychiatric Association, 2013). Two of however larger randomized controlled trials testing the efficacy of
the most important features of chronic MDD are the slower rate of MBCT in chronic depression are lacking.
improvement and a poorer treatment response (Klein, Shankman & The only psychotherapeutic model to have been specifically
Rose, 2006). Approximately 50% of chronically depressed patients developed for the treatment of chronic depression is the cognitive
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
fail to respond to antidepressant medication or psychotherapy and behavioral analysis system of psychotherapy (CBASP, Mc-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
another 20% do not achieve complete remission (Harrison & Stewart, Cullough, 2000). In contrast to the cognitive focus of MBCT,
1995; Keller et al., 1998; Kocsis et al., 1988; Thase et al., 1996). CBASP mainly has an interpersonal orientation. It is a highly
Accordingly, efforts to improve treatment outcome in this highly structured learning approach integrating behavioral, cognitive, and
challenging population are needed. predominantly interpersonal treatment strategies. Assuming that
One psychotherapeutic approach to have recently been proposed as early interpersonal trauma leads to dysfunctional mechanisms of
a treatment option for chronic MDD is mindfulness-based cognitive derailed affective and motivational regulation and to a reduction of
therapy (MBCT; Segal, Williams, & Teasdale, 2002). MBCT was perceived functionality, the main objectives in CBASP are to learn
originally designed and evaluated for relapse prevention of remitted to recognize the consequences of one’s own behavior on other
MDD patients. A meta-analysis by Piet and Hougaard (2011) showed persons and to develop social problem solving skills and empathy.
that MBCT plus treatment as usual reduced risk of relapse by 43% for Based on the assumptions about relationships patients have formed
formerly depressed patients with three or more previous episodes in following experiences in their early history with being maltreated
comparison to treatment as usual alone. by significant others, patients formulate a proactive transference
MBCT is a group-based program combining intensive training hypothesis (e.g., “I have nothing to expect from my therapist”). In
in mindfulness (Kabat-Zinn, 1990) with cognitive– behavioral el- the CBASP group version used in the present study, patients also
ements targeting depression. In previous trials, MBCT was usually formulated transference hypotheses regarding the other group
delivered in eight weekly group sessions with a group size ranging members (e.g., “If I make myself vulnerable, I will be ridiculed”).
from 12 to 15 patients. The core skill that MBCT aims to teach is By means of interpersonal discrimination exercises, these hypoth-
the ability to recognize and disengage from mind states character- eses are contrasted with the actual behavior of the therapist and the
ized by self-perpetuating patterns of ruminative, negative thought group members to modify dysfunctional expectations. In this way,
that escalate and maintain depressive symptoms. In contrast to the patient learns to read other persons by focusing on their overt
getting lost in negative modes of mind and being preoccupied with behavior and the effects he or she has on them.
the past or future scenarios, MBCT fosters a nonjudgmental aware- The therapist gives the patient direct feedback by expressing his
ness of the present moment experience, including one’s sensations, or her personal reactions to the patient’s dysfunctional behavior
thoughts, bodily states, consciousness, and the environment, while patterns and offers alternatives (disciplined personal involvement).
encouraging openness, curiosity, and acceptance (Bishop et al., However, in a group format, disciplined personal involvement is
2004; Kabat-Zinn, 2003). The mindful awareness of the here-and- used less frequently when it comes to dysfunctional behavior in the
now encompasses a decentered view on cognitions: By intensive group and is often replaced by using the Kiesler Interpersonal
training in mindfulness, patients are supported to recognize that Circle model in an educative and structuring way. Kiesler (1982)
(even long-held) thoughts and feelings are events in the mind and operationalized the way people interact as reciprocal interpersonal
not self-evident truths or aspects of the self (Teasdale, Moore, transactions carried out within two domains: (a) power (dominance
Hayhurst, Pope, Williams, & Segal, 2002). Moreover, mindfulness vs. submission) and (b) affiliation (hostile vs. friendly) using a
helps patients to turn towards rather than escape or avoid experiences circumplex design with power and affiliation serving as
(e.g., dysphoric mood) without getting lost in ruminative, negative perpendicular-intersecting diameters in the circle. The patient
thoughts. In addition, antidepressive cognitive– behavioral therapy chooses his or her position in the circle (e.g., friendly dominant)
elements such as exercises on taking alternative viewpoints on cog- according to the outcome he or she desires for the interpersonal
nitions (e.g., just watching thoughts come and go, without feeling that situation (e.g., “I want to tell the group that I am disappointed”)
one has to follow them) or activity scheduling are introduced. How- and compares it with the impact of his or her usual behavior
ever, it should be highlighted that MBCT focuses on changing the position (e.g., hostile-submissive). Most of the group sessions
relationship to thoughts rather than changing the cognitive content. comprise step-by-step situational analyses in which patients learn
Besides its effects in relapse prevention it was hypothesized that to formulate a desired outcome in an interpersonal situation and
MBCT might also assist chronically depressed patients to facilitate how to achieve this outcome by role playing goal-oriented behav-
decentered and self-compassionate views of typical maladaptive ior. The percent distribution of situation analyses and the other
core beliefs. By training in mindfulness (e.g., during sitting med- techniques is about 70:30 in both individual and group sessions.
