Journal of Affective Disorders 152-154 (2014) 268–276

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Cognitive Behavioural Analysis System of Psychotherapy (CBASP)

for chronic depression: Clinical characteristics and six month clinical
outcomes in an open case series.
John S. Swan a,n, Robert MacVicar b, David Christmas b, Rob Durham b, Petra Rauchhaus c,
James P. McCullough Jrd, Keith Matthews a
a
Division of Neuroscience, Medical Research Institute, University of Dundee, Ninewells Hospital and Medical School, UK
b
Advanced Interventions Service, NHS Tayside and University of Dundee, Level 6, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
c
Dundee Epidemiology and Biostatistics Unit, Division of Population Health Sciences, Medical Research Institute, University of Dundee, UK
d
Department of Psychology, Virginia Commonwealth University, Richmond, USA

art ic l e i nf o a b s t r a c t

Article history: Background: Evidence-based guidance on how best to treat chronic depression is limited. Cognitive
Received 12 July 2013 Behavioural Analysis System of Psychotherapy (CBASP) has shown some promise with this ‘difficult-to-
Received in revised form treat’ clinical group. This case series was designed to assess the acceptability and utility of this novel
25 September 2013
treatment in routine clinical practice within the U.K. National Health Service.
Accepted 25 September 2013
Available online 5 October 2013
Methods: We offered an open trial of CBASP to a cohort of 115 referred patients within primary and
secondary care. Diagnostic interview and standardised outcome measures were administered before and
Keywords: after 6 months of CBASP with a trained, accredited therapist.
Case series Results: Seventy-four patients entered therapy, with 46 completing. 30% met criteria for remission ( r 8
Chronic depression
HRSD-24 score) and a further 30% met criteria for clinically significant change (4 8 and r15 HRSD-24
CBASP
plus 50% reduction in baseline score). Thirty-nine per cent made “No change”. Group measures of quality
Psychotherapy
Treatment-refractory of life, social functioning and interpersonal functioning also improved.
Limitations: This was an open study design with a moderate sample size and no control group. Ratings
were not completed using a blinded procedure.
Conclusions: CBASP is an acceptable therapy for a large proportion of patients with chronic depression
and was associated with clinically significant change in 60% of completers.
Crown Copyright & 2013 Published by Elsevier B.V. All rights reserved.

1. Introduction quality of life, social and occupational functioning (Ustun et al.,

Depressive episodes are conceptualised as being ‘chronic’ when
diagnostic criteria for Major Depression are met continuously for
two years or more with fewer than 8 weeks of remission (APA,
2000). One in five patients with a major depressive episode develop
a chronic course of illness and chronic depression accounts for
around half of all patients being treated in mental health care
systems. Approximately 3% of the adult population in the Western
world experiences a chronic Major Depressive Episode (Kessler
et al., 1994; Arnow and Constantino, 2003; Torpey and Klein, 2008)
and the mean duration of chronic episodes falls within the range of
17–30 years. This contrasts with a mean duration of 20 weeks for
non-chronic episodes (Gilmer et al., 2005; Kocsis et al., 2008). It
should be noted that all forms of depression impact adversely
n
Correspondence to: University of Dundee, Advanced Interventions Service,
Level 6, Ninewells Hospital and Medical School, Area 7, Level 6, South Block,
Dundee, DD1 9SY, UK. Tel.: þ 44 1382 878742.
E-mail addresses: johnswan@nhs.net, jsswan@dundee.ac.uk (J.S. Swan).
2004; Wittchen et al., 2011). Evidence indicates that these effects
are more pronounced in the more chronic forms of the disorder
(Wells et al. 1992). Those who develop chronic depression can
expect reduced wellbeing leading to higher use of health services,
more periods of illness, longer spells in hospital, higher rates of self-
harm and reduced economic and social circumstances (Howland,
1993; Arnow and Constantino, 2003; Torpey and Klein, 2008).
The past 20 years have led to a clearer definition of the nature,
characteristics and effects of chronic depressive disorders but treat-
ment efficacy has not kept up with our ability to describe the
phenomenon. Some pharmacological therapies have been shown to
exert beneficial effects (De Lima et al., 1999; Kocsis et al., 2003;
Cuijpers et al., 2010); however evidence supporting the efficacy of
specific psychological therapies is, at best, modest (Stimpson et al.,
2002; Cuijpers et al., 2010). Time limited, depression-specific therapies
such as Interpersonal Therapy (IPT) (Klerman et al., 1974, Klerman
et al., 1984) and Cognitive Behavioural Therapy for Depression (CBT-D)
have been found to produce remission rates similar to those with
antidepressant medication in studies of patients with acute major

0165-0327/$ - see front matter Crown Copyright & 2013 Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2013.09.024

