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There are several methods utilized in the treatment of mental health-related issues. CBT, DBT, PE, CPT, Behavior therapy, reality therapy, and REBT are just a few of those common therapies. It is not uncommon for patients to also consider alternative treatment methods such as acupuncture, hypnosis, religious/spiritual counseling, ECT, pharmacology, cultural healer/medicine man etc. For this paper, you will discuss various types of treatment approaches, both psychotherapeutic and alternative therapeutic practices, as well as the role of the clinical manager in supporting the clinician during the patient’s treatment process.General Requirements:Use the following information to ensure successful completion of the assignment:This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.This assignment requires that at least two additional scholarly research sources related to this topic, and at least one in-text citation from each source be included.You are required to submit this assignment to LopesWrite. Refer to the directions in the Student Success Center.Directions:Write a paper (1,250-1,500 words) discussing the various types of treatment approaches, both psychotherapeutic and alternative therapeutic methods, as well as the role of the clinical manager in supporting the clinician during the patient’s treatment process. Include the following in your paper:A brief identification and explanation of one psychotherapy treatment and one non-traditional or alternative treatment approach.A research-based contrast of the application of these treatments when working with clients presenting anxiety, depression, personality disorder, or PTSD.A research-based discussion of the role of the clinical manager when working with a clinician serving a client that expressed interest in including an alternative treatment method as part of the overall treatment plan.A research-based argument for the acceptance of a psychopharmacology approach for some disorders.Rubric:A brief identification and explanation of one psychotherapy treatment and one non-traditional or alternative treatment approach is thoroughly presented.A research-based contrast of the application of these treatments is thoroughly presented. Ideas are supported with scholarly current or seminal research.A research-based discussion of the role of the clinical manager is thoroughly presented. Ideas are supported with scholarly current or seminal research.A research-based argument for the acceptance of a psychopharmacology approach is thoroughly presented. Ideas are supported with scholarly current or seminal research.Synthesis of source information is present and is scholarly. Argument is clear and convincing, presenting a persuasive claim in a distinctive and compelling manner. All sources are authoritative.All required elements are present. Scholarly research sources are topic-related, and obtained from highly respected, professional, original source.Thesis and/or main claim are clear and comprehensive; the essence of the paper is contained within the thesis.The document is correctly formatted. In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error.Reference and material to read:Wheeler, R. B. (2012). Alternative treatments for mental health. Everyday Health.URL:http://www.everydayhealth.com/alternative-health/treatment-regimens/alternative-approaches-to-mental-health-care.aspxMehl-Madrona, L. E. (n.d.). Development of an integrated program with conventional American medicine and evaluationof effectiveness. Traditional (Native American) Indian Medicine.URL:http://www.healing-arts.org/mehl-madrona/mmtraditionalpaper.htm
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Journal of Consulting and Clinical Psychology
2012, Vol. 80, No. 6, 995–1006
© 2012 American Psychological Association
0022-006X/12/$12.00 DOI: 10.1037/a0030452
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Comparative Effectiveness of Medication Versus Cognitive-Behavioral
Therapy in a Randomized Controlled Trial of Low-Income Young Minority
Women With Depression
Juned Siddique
Joyce Y. Chung
Northwestern University
National Institute of Mental Health, Bethesda, Maryland
C. Hendricks Brown
Jeanne Miranda
University of Miami
University of California, Los Angeles
Objective: To examine whether there are latent trajectory classes in response to treatment and whether
they moderate the effects of medication versus psychotherapy. Method: Data come from a 1-year
randomized controlled trial of 267 low-income, young (M ⫽ 29 years), minority (44% Black, 50%
Latina, 6% White) women with current major depression randomized to antidepressants, cognitivebehavioral therapy (CBT), or referral to community mental health services. Growth mixture modeling
was used to determine whether there were differential effects of medication versus CBT. Depression was
measured via the Hamilton Depression Rating Scale (Hamilton, 1960). Results: We identified 2 latent
trajectory classes. The first was characterized by severe depression at baseline. At 6 months, mean
depression scores for the medication and CBT groups in this class were 13.9 and 14.9, respectively
(difference not significant). At 12 months, mean depression scores were 16.4 and 11.0, respectively (p
for difference ⫽ .04). The second class was characterized by moderate depression and anxiety at baseline.
At 6 months, mean depression scores for the medication and CBT groups were 4.4 and 6.8, respectively
(p for difference ⫽ .03). At 12 months, the mean depression scores were 7.1 and 7.8, respectively, and
the difference was no longer significant. Conclusions: Among depressed women with moderate baseline
depression and anxiety, medication was superior to CBT at 6 months, but the difference was not sustained
at 1 year. Among women with severe depression, there was no significant treatment group difference at
6 months, but CBT was superior to medication at 1 year.