itation), chronically depressed patients might learn to recognize The efficacy of CBASP as a principal treatment (as opposed to
when they lose contact with the here-and-now and develop the an augmentation strategy in the context of a pharmacotherapy
MBCT AND CBASP FOR CHRONICALLY DEPRESSED PATIENTS 953
algorithm) was shown in a large American study (Keller et al., facilities or private practices. All individuals interested in partici-
2000) and a smaller German study that comprised 22 individual pating in the study took part in a telephone screening based on the
outpatient sessions over 16 weeks (effect size of d ⫽ 1.4; Schramm mood disorder module of the Structured Clinical Interview for
et al., 2011). These findings were confirmed in a recent network DSM–IV (SCID, Wittchen, Wunderlich, Gruschwitz, & Zaudig,
meta-analysis (Kriston, von Wolff, Westphal, Hölzel & Härter, 1997). Patients who seemed eligible were invited to an extended
2014), which concluded the CBASP approach was recommended diagnostic interview. Diagnoses were assessed using the SCID
over interpersonal psychotherapy for chronically depressed pa- Axis I and Axis II disorders. All diagnostic evaluations were
tients. Adapted to a group modality, CBASP showed encouraging conducted by trained and certified clinical psychologists and were
results in treatment-resistant depression in a single-arm pilot study reviewed by senior study investigators (Johannes Michalak and
(Sayegh et al., 2012). Elisabeth Schramm).
We report a bicenter randomized clinical trial (RCT) that treated All patients had a current major depressive episode (MDE) as
chronically depressed patients with either MBCT plus treatment as defined by the Diagnostic and Statistical Manual of Mental Disorders
usual (TAU), CBASP (group version) plus TAU or TAU alone.
(4th ed.; DSM–IV; American Psychiatric Association, 1994) and had
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Treatments Measures
TAU. All patients were instructed that they should be in Primary outcome measure. The primary outcome measure
individual treatment by either a psychiatrist or a licensed psycho- was the 24-item Hamilton Depression Rating Scale (HAM-D;
therapist (not a member of the study team) during the study period. Hamilton, 1967; Guy, 1976), a widely used interview-based mea-
If patients were already in psychiatric or psychotherapeutic indi- sure of the severity of depressive symptoms covering a range of
vidual treatment at study intake, they continued their treatment affective, behavioral, and biological symptoms. The HAM-D was
with this psychiatrist or psychotherapist. Patients were encouraged administered at baseline and posttreatment after the 8-week treat-
to continue any current medication and to attend appointments ment phase by five trained doctoral-level psychologists. To main-
with their psychiatrist or psychotherapist. There were no restric- tain rater blindness, patients were instructed at the beginning of
tions on other forms of supplementary treatment. each interview not to mention their treatment condition or their
MBCT. The treatment protocol followed the MBCT manual psychotherapist. To enhance reliability of the assessment, the
developed by Segal, Williams and Teasdale (2002). The program Structured Interview Guide for the HAM-D (Moberg et al., 2001)
was applied. A sample of 36 interviews from the baseline assess-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
gated into two components (the latent state St and the measurement We also computed proportions of remitters. A remitter was
error εikt), whereas the assessments made via the BDI are disag- defined as a participant with a HAM-D score of less than 8 at
gregated into three components (the latent state St, the method posttreatment.