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 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276
depression (Hollon et al., 2002), but these treatments have not been
shown to be as efficacious when applied in the context of chronic
depression (McCullough, 2000; Cuijpers et al., 2010)
Specific clinical guidelines for the treatment of chronic depres-
sion are sparse. The UK National Institute for Health and Clinical
Excellence guideline for the treatment of depression (NICE 2009)
suggests that the diagnosis, and hence the choice of treatment of
depression should not simply rely on “symptom count” and that
depression should be assessed and categorised by taking account
of “both the degree of functional impairment and/or disability…
and the duration of the episode”. However this guideline only
classifies depression in terms of “severities of depression” and
denotes sub-threshold, mild, moderate and severe depression. These
categories or distinctions are based on symptom count and degree of
impairment; no consideration or guidance is given to the effect of
symptom burden or impairment, and hence choice of treatment, in
the context of the duration of episode. Therefore, the guidance
contained within the NICE depression guide is problematic when
considering evidenced-based psychotherapies for chronic depression.
Cuijpers et al. (2010) conducted a meta-analysis of 16 randomised
trials examining the effects of psychotherapy specifically on chronic
depression. Psychotherapy was found to have a small, but significant,
effect (d¼ 0.23). Combination treatment (with medication) was more
effective than either medication or psychotherapy alone. Twenty one
psychological therapies were examined including Cognitive Beha-
vioural Therapy, Interpersonal Therapy and 8 remaining “other”
studies. The Cognitive Behavioural Analysis System of Psychotherapy
model (CBASP) was listed in the “other” category. Cuijpers et al.
discussed possible reasons for the small overall effect size. The
identification of small sample sizes and poor study design were
notable, but one study was highlighted – the study of CBASP by
Keller and colleagues – which was described as the most influential
study in terms of sample size, effect size and as an exemplar of the
possible effect of psychotherapy in patients with chronic depression.
CBASP was specifically formulated to meet the challenges and
clinical requirements of the chronically depressed patient. The unique-
ness of CBASP as a therapy cannot be understood in isolation from
consideration of the idiosyncratic psychopathology of chronic depres-
sion. In attempting to transform habitual and treatment resistant
patterns of behaviour, CBASP therapists choreograph a collaborative
focus on resolving current problems of living using behavioural
analytic procedures. In CBASP, patients are perceptually connected/
re-connected with the interpersonal consequences of their behaviour.
Once the perception of a functional connection between behaviour
and consequences is learned, the patient is taught the behavioural
skills necessary to bring about more empathically responsive/appro-
priate interactions in their specific interpersonal setting. The emphasis
is on behavioural social problem-solving; cognitions are important but
only in as much that they lead to environmental-social consequences.
Simultaneously, CBASP therapists deliberately manage transference
issues (learned interpersonal expectancies) within the therapeutic
relationship. These learned expectancies have their roots in develop-
mental histories of early adverse life events. The way CBASP therapists
manage and modify these transference issues and the way they
understand and manage their own reactions to the patient's learned
expectancies, make CBASP a unique model when compared to other
treatments for depressive disorders.
In a multicentre randomised controlled trial in the USA, Keller
et al. (2000) compared the acute (12 week) efficacy of an antide-
pressant medication (nefazodone) both to CBASP when administered
alone and to a condition where the drug was administered with
CBASP. A total of 681 patients meeting criteria for the different
subtypes of chronic depression and with a baseline HRSD-24 score of
at least 20, were treated with nefazodone alone (titrated to a dose of
600 mg, n¼ 220); CBASP alone (16–20 sessions, n¼ 216); or a
combination of both, (n¼226). Post-therapy remission and rates of
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269
improvement (based on HDRS-24 scores) were: nefazodone (48%);
CBASP (48%); combination (73%) (Keller 2000). A secondary analysis
of these data suggests that psychotherapy in the form of CBASP
provides additional benefit for those with a history of early adverse
life events or childhood trauma (Nemeroff et al., 2003). However, in a
more recent study comparing CBASP with supportive psychotherapy
as an adjunct to pharmacotherapy in the management of treatment-
resistant chronic depression (the REVAMP study), Koscis and collea-
gues failed to demonstrate a difference between the therapies, or an
advantage over medication alone (Kocsis et al., 2010). The REVAMP
study, however, deviated significantly from the original CBASP study
design: (1) pharmacotherapy alone was administered during the
acute phase I; (2) the non and partial responders were given an
“augmented” dose of psychotherapy (CBASP or Supportive Therapy)
in Phase II; (3) the majority of subjects opted for pharmacotherapy at
the outset of the study; and (4) the mean number of CBASP
psychotherapy sessions was fewer than thirteen (Schramm, 2010).
There were also some significant differences in the clinical charac-
teristics of the patients in the two studies. These key differences may
help explain the failure to replicate findings from the Keller study.
In a small randomised controlled trial (n¼30), in a European
sample (Germany), a course of CBASP (mean number sessions¼21.2),
was shown to have roughly equivalent efficacy to a similar course of
IPT (based on clinician rated depressive symptoms). Eligible patients
were required to have a diagnosis of early-onset depression with a
baseline HRSD of Z16 (mean 23.2) and were required to be drug free
prior to and for the duration of the study. Seventy two per cent of
patients (n¼21) had previously experienced psychotherapy with only
21% (n¼6) having had no prior treatment of any kind (Schramm et al.,
2011).
In the current study, the primary objective was to conduct an
extended case-series of CBASP delivered by trained therapists to
chronically depressed patients in order to test the feasibility,
acceptability and utility of this approach within the context of a
publicly-funded national healthcare system (UKNHS). In this paper
we present a detailed description of the clinical characteristics of
the cohort and address three main questions:
1. What proportion of patients would agree to a trial of CBASP?
2. Would offering 20 h of therapy within a 6 month period be a
viable target or “dose” of therapy in future studies of CBASP?
3. What proportion of patients would meet criteria for improve-
ment and remission within this 6 month period?
2. Methods
2.1. Participants
We recruited a cohort of patients who met diagnostic criteria
for chronic depression and who were representative of patients
routinely seen within secondary care mental health services in the
UK. All participants provided written informed consent. Ethical
approval for the conduct of this study was provided by the East of
Scotland Research Ethics Service. Referrals of adult patients (Z18
years) with a primary diagnosis of chronic depression were invited
from primary, secondary and tertiary mental health services
located in Tayside and Lothian, Scotland, UK.
2.2. Inclusion criteria
1. The presence of chronic major depressive disorder based on DSM-
IV using the Mini International Neuropsychiatry Interview V.5
(MINI) (Sheehan et al., 1998), or a recurrent major depressive
disorder with incomplete remission between episodes (APA 2000).
270 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276