Keywords: personalized medicine, paroxetine, buproprion, CBT, growth mixture model
Major depression, a disorder with early onset and an often
chronic course, imposes a high individual burden of pain, suffering, and disability. Ethnic minority and poor individuals are less
likely to receive treatment, particularly guideline-informed care,
for major depressive disorder than are White and middle-class
individuals (U.S. Department of Health and Human Services
[DHHS], 2001). This may be related to the fact that most depression treatment studies include primarily White and middle-class
populations (DHHS, 2001), so that little is known about the
usefulness of established treatments for more disadvantaged populations. Establishing the effectiveness of depression care in this
population is particularly important because rates of depression are
elevated in women, younger age cohorts, and those living in or
near poverty (Andrade et al., 2003). Because low-income women
with depression have few resources and many challenges to overcome to begin and continue with treatment, it is important to make
thoughtful, personalized decisions regarding the most effective
intervention for a given patient. If an initial treatment strategy is
This article was published Online First October 22, 2012.
Juned Siddique, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine; Joyce Y. Chung, National Institute
of Mental Health, Bethesda, Maryland; C. Hendricks Brown, Department
of Epidemiology and Public Health, University of Miami Miller School of
Medicine; Jeanne Miranda, Department of Psychiatry and Biobehavioral
Sciences, University of California, Los Angeles.
This work was supported by Agency for Healthcare Research and
Quality Grant R03-HS018815, National Institute of Mental Health
(NIMH) Grant R01-MH040859, and National Cancer Institute Grant
K07-CA154862. None of the funding agencies played a role in the
design and conduct of the study; collection, management, analysis, and
interpretation of the data; or preparation, review, or approval of the
article. Juned Siddique, Joyce Y. Chung, and Jeanne Miranda do not
have any conflicts of interest to disclose. C. Hendricks Brown is
principal investigator on two NIMH grants that evaluate the impact of
antidepressants (R01-MH040859 and R01-MH080122). He has also
served as a principal investigator on a research grant funded by JDS
Pharmaceuticals that supported the evaluation of a behavioral prevention program for suicide.
Correspondence concerning this article should be addressed to Juned
Siddique, Department of Preventive Medicine, Northwestern University
Feinberg School of Medicine, 680 North Lake Shore Drive, Suite 1400,
Chicago, IL 60611. E-mail: [email protected]
995
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
996
SIDDIQUE, CHUNG, BROWN, AND MIRANDA
not effective, patients may not have the additional resources or
the desire to pursue another course of treatment. In this article we
describe an exploratory analysis to investigate whether there are
latent trajectory classes in response to treatment and whether these
latent classes moderate the effects of antidepressants versus cognitive behavioral therapy (CBT) in a sample of low-income young
minority women.
Comparative effectiveness research has recently received a considerable amount of attention due to the desire by many stakeholders to have more evidence about the relative merits and costs of
medical interventions. The U.S. Congress asked the Institute of
Medicine as part of the American Recovery and Reinvestment Act
of 2009 to determine national priorities for comparative effectiveness research. Among the 100 highest priority research topics
identified by the Institute of Medicine, Committee on Comparative
Effectiveness Research Prioritization (2009), was “Compare the
effectiveness of pharmacologic treatment and behavioral interventions in managing major depressive disorders in adolescents and
adults in diverse treatment settings” (p. 111).
There are three key features of comparative effectiveness research: (1) direct comparison of effective interventions, (2) their
study under real-world conditions, and (3) research on what patients benefit the most from a given intervention (Sox & Greenfield, 2009; Wang, Ulbricht, & Schoenbaum, 2009). The need for
comparative effectiveness research is particularly pressing in the
area of mental disorders because only about one fourth of individuals with a mental disorder receive minimally adequate treatment
(Wang, Demler, & Kessler, 2002).
Effective treatments for major depression include antidepressant
medications and psychotherapies (American Psychiatric Association [APA], 2000; Thase & Kupfer, 1996). Most U.S. psychiatrists
favor selective serotonin reuptake inhibitors for first-line medication treatment (Olfson & Klerman, 1993), with treatment extended
to at least 6 months to maintain clinical effectiveness (Agency for
Healthcare Research and Quality [AHRQ], 1993). CBT is also an
effective treatment for major depression. Several studies have
found the effectiveness of psychological and medical interventions
for depression to be similar (Bortolotti, Menchetti, Bellini, Montaguti, & Berardi, 2008; Casacalenda, Perry, & Looper, 2002;
DeRubeis et al., 2005).