factor Mt, and the measurement error εikt). Within this modeling The secondary outcomes assessing mental health and social
approach the latent state St represents the occasion-specific de- adaptation (i.e., SF-36 and SASS) were investigated with a single-
pressive symptoms assessed via the HAM-D (occasion: pre- and indicator true-change model for each outcome separately. The
posttreatment assessment). The method factor Mt represents the CTC(M-1) approach used for the simultaneous analysis of
occasion-specific component of the assessment made via the BDI HAM-D and BDI was not used for these outcomes because a
that is not shared with the assessment of the same occasion made comparison of two assessment methods was not required. In ad-
via the HAM-D. Using this approach, consistency coefficients can dition, a SEM with all five relevant scales (four mental health
be computed that represent the amount of variance in the BDI that subscales of SF-36 as well as SASS) was not feasible with the
is shared with HAM-D assessment, indicating the degree of con- obtained sample size.
The true-change models were analyzed using Mplus Version 7
vergent validity between the two assessment methods.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
(Muthén & Muthén, 1998 –2013) and all additional analyses were
To incorporate the inherent longitudinal nature of the study in
This document is copyrighted by the American Psychological Association or one of its allied publishers.
36 Patients in ITT analysis (A: 35 Patients in ITT analysis (A: 35 Patients in ITT analysis (A:
Analysis
Figure 1. CONSORT flow diagram. MBCT indicates mindfulness-based cognitive therapy; CBASP ⫽
cognitive behavioral analysis system of psychotherapy; TAU ⫽ treatment as usual. A indicates the Ruhr
megalopolis site; B indicates Freiburg site.
Treatment Compliance or TAU plus CBASP (n ⫽ 19, 76%) (see Table 1). Medications
were mostly selective serotonin and norepinephrine reuptake
TAU. Of the 85 patients participating in the posttreatment
inhibitors (n ⫽ 29, 34.1%) and selective serotonin reuptake
assessment from whom data on treatment during the 8-week study
inhibitors (n ⫽ 17, 20%). Five patients (5.9%) received tricyclic
period are available, 46 (54.1%) had one or more individual
antidepressants whereas four (4.7%) took Agomelatin and three
appointments with a psychiatrist (average number of appoint-
(3.5%) received MAO inhibitors (note that a small number of
ments ⫽ 2.22; SD ⫽ 1.86) and 31 (36.5%) had sessions with a
patients took antidepressant medication from two of these sub-
licensed psychotherapist (average number of sessions ⫽ 3.68;
stance classes). Nine patients (10.6%) took neuroleptic medi-
SD ⫽ 2.00). There were no significant differences between pa-
tients exclusively treated with TAU and patients additionally cation, whereas one (1.2%) was on lithium. No reliable infor-
treated with MBCT or CBASP in the number of individual ap- mation on medication dose was available. There were no
pointments with a psychiatrist (2 ⫽ 1.66, df ⫽ 2, p ⫽ .44), in the significant differences in AD intake between study sites (2 ⫽
number of psychotherapy sessions (2 ⫽ 0.38, df ⫽ 2, p ⫽ .83), or 0.30, df ⫽ 1, p ⫽ .58). A minority of 15 patients (17.6%) did
in the average number of sessions they received—number of not report any treatment (no sessions with a psychotherapist or
appointments with a psychiatrist: F(2, 82) ⫽ 2.17, p ⫽ .12; psychiatrist and no antidepressant medication) within the
number of individual sessions with a psychotherapist: F(2, 82) ⫽ 8-week study period.
0.18, p ⫽ .84. Moreover, we found no significant differences MBCT and CBASP. Of the 71 patients allocated to one of the
between conditions in the proportion of patients treated with group therapies, 20 patients (28.2%) discontinued therapy or at-
antidepressant medication. tended fewer than four sessions (10 MBCT patients [27.8%] and
However, it should be noted that on a descriptive level the 10 CBASP patients [28.6%], 2 ⫽ 0.003, df ⫽ 1, p ⫽ .96).