2. Depressive symptoms present for at least 2 years with less than therapy); and Phase 3 (end-of-therapy assessment). This paper
2 months of feeling well in that 2 year period. reports the findings from baseline and post-therapy assessments.
3. A score of Z17 on the 24-item Hamilton Rating Scale for
Depression (HRSD-24) (Hamilton 1967). 2.5. Assessments of diagnosis, co-morbidity, and symptom burden

The following assessments were used: Mini International

2.3. Exclusion criteria
Neuropsychiatry Interview V.5 (MINI) (Sheehan et al., 1998);
Hamilton Rating Scale for Depression 24-item version (HRSD-24)
1. A current and/or lifetime diagnosis of: schizophrenia or other
(Hamilton 1967); Beck Depression Inventory-II (BDI-II) (Beck et al.,
psychotic disorder; bipolar disorder; dementia; head trauma or
1996); Brief Symptom Inventory (BSI) (Derogatis and Melisaratos,
any other organic disorder affecting memory and recall; a primary
1983). The general severity index (GSI) of the Brief Symptom
eating disorder, anxiety disorder; severe substance abuse or severe
Inventory (BSI) provides a global measure of current symptom
alcohol problems;
burden, and the scale provides nine subscale scores representing:
2. A diagnosis of antisocial, schizotypal or severe borderline person-
somatisation; obsessive-compulsive; interpersonal sensitivity;
ality disorder;
depression; anxiety; hostility; phobic anxiety; paranoid ideation;
3. Severe and current high risk of suicide based on the MINI
and psychoticism. Normative data are available for adult clinical
diagnostic interview and/ or clinical judgement exercised by
and non-clinical populations. Participants were also invited to
the clinician. NB – No one was excluded using this combination
complete the Childhood Trauma Questionnaire (CTQ) at baseline.
of decision making heuristic;
The CTQ is a 28-item self-report inventory providing screening for
4. A course of ECT in the previous 6 months; and
histories of abuse and neglect. The CTQ inquires about five types of
5. Over a three month period, 115 adults were referred. Patient
maltreatment – emotional, physical and sexual abuse, emotional
flow through the study is shown below in Fig. 1.
and physical neglect (Bernstein and Fink, 1998).

2.6. Details of CBASP therapy

2.4. Assessments
The treatment objective was to offer 20 sessions of CBASP
Assessment of participants consisted of three phases: Phase 1 within a 6-month period. The first four sessions were of one and a
(baseline assessment); Phase 2 (process measures throughout half hours with the remainder being of one hour duration. All

Problems at outset (N = 32) Written Referrals requesting inclusion into

Rejected for diagnostic reasons Case Series (N = 115).
(clearly no mood disorder Referrals screened for eligibility and
present) (N = 14) patients invited to attend screening
Patient declined offer of appointment
screening assessment (N = 14)
Appointments accepted but
failed to attend (N =4)

Excluded ( N = 9)
Accepted and Attended Screening
Diagnostic reasons
Assessment (N = 83)
i.e. other primary
axis I or II

Attended and participated in pre-therapy,

Early withdrawal (N = 19)
baseline assessment (N = 74)
These patients voluntarily
withdraw from therapy
between sessions 0-3

Protocol Breaches (N = 3) Engagement with therapy ( N = 55) Later withdrawal (N = 6)

One therapist fails to adhere These patients engage with therapy and receive These patients voluntarily
to protocol regarding timing between 4 and 20 sessions withdraw from therapy
of follow- up on completion between sessions 4 -20 and
of therapy. These data not do not provide follow-up
eligible for inclusion in data
set
Complete Outcome Data ( N = 46)
Intention to treat (ITT) analysis (Multiple Imputation)
performed comparing means at pre and post therapy at levels
N =74 and N = 55 and N = 46

Fig. 1. Patient Flow: CBASP case series.

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 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276
sessions were audio-recorded to aid clinical supervision and to
facilitate post-therapy rating for protocol adherence. Treatment
was provided by eleven therapists, each of whom was a trained
and experienced CBT therapist. There were 6 female and 5 male
therapists. Eight of the therapists had a core profession in mental
health nursing, 2 were clinical psychologists and 1 was a con-
sultant psychiatrist. All therapists had received additional training
in CBASP and had experience of delivering CBASP prior to the
study. Therapists met for regular clinical supervision and the six
months of therapy was structured according to a therapist proto-
col (McCullough, 2000, 2001, 2003, 2006).
2.7. Statistical considerations
Data were analysed using SAS version 9.2. Descriptive data are
presented as frequency/% for categorical variables and mean/(SD)
for continuous variables. ANOVA and χ2 tests were performed to
test for significance of changes from baseline. Variables likely to
influence the outcome were included in the analysis. Linear
Regression models were built for main outcome scores utilising
both a forward and stepwise selection model including all vari-
ables. Models were then assessed for goodness of fit using Akaike
Information Criterion (AIC) and the best-fit model chosen. Multi-
ple imputation was used to generate 20 datasets and the results
combined across datasets. This approach imputes missing data but
also accounts for the uncertainty around the imputation simulta-
neously and is now the standard for missing data. This method
assumes data is missing at random (MAR), that is, the probability
of “missingness” depends on the previous values but is indepen-
dent of values that might have been obtained.
3. Results
3.1. Demographics
All 74 participants were Caucasian. The age range was 18–72
with the mean age being 44 years (SD ¼10.27). There were 24
(32%) men and 50 (68%) women. In terms of relationships, 31
(42%) were married/co-habiting, 20 (27%) had never married while
22 (30%) were separated or divorced and 1 (1.4%) was widowed.
Twenty three (31%) were in full time employment, 7 (9%) in part
time employment, 23 (31.1%) were unemployed, 2 (2.7%) were
retired, 3 (4.1%) were “homemakers”, 1 person (1.4%) was a
University student and 15 (20%) were receiving benefits associated
with long term inability to work.
The Scottish Index of Multiple Deprivation (SIMD) identifies small
area concentrations of multiple deprivations across all of Scotland in
a consistent way. SIMD quintiles rank deprivation from ‘most
deprived’ (SIMD 1) to ‘least deprived’ (SIMD 5). The distribution of
participants was: SIMD 1 (N¼ 15, 20%); SIMD 2 (N¼11, 15%); SIMD 3
(N¼ 11, 15%); SIMD 4 (N¼29, 39%); SIMD 5 (N¼8, 11%).
3.2. Duration of current episode and age of onset
At baseline, participants were asked about their current epi-
sode of depression and also their index episode. The mean
duration of current episode was estimated at 15.5 years, with a
median of 11.5 years (range 2–50 years). Age of onset of index
episode was reported as being before the age of 15 by 43.2% of
participants and over the age of 30 by 20.3%; 58.1% (41/74) met
criteria for early onset chronic depression (index episode before
the age of 21 years) (Klein et al., 1999; McCullough, 2000; Hammen
et al., 2008).
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271
Diagnostic Category Derived from MINI
Pre and Post Therapy
Generalised Anxiety Disorder
Diagnostic Category
Substance Abuse
Substance Dependence
Alcohol Abuse
Alcohol Dependence
Post Traumatic Stress Disorder
Obsessive Compulsive Disorder
Social phobia
Agoraphobia
Panic Disorder
Chronic Depression/Dysthymia
Major Depressive Episode
0 10 20 30 40 50 60 70 80 90 100
Pre-CBASP n= 74 Pre- CBASP Completers n=46 Post-CBASP n=46
Fig. 2. Diagnostic categories. Pre and post therapy. Figure shows the diagnostic
status at baseline assessment for all patients assessed (n ¼74) and for those 46
patients who completed treatment. Diagnostic status for completers (n ¼46) post
therapy is also shown.
3.3. Co-morbidity
Fig. 2 below shows that while all participants met criteria for
chronic depression there were high degrees of co-morbidity. Most
noteworthy were the percentages of patients also meeting DSM-IV
criteria for Generalised Anxiety Disorder (86.5%); Agoraphobia
(62.2%); Panic Disorder (58.1%) and Social Phobia (58.1%).
3.4. Trauma and early adverse life events
Fig. 3 details the findings relating to participants' retrospective
self assessment of the nature and severity of trauma and early
adverse life events; 47.3% (n ¼35) of our patients reported the
experience of significant emotional abuse, 31.1% (n ¼23) experi-
enced significant physical abuse, 20.3% (n ¼15) reporting signifi-
cant sexual abuse, 47.3% (n ¼35) experienced significant emotional
neglect and 24.3% (n ¼18) reported significant physical neglect.
3.5. Medication status
The dose, drug, and class of medication were recorded at
baseline and Defined Daily Doses (DDD) were calculated. The
DDD is the assumed average maintenance dose per day, for its
main indication in adults. Data for one patient were missing. The
majority of patients (66/73; 90%) were taking at least one anti-
depressant drug, with only seven patients (9.6%) taking no
medication at baseline. Of those patients taking medication,
32/66 (48.5%) were taking one drug; 22/66 (33.3%) were taking
two drugs; 9/66 (13.6%) were taking three drugs; and 3/66 (4.5%)
were taking four drugs. Overall, 34/66 (51.5%) were taking at least
two drugs. Of the 65 patients that were taking an antidepressant,
56 (86.2%) were taking a single antidepressant, and 9 (13.8%) were
taking two antidepressants. The class of drug used was: SNRI
(37.0%); SSRI (30.1%); NaSSA (17.8%); tricyclic antidepressant
(13.7%); and MAOI (1.4%). The high rate of prescription of SNRIs
is suggestive that many of these patients were not prescribed first-
line drug therapies.
The mean number of multiples of the Defined Daily Dose (DDD)
being taken was 1.94 and for most drug classes the mean multiple
of the DDD was between 1.5 and 2.0. Dosing of antidepressants
was, on average, at least 50% greater than the DDD. Of the 74
antidepressants being prescribed, 91% were at a dose equal or
greater than the DDD. In two cases where the dose was sub-
optimal, the patient was on multiple antidepressants (in combina-
tion) and the primary antidepressant was being taken at adequate
dose. In total, 61/73 (84%) patients were receiving at least one
antidepressant at a level equal to or greater than the DDD.
272 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276