number of patients receiving antidepressant medication was Separate analyses for both sites revealed no significant difference
lower in patients exclusively treated with TAU (n ⫽ 17, 53.1%) in the rate of discontinuation of MBCT and CBASP in the two
than in patients who received TAU plus MBCT (n ⫽ 21, 75%) centers (Site A: MBCT ⫽ 7, CBASP ⫽ 9; 2 ⫽ 0.34, df ⫽ 1, p ⫽
MBCT AND CBASP FOR CHRONICALLY DEPRESSED PATIENTS 957
Table 1
Sample Characteristics
.56; Site B: MBCT ⫽ 3, CBASP ⫽ 1; 2 ⫽ 1.01, df ⫽ 1, p ⫽ .32). liams & Gemar, 2002) by a licensed psychotherapist with experience
Patients who attended four or more therapy sessions did not differ in conducting MBCT groups. Adherence in both centers was con-
on any of the demographic or baseline clinical characteristics from firmed by a score of 1.88 for therapies conducted at Site A and 1.71
those who discontinued therapy or attended fewer than four ses- at Site B (scale range: 0 –2). Adherence to the CBASP manual was
sions. There were no suicides, suicide attempts, or other serious rated with the CBASP Adherence Scales (McCullough, 2003) by
adverse events. Elisabeth Schramm. Adherence in both centers was confirmed by an
average overall score of 4.62 for therapies conducted at Site A and
Treatment Adherence and Competence 4.90 at Site B (scale range: 1–5).
Adherence to the MBCT manual was rated with the Mindfulness- Competence of delivery of MBCT was rated with the Mindfulness-
Based Cognitive Therapy Adherence Scale (Segal, Teasdale, Wil- Based Interventions—Teaching Assessment Criteria (Crane et al.,
Table 2
Means and Standard Deviations (in Parentheses) of Depressive Symptoms at Baseline
and Posttreatment
HAM-D Score
Overall
Baseline 23.03 (6.27) 24.71 (6.69) 23.87 (6.33)
Posttreatmenta 17.86 (10.37) 14.64 (8.85) 21.16 (8.16)
Site A
Baseline 24.63 (5.63) 24.91 (6.55) 23.87 (6.58)
Posttreatmenta 20.18 (10.24) 15.14 (8.19) 20.82 (8.52)
Site B
Baseline 19.83 (6.49) 24.33 (7.22) 21.67 (5.80)
Posttreatmenta 14.27 (9.97) 14.00 (10.01) 21.90 (7.67)
BDI-Score
Overall
Baseline 31.31 (9.55) 30.26 (7.52) 29.76 (7.42)
Posttreatmenta 22.69 (12.11) 22.28 (12.54) 28.34 (10.27)
Site A
Baseline 33.42 (8.03) 30.00 (7.08) 30.00 (7.73)
Posttreatmenta 23.71 (11.59) 22.93 (12.82) 27.68 (9.34)
Site B
Baseline 27.08 (11.24) 30.75 (8.58) 29.33 (7.14)
Posttreatmenta 20.78 (13.54) 21.45 (12.73) 29.80 (12.49)
Note. HAM-D ⫽ Hamilton Rating Scale for Depression; BDI ⫽ Beck Depression Inventory.
a
No imputation of missing data.
958 MICHALAK, SCHULTZE, HEIDENREICH, AND SCHRAMM
Table 4
Site Comparisons From the Multiple-Group SEM With the Regression Predicting the True-
Changes of the HAM-D (Reference-Measured States; SC) and BDI Specific Components (Method
Factors MC) by Intervention Type
Predicting SC
(Intercept) ⫺0.16 ⬍.001 ⫺0.07 .27 ⫺0.08 .25
MBCT ⫺0.02 .76 ⫺0.22 .01 0.20 .06
CBASP ⫺0.17 .01 ⫺0.43 ⬍.001 0.26 .06
Predicting MC
(Intercept) 0.03 .37 0.02 .68 0.01 .90
MBCT ⫺0.16 .06 0.00 .99 ⫺0.16 .29
CBASP ⫺0.02 .80 0.02 .81 ⫺0.04 .68
Note. HAM-D ⫽ Hamilton Rating Scale for Depression; BDI ⫽ Beck Depression Inventory; MBCT ⫽
mindfulness-based cognitive therapy; CBASP ⫽ cognitive behavioral analysis system of psychotherapy.