Childhood Trauma Questionnaire (n=74)

None/Minimal Low/Moderate Moderate/Severe Severe/Extreme

73

% of Sample Reporting Trauma 64.9

47.3% Report 31.1% Report 20.3% Report 47.3% Report 56.8 24.3%
Significant Significant Signifcant Significant Report
Emotional Abuse Physical Sexual Abuse Emotional Signifcant
Abuse Neglect Physical
Neglect

35.10 33.8 32.4

28.4
24.3
20.3 18.9
17.6
13.5 14.9 13.5
10.8 12.2 10.8
6.8 8.1
4.1

Emotional Abuse Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect
Type of Trauma
Fig. 3. Trauma and early adverse life events: The Childhood Trauma Questionnaire. Figure shows patients retrospective self-report of how often certain childhood events
occurred.

Only three patients were taking an antidepressant at a dose lower
than the DDD and only seven patients (9%) were on no medication.
Two patients (3%) were receiving drugs for other indications
(disulfiram N ¼ 1; tramadol N ¼ 1). Between baseline and end-of-
therapy, 74% of participants reported no change in antidepressant
medication; 6% had reduced or discontinued antidepressant med-
ication; 11% reported new antidepressant medication had been
introduced; and 9% had doses of antidepressants increased.
3.6. Recruitment and retention
One hundred and fifteen patients were referred; seventy four of
those agreed to enter therapy. Therefore, 72.2% of those referred
went on to agree to trial of CBASP. Fifty two people completed
between 4 and 20 sessions and 46 of those attended post therapy
assessment. The mean number of sessions attended was 16.4
(SD ¼4.6) with the median (range) being 18.5 (4–22). One of our
aims was to establish if 20 hours of therapy within a 6 month
period was a viable target; a mean of 16.4 sessions attended
translates into a mean number of 18.5 hours of therapy, (sessions
1–4 were of one and half hours duration). The mean (7 SD)
number of sessions cancelled was 2.1 74.6 and the mean number
of sessions not attended was 0.9. For those who stayed engaged
with therapy past session 3, the drop-out rate was low (6/52 ¼
11.5%). There were no adverse/serious events observed or
recorded.
3.7. Changes in symptom severity
Table 1 reports the changes in HRSD-24 and BDI-II scores over
the six months of treatment. There was no difference on these
two, or in any other measures, at baseline for individuals who
dropped out of treatment between 0 and 3 sessions or for those
who continued in therapy (n ¼52) and for those who provided
post therapy data (n¼ 46). ANOVA with number of sessions as
covariate was performed.
3.7.1. HRSD-24
The mean 7SD HRSD-24 score pre-treatment was 26.9 76.5.
Post-treatment the mean value was 13.3 (SD ¼9.1; p o0.0001),
giving an uncontrolled effect size of d¼ 1.7. Multiple imputation
(MCMC method, 20 iterations) was performed on the datasets for
n¼ 52 and n ¼ 74, to take account of the degree of “missingness” in
the data arising from differential drop out and variation in number
of sessions completed in the 6 month treatment period. The
reductions in HRSD-24 and BDI-II (reported below) remained
statistically significant in both the imputed datasets (n ¼ 52 and
n¼ 74) and the dataset for the 46 “completers” (p o0.0001).
Treatment response was defined at the outset using the
following criteria: a score of 8 or less on the HRSD-24 was defined
as “remission”; “clinically significant improvement” was defined as
a score of 48 r15 þ50% reduction in HRSD-24 score and “no
change” as neither of the previous two criteria (Keller, 2000).
Table 1 reports the final categories post treatment (for both the
HRSD-24 and BDI-II). Fourteen (30.4%) individuals met criteria for
remission, 14 (30.4%) showed clinically significant improvement
and 18 (39.2%) individuals showed no change. In all, 28 out of 46
completers (60.8%) appeared to accrue substantial benefit from a
trial of CBASP. This represents 38% of the participants who
provided baseline data.
3.7.2. BDI-II
The mean score on the BDI-II changed from a pre-treatment
value of 38.8 (SD ¼10.7) to a post-treatment value of 24.2 (SD ¼
16.8; p o0.0001) giving an uncontrolled effect size of d ¼1.03.
Table 1 shows that prior to 6 months of therapy (n ¼74), 85.1% of
patients who began therapy were in the “Severe” classification,
10.8% in “Moderate”, 2.7% in “Mild” and 1.4% in the “Minimal”
category. Post treatment (n ¼ 46), 34.8% of patients were in the
“Minimal” category, 13% in “Mild”, 8.7% in “Moderate” and 43.5%
the “Severe” category.
Repeating this analysis using cut-off points for the HRSD-24
(0–9 ¼ None; 10–17 ¼Mild; 18–26 ¼Moderate; 27–38 ¼Severe and
39–50/75 ¼ Very severe) showed that prior to therapy 9 of the 74

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 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276 273

Table 1
HRSD-24 and BDI-II: ANOVA with number of sessions as covariate with counts of changes in category of BDI-II and HRSD-24.

ANOVA with number of sessions as covariant

Measure Pre-therapy/baseline Post therapy

0–3 sessions (n¼ 22) 4–20 sessions Total (n¼ 74) 4–20 sessions (n¼ 52) P value
Mean (SD) (n ¼52) Mean (SD) Mean (SD) Mean (SD) significance

HRSD-24 25.7 (7.51) 27.3 (6.10) 26.9 (6.50) 13.3 (9.07) o0.0001
BDI-II 38.1 (11.38) 39.1 (10.55) 38.8 (10.70) 24.2 (16.87) o0.0001

Changes in clinical severity for the BDI-II

Category of severity Pre therapy Post therapy

0–3 sessions 4–20 sessions Total (n¼74) 4–20 sessions

(n¼ 22) N (%) (n ¼52) N (%) N (%) (n¼ 52) N (%)

Minimal (0–13) 1 (4.5) 0 (0.0) 1 (1.4) 16 (34.8)

Mild (14–19) 0 (0.0) 2 (3.8) 2 (2.7) 6 (13.0)
Moderate (20–28) 2 (9.1) 4 (11.5) 8 (10.8) 4 (8.7)
Severe (29–63) 19 (86.4) 46 (85.2) 63 (85.1) 20 (43.5)

HRSD-24: Remission, significant improvement and no change

Category Patients who completed 4–20 sessions (n ¼46) N (%)

Remission r8 HRSD score 14 (30.4)

Clinically significant improvement r 15þ50% reduction in HRSD score 14 (30.4)
No change (neither of above) 18 (39.2)

BSI Subscales and GSI Global Index BSI Subscales and Global Severity Index Pre and Post

Pre and Post CBASP CBASP (Outpatient norms)

70
85
65
80
60
Mean T-Score

Mean T Socres

75
70 55

65 50
60 45
55 40
50
35
45
30
40 Som O-C I-P Dep Anx Hos Phob Par Psychot GSI
Anx

Clincal Norms Pre-CBASP (n=74) Post CBASP (n=46)

Fig. 5. BSI profile (pre-therapy (n ¼74) and post-therapy (n¼ 46)) in comparison to
Non-Clinical Norms Pre-CBASP Completers n=46 outpatient norms. Figs. 4 and 5 show T-scores on the nine BSI subscales plus the
Pre-CBASP n=74 Post CBASP global severity index (GSI) pre and post treatment in relation to clinical (adult
psychiatric outpatients) and non-clinical normative data. Fig. 4 shows the baseline
Fig. 4. T scores on BSI subscales and the GSI global index pre- therapy compared to profile for those patients who went on to complete therapy to allow comparison of
adult “non-patient” norms at baseline (n¼ 74) and for that group of patients who profiles of symptom burden between the group who began therapy (n ¼74) and the
completed therapy (n¼ 46) with post therapy BSI profile (n ¼46). group who completed (n¼ 46).

patients (9.5%) were in the “Very severe” category; 37 (50%) were
in the “Severe” category; 30 (40.5%) were in the “Moderate”
category and no patients were placed in the “Mild” or “None”
categories. Post therapy, of the 46 patients who completed, none
were in “Very severe”; 3 (6.6%) were in “Severe”; 8 (17.4%) were in
“Moderate”; and 17 (36.9%) and 18 (39.1%) patients were now in
the “Mild” and “None” categories respectively.
3.7.3. BSI
Fig. 4 shows T-scores on the nine BSI subscales and global
severity index for entrants and completers at baseline, and for
completers post-therapy, relative to non-clinical adult normative
data. With the exception of the paranoid subscale the symptom
profile of entrants and completers are very closely-matched and
both groups fall between 2 and 3 standard deviations above adult
norms. Post-therapy (n ¼46) there was a reduction across all
subscales and the GSI with values falling between about 2.5 to
1 standard deviation above non-clinical adult norms. Notably
there is a reduction of about 1 standard deviation on the hostility
subscale and the global severity index with a reduction of
1.5 standard deviations in the paranoid ideation subscale.
Fig. 5 repeats the above analysis using adult psychiatric
normative data and pre and post scores for completers. In the
comparison with adult psychiatric outpatient norms, the spread of
differences in standard deviation across the 9 dimensions and the
GSI prior to therapy is 0.5 to 1.5 above outpatient norms. Six
months of CBASP was associated with a reduction in all subscales
of about 1–0.5 standard deviations. On the sub-scales relating to
interpersonal sensitivity, depression, anxiety, hostility and para-
noid ideation, the reductions are about 0.75 of a standard devia-
tion from the mean of outpatient norms. Overall the difference in