960 MICHALAK, SCHULTZE, HEIDENREICH, AND SCHRAMM
nificant, the more fine-grained analyses revealed that this result group size in MBCT, this issue should be explored in future
was largely attributable to very small improvements in HAM-D research.
scores and large TAU effects for MBCT patients treated at Site A, One difference between treatment sites was the effect of TAU.
whereas MBCT was more effective than TAU at Site B. Remark- Although the differences were not significant in the direct com-
ably, this result cannot be attributed to allegiance effects since Site parison, at Site B TAU had nearly no effect, but at Site A TAU
A was more specialized in MBCT. Though the difference between resulted in significant improvements in depressive symptoms as-
the effects of MBCT and CBASP was not statistically significant sessed with both HAM-D and BDI. This difference might be
(possibly due to insufficient power to detect differences) there is a attributable to differences in recruitment strategies between the
preliminary indication of a larger effect of CBASP. centers. Patients at Site A were recruited by media announcements,
Self-reported depressive symptoms (BDI) and clinicians’ ratings at Site B they were recruited from health care facilities or private
(HAM-D) showed good consistency in state assessments as well as practices. Although we found no significant differences with re-
in their assessments of changes. When analyzing our data with a spect to medication or supplementary individual psychotherapy in
SEM approach, we found no indication that the effects differed the TAU condition between the two centers, it could be spec-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
within any of the three intervention approaches by method of ulated that patients at Site B might have had a longer history of
This document is copyrighted by the American Psychological Association or one of its allied publishers.
assessment (as seen by the absence of significant regression ineffective TAU. This might have motivated health care pro-
weights on the method effects Mc). This indicates consistent in- viders at Site B to refer patients to our study with alternative
tervention effects, the detectability of which does not depend on treatment approaches and might have had the effect that the
the assessment method but is evident across self-reports (BDI) and patients were highly resistant to TAU. The differences in sub-
clinicians’ ratings (HAM-D). type of depression observed between the two sites, namely the
However, the supplementary analysis with the more traditional higher proportion of patients with chronic major depression at
HLM approach revealed that when treatment effects were assessed Site B and more patients with recurrent depression with incom-
by self-report with the BDI, MBCT was superior to TAU. All other plete remission (i.e., a more fluctuating type of depression) at
HLM analyses revealed similar effects to those of the SEM ap- Site A, support this assumption. Notably, differences in efficacy
proach. Although these indicate some differences between the between treatment sites have been reported repeatedly in psy-
effects for BDI and HAM-D, overall CBASP showed more con- chotherapy RCTs in depression, for example, in the NIMH
sistent effects. Treatment of Depression Collaborative Research Program (El-
The effect size for the reduction in depressive symptoms was kin et al., 1989) and in a recent dismantling study on MBCT
particularly large at Site B, the center with more experience in (Williams et al., 2014).
CBASP, and comparable to effect sizes reported in previous re- The difference in TAU between treatment sites affected com-
search on CBASP. In the study by Keller and colleagues (2000), parisons with CBASP and MBCT and resulted in larger estimates
the remission rates for individual CBASP (33%) after 12 weeks of between-groups effect sizes for the treatment groups at Site B.
were similar to our results (33% in the CBASP group at Site B, In particular, the effect size of MBCT was dependent on treatment
26% overall across both sites) after 8 weeks. However, it should be site. These differences between centers could not be attributed to
noted that the majority of patients in our study were on stable differences in adherence or competence. We found good adherence
medication. The combined nefazodone and CBASP condition in and competence ratings for both MBCT and CBASP at both
the Keller et al. study achieved a higher remission rate of 48%. The treatment sites. Moreover, therapists at both centers had intensive
results suggest that CBASP in a group modality is a useful and training in MBCT and CBASP. In particular, the MBCT therapist
potentially more economical alternative to individual CBASP at Site A had considerable experience in conducting MBCT
treatment. groups. During the trial the quality of each treatment was moni-
In contrast, the effects of MBCT in our study were smaller than tored by the senior investigators. Moreover, interrater correlations
those reported in previous trials with chronically depressed pa- for HAM-D were excellent, making it unlikely that systematic
tients (Barnhofer et al., 2009; Eisendrath et al., 2008; Kenny & differences in rating procedures were responsible for the differ-
Williams, 2007). For example, in the Kenny and Williams study ences in HAM-D effects between centers.