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274 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276
the GSI between pre and post therapy is statistically significant at
p ¼0.01; the difference in positive symptom total (PST), pre-
therapy¼41.8 (SD ¼8.40) to post-therapy ¼36.9 (SD ¼12.37) is
significant at p o0.01; the difference in the positive symptom
distress index (PSDI), pre-therapy¼2.80 (SD ¼1.38) to post-
therapy¼1.9 (SD ¼0.94) is significant at p o0.01.
3.7.4. Changes in diagnostic/co-morbidity status
Fig. 1 (above) shows that, whereas all participants met diag-
nostic criteria for MDE AND chronic depression pre-therapy, post-
therapy 67.9% of patients no longer met diagnostic criteria for
major depression. Also noteworthy is the 32.9% reduction in
patients meeting DSM-IV criteria for GAD, the 26% reduction in
the Social Phobia category with reductions of around 20% in the
majority of the other diagnostic categories.
4. Discussion
We sought to recruit a cohort of patients who met diagnostic
criteria for chronic depression but who also represented the
population of patients who present to publicly funded secondary
care mental health services in the UK. We wished to establish the
proportion of patients who would engage with and potentially
respond to, a trial of 20 sessions of CBASP over a 6 month period. A
further aim was to provide a detailed description of the clinical
characteristics of the chronic depression sample.
In recruiting and assessing participants in this case series, we
aligned with Klein's position with respect to the utility of viewing
chronic depression as a unitary category (Klein, 2008; Klein, 2010).
While it has been established that individuals with chronic depres-
sion differ from those with non-chronic depression on a variety of
clinically and aetiologically significant variables, a range of studies
have shown there are no differences between the different forms of
chronic depression on these clinically and aetiologically significant
variables. Neither is there compelling evidence that supports
maintaining existing distinctions between dysthymia and other
forms of chronic depression that are “stable, aetiologically mean-
ingful or clinically useful” (Cassano and Savini, 1993; McCullough,
Klein et al., 2000; McCullough et al, 2003; Klein, 2010).
Baseline assessment revealed high levels of depressive symp-
toms and an elevated general psychopathological symptom bur-
den. Patients also reported well established, on-going multi-
agency contact with mental health services over lengthy periods
of time. The mean length of the current depressive episode at
baseline was 15.5 years. Ninety per cent of participants were
taking antidepressant medication. Our data revealed that there
were robust levels of antidepressant treatments over considerable
time periods prior to the introduction of 6 months of CBASP. Over
the 6 month study medication rates remained constant and no
new pharmacotherapy regimes were initiated during the study.
A mean of 16.4 sessions (18.5 h) of CBASP were administered and
61% of patients made significant clinical gains. Thirty per cent
achieved remission and 30% met criteria for clinically significant
improvement. These rates of remission and improvement somewhat
paralleled the Keller et al. study using the HRSD-24 pre- post treat-
ment scores (Keller 2000). These changes in depressive symptom
burden associated with up to 20 sessions of CBASP in a 6 month
period compare favourably with those found for 20 sessions of
cognitive therapy by Paykel (Paykel et al., 1999) where remission
rates were 25%. Comparison with the benchmark study in CBASP by
Keller (2000) where the overall response rate was 48% in the
psychotherapy only group shows that our overall improvement rate
of 61% was favourable and rather better when compared with the
overall response rates of 37.5% (remission rate of 15% with mean of
12 sessions) achieved by Kocsis et al. (2010). A recent randomised
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controlled trial (CoBalT) examining the efficacy of adapted CT in
‘treatment resistant depression' for patients in primary care in the
UK found that 46% of participants in the intervention group
(6 months of adapted CT; 12–18 sessions) met criteria for response
(at least 50% reduction in BDI score pre to post) (Wiles et al., 2012).
The degree of chronicity of depression in the CoBalT trial was
variable. It is worth noting that the apparent response rate in our
series is in the context of 100% of our participants meeting diagnostic
criteria for chronic depression compared to 58% in the intervention
group in the CoBalT study.
In our study, benefits other than reduction in depressive
symptomatology were evident after 6 months of therapy. Specific
pre-and post-treatment assessments of symptoms and diagnostic
status showed a reduction in the degree of co-morbidity. (See
Fig. 1) This reduction in symptom burden was reflected in changes
in the Brief Symptom Inventory (BSI). Significant changes across all
eight dimensions as well as the BSI global severity index indicate that
there was a reduction in the general psychopathological symptom
burden. Reductions in the scores observable in all subscales of the BSI
were achieved. Noteworthy were the reductions in Hostility (1 SD)
and Paranoid Ideation (1.5 SD) in comparison with non-patient
normative values; these notable reductions persist when the com-
parison is made with psychiatric outpatient values with reductions of
around 0.75 of a standard deviation for Interpersonal Sensitivity,
Hostility and Paranoid Ideation.
CBASP is a therapy designed and targeted towards chronic
depression and it appeared to exert broader beneficial effects on
psychopathology. Most noteworthy was the 32.9% reduction in
patients meeting DSM-IV criteria for GAD, the 26% reduction in the
Social Phobia category with reductions of around 20% in the
majority of the other diagnostic categories.
CBASP, unlike “Beckian” cognitive therapy (CT) (Beck et al., 1979)
has been designed specifically to treat the chronically depressed
patient. CBASP is specifically constructed as a behaviourally orientated
therapy with an essential interpersonal focus. Patient problems are
not formulated from the “inside-out” or in terms of conditional beliefs
that are assumed to potentiate vulnerability to depression as well as
being responsible for lack of response to treatment. In CBASP, there is
an emphasis on an “outside-in” perspective. CBASP conceptualises
thoughts or cognitions as important, but only as a step in a chain of
intra-personal events that lead to behaviour that has identifiable
interpersonal consequences. Interpersonal consequences “trump”
cognitions in CBASP; this is not the case in CBT where cognitions
take primacy over interpersonal consequences. CBASP aims to con-
nect/re-connect the chronically depressed person with the fact that
unpleasant or personally troubling social consequences are often
self-productions and related to overly passive/dominant or overly
hostile/friendly social behaviours. Once this connection is established
patients are taught to be goal directed in how to better navigate social
interactions. More effective social behaviours and attitudes are taught
and hopefully instilled over time allowing patients to meet their
desired outcomes for more personally positively rewarding conse-
quences in their social world (Swan and Hull, 2007). The significant
shifts in the Hostility, Interpersonal Sensitivity and Paranoid Ideation
as well as the Depression and Anxiety may indicate that CBASP is
targeting and improving social behaviour. Constantino et al. have also
found that interpersonal change is linked to depression reduction in
chronically depressed patients. More specifically they found that a
decrease in Hostility is associated with greater degrees of depression
reduction over time (Constantino et al., 2012).
4.1. Limitations of the study
Interpretation of these data is limited by the absence of a control
or comparison group, the co-administration of psychotropic med-
ication and the lack of rater blinding to treatment. The fact that all
 J.S. Swan et al. / Journal of Affective Disorders 152-154 (2014) 268–276
patients treated were Caucasian though highly representative of the
Scottish/UK population in terms of religious and cultural beliefs
may limit generalisation of results.
A potential additional limitation of the study is related to the
“dose” of therapy. While the mean number of sessions given in
6 months in our study (16.4), is the same as the mean number of
sessions achieved in the original Keller trial (Keller, 2000) and we
approached our ad hoc target of a desired 20 h of therapy (18.4 h)
it may be that more hours/sessions spent in therapy might have
led to improved outcomes.
4.2. Strengths of the study
First, trained raters were utilised who remained independent
from the team of therapists and had no theoretical or practice
affiliation with the therapy. Second, study participants were care-
fully described by detailed structured clinical assessment and
rigorous inclusion/exclusion criteria were adhered to. Third, we
were careful to establish that participants had well-established
routine mental healthcare in place for considerable periods of time
prior to CBASP. There was little or no change in these treatment
regimes during the study. Therapists followed a treatment protocol
and analysis shows high fidelity to the treatment model. Fourth, all
eleven therapists were rigorously trained to administer the CBASP
model and had met training criteria. Another strength of the study
which led to acceptable fidelity ratings was that regular and frequent
clinical supervision was administered throughout the study.
One subsidiary, but important, aim of the study was to establish
the acceptability of CBASP to patients in the UK NHS. It appears that
CBASP may contain some characteristics that ameliorate the usually
high attrition rates found in this group of patients. Seventy four or
72.2% of all those referred agreed to a trial of CBASP therapy with 19
(26%) leaving therapy prematurely between the first and third
sessions. For the 55 patients who received between 4 and 20
sessions, only 6 (11%) withdrew. This attrition rate of around 11%
is markedly low compared to other studies of psychological therapy
in depression and represents attrition rates of 50% less than those
found in mental health services (Wells, 2013). Therefore, once
patients remained in the study after 3 sessions, attrition rates
dropped markedly. The presence of differential attrition rates –
moderately high (26%) in early sessions (0–3), versus markedly low
(11%) attrition rates in later sessions (4–20) – is intriguing. One
possible explanation for this differential may lie in the focus of the
early preparatory assessment sessions in CBASP. In practice, sessions
1–4 are taken up with a review of the course of the patient's chronic
depression over time and with assessing the nature and effect of a
small and select number of significant relationships. While this
focus is vital to what lies ahead in a course of CBASP, it does not
provide the opportunity for relief of interpersonal distress in the
way that time spent in CBASP beyond session 4 might.
Summarily, the findings reported in this paper appear to support
the proposition that CBASP may be an effective and acceptable
treatment within a public healthcare system. However, much
remains to be done. Given the relapsing nature of depression,
especially in the context of chronic depression, it is important to
establish the longer term outcomes of this intervention. Looking
further into the future, there is the need to evaluate the efficacy
of CBASP in a formal RCT comparing CBASP with CBT adapted for
chronic depression.
Role of funding source
The authors wish to acknowledge the Chief Scientist Office, Scotland and NHS
Tayside Endowments for grant support and the Scottish Mental Health Research
Network for assistance with data collection.
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275
Conflict of interest
KM has been a member of advisory boards for studies into Deep Brain
Stimulation for Obsessive-Compulsive Disorder and Depression sponsored by
Medtronic. He has received educational grants from CyberonicsInc and Schering
Plough, and has received research funding from St Jude Medical for a multi-centre
clinical trial of Deep Brain Stimulation for depression. He has received travel and
accommodation support to attend meetings from Medtronic and St Jude Medical.
DC has received consultancy fees from Servier Laboratories and honoraria for
lectures from Wyeth and Lilly. He has received travel and accommodation expenses
to attend training meetings from Medtronic and Cyberonics Inc. He has been
involved in research studies sponsored by Cyberonics Inc. and St Jude Medical.
Acknowledgements
The authors wish to thank Frances Robertson for her contribution to study
management and data collection and to the other study therapists: Marianne
Liebing-Wilson, Victor Morton, Fiona Wilson, Maureen Robertson in Tayside and
Patricia Graham, Massimo Tarsia and Stewart Buchan in Lothian
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