with treatment-resistant depressed patients, the prepost effect size The more consistent effect of CBASP on depressive symptoms
for BDI was d ⫽ 1.04. However, effect size estimates in previous in our study might indicate that besides common factors like
studies were based on smaller samples or derived from uncon- alliance or group cohesion some specific factors are important in
trolled designs. In our study, adherence and competence were the treatment of chronically depressed patients. It could be spec-
good, making it unlikely that suboptimal application of MBCT ulated that the more active, problem-solving, and interpersonal
caused the smaller effects. One difference, however, was that with focus of CBASP might have some benefit for this highly avoidant
up to six patients per group, the MBCT condition in the present group of patients (Brockmeyer, Kulessa, Hautzinger, Bents, &
study had a smaller group size than typically used in MBCT (12 to Backenstrass, 2015). It might assist them to form a representation
15 patients). It might be that the relatively small number of patients of the effects of their behavior in an interpersonal context and
in the MBCT groups sometimes hindered optimal exchange be- might help them to develop new and more satisfying ways to
tween patients in the groups, because only a few patients contrib- establish and maintain important relationships. The active and
uted to the group discussions. However, it also seems possible that problem-focused style of CBASP might be beneficial because it
the avoidant style of chronically depressed patients might reduce provides patients with immediate feedback on the impact their
the efficacy of lager groups. Because the relationship between behavior has on others. Moreover, focusing their attention on
group size and outcome in group therapy is empirically unexplored present-moment interaction might prevent them from drifting into
(Burlingame, Fuhriman & Mosier, 2003), particularly the effect of ruminative states of mind. In contrast, because the mindfulness
MBCT AND CBASP FOR CHRONICALLY DEPRESSED PATIENTS 961
exercises during the sessions and the regular mindfulness practice Although in the present study the effects of CBASP were more
at home as core components of MBCT require a relatively high consistent than those of MBCT, our trial was underpowered to
degree of attentional and motivational self-regulation, some pa- reliably detect differences between the two treatment conditions.
tients with chronic depression might be overchallenged by the Fourth, the results in the TAU condition suggest that recruitment
requirements of MBCT. This might have resulted in a more limited of patients might have affected the findings. Hence, future research
efficacy of MBCT in our study. If these differences in the efficacy should use optimized recruitment strategies (e.g., searching in
of MBCT and CBASP can be replicated in future studies, this computerized practice databases in primary care settings to iden-
might call into question the assumption of the so-called dodo-bird tify patients; see Kuyken et al., 2008) to improve generalizability
verdict (Luborsky, Singer, & Luborsky, 1975) that all psychother- of the results. Fifth, it cannot be ruled out that the greater effects
apies, regardless of their specific components, produce equivalent of CBASP were attributable to a higher dose of treatment. Patients
outcomes. in the CBASP condition received two individual preclass sessions
Effects of both psychotherapeutic approaches on social func- due to the necessity of assessing the significant other history
tioning and quality of life were moderate. In contrast to the effect before the groups started, compared to one preclass interview in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
of CBASP on depressive symptoms we observed no significant the MBCT condition. Moreover, the individual preclass interview
This document is copyrighted by the American Psychological Association or one of its allied publishers.
effect of CBASP on social functioning or any subscale of SF-36. in the MBCT condition had a focus on informing patients about the
Research on the sequencing of change during psychotherapy has program, whereas in individual sessions in the CBASP condition
shown that an enhancement of life functioning usually occurs in the transference hypothesis was derived. Thus, in addition to the
later phases of treatment after a phase of reduction in symptom- difference in dose, the individual CBASP sessions might have had
atology (see phase model of psychotherapy by Howard, Lueger, a stronger therapeutic impact.
Maling, & Martinovich, 1993). Correspondingly, it might be that a In conclusion, the results of the present study demonstrate the
higher dose of treatment would be needed before an enhancement efficacy of CBASP in a group format for the treatment of chronically
of life functioning could be observed in this difficult to treat group depressed patients. MBCT was effective in one of the study centers
of chronically depressed patients. but not in the other. It is unlikely that potential allegiance or differ-
Dropout rates were relatively high with approximately 28% of ences in adherence between conditions were responsible for these
patients discontinuing treatment in both group treatment condi- effects. Although these findings need replication, the results of this
tions. These numbers are considerably higher than those reported study might inform future research on the possible role of the more
in previous studies of MBCT in chronically depressed patients active, problem-solving, and interpersonal focus of CBASP for the
(e.g., Barnhofer et al., 2009 12.5%; Eisendrath et al., 2008, 7%; successful treatment of chronically depressed patients.
Kenny & Williams, 2007, 1%) but are comparable to those re-
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