Other work has shown that CBT produces sustained clinical
gains compared with antidepressant medications that are withdrawn after clinical response (Blackburn, Eunson, & Bishop, 1986;
Evans et al., 1992; Kovacs, Rush, Beck, & Hollon, 1981; Miller,
Norman, & Keitner, 1989; Shea et al., 1992; Simons, Murphy,
Levine, & Wetzel, 1986). In a study of responders to 16 weeks of
treatment, patients treated with cognitive therapy were more likely
to have a sustained response during 12-month follow-up than were
those withdrawn from medications; and they were just as likely to
have sustained response as patients who kept taking medications
through the follow-up (Hollon et al., 2005). These results suggest
that CBT may have important advantages over the long term by
preventing relapse after treatment has ended.
Here we performed a comparison of antidepressants versus CBT
over the course of a year using data from the Women Entering
Care (WECare) study—a clinical trial of predominantly poor
young minority women with depression. Initial analyses of the
WECare data examined the effectiveness of medication or CBT
interventions versus community referral (Miranda et al., 2003,
2006). The WECare investigators found that both guidelineconcordant antidepressant medication and a cognitive-behavioral
psychotherapy were significantly more effective than referral to
mental health care in the community for lowering depressive
symptoms and improving functioning at 6 and 12 months after
depression was identified. At 6 months, depression treatment outcomes showed that 44.4% of medication, 32.2% of psychotherapy,
and 28.1% of community referral patients had remitted (Miranda et
al., 2003). At 12-months, remission rates were 51% for medication, 57% for CBT, and 37% for treatment as usual (TAU; Miranda
et al., 2006). Unlike the present analysis, these earlier analyses
assumed that all participants’ trajectories centered around a single
average trajectory over time, an assumption that may not be
reasonable in the presence of large amounts of between-subjects
heterogeneity. In our study, we investigated whether a single
underlying trajectory pattern is a valid assumption or whether a
more complex model with multiple trajectories fits the WECare
data better.
Patients, practitioners, and third-party payers seek guidance as
to the type, amount, and cost of treatments that are effective for
depression. The current state of the field is that there is no good
method to predict which patients with depression will do better on
medications versus psychotherapy and, within each treatment modality, which agent or approach is more effective. For most people
with depression, the current evidence base does not point to either
medication or psychotherapy as working better than the other.
In the present study, we compared the two active WECare
interventions (medication and CBT) using a novel statistical
method, growth mixture modeling (B. Muthén et al., 2002; B.
Muthén & Shedden, 1999), which allowed us to identify and
predict multiple response trajectories. We began by identifying
several subtypes of clinical response trajectories among the
WECare subjects and then compared the effectiveness of antidepressant medication versus cognitive-behavioral therapy within
these trajectories.
After modeling the various response trajectories in the WECare
data, we classified participants into the response trajectories in
terms of their baseline characteristics to identify which patients
were more likely to benefit from a given intervention. Our overall
goal was to contribute to the development of personalized interventions for individuals with depression.
Method
Study Design
The data used in this analysis come from the WECare clinical
trial conducted by Miranda et al. (see Miranda et al., 2003, 2006,
for details on their design and methods). Details about participant
selection, exclusion, and randomization are summarized the Appendix. Briefly, the study used the Primary Care Evaluation of
Mental Disorders (Spitzer et al., 1994) as a depression screen in
women attending social service agencies and safety net health
clinics (e.g., Title X family planning clinics) in Prince George’s
and Montgomery Counties, Maryland, and in Arlington and Alexandria, Virginia. Women who screened positive for major depression (11% of those assessed) were invited to participate in confirmatory psychiatric diagnostic telephone interviews. Subjects were
excluded if they failed to meet a Composite International Diag-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
COMPARATIVE EFFECTIVENESS OF MEDICATION VERSUS CBT
nostic Interview (CIDI; World Health Organization [WHO], 1997)
diagnosis of major depression; were bereaved; were suicidal; had
symptoms of mania, psychosis, current alcohol, or other substance
abuse; were pregnant or planned to become pregnant; were currently breastfeeding; or were currently receiving mental health
care. Those women with confirmed major depressive disorder
diagnoses who were willing to participate in the study were randomized to receive pharmacotherapy, CBT, or community referral.
Raters were blinded to treatment assignment. The study recruited
a diverse ethnic sample of women (i.e., Latinas born in Latin
America and African American and White women). Ethnicity was
self-reported based on options defined by the study investigators.
The study was approved by the relevant institutional review
boards, and all patients provided written informed consent.
Two hundred sixty-seven women consented to treatment and
were randomized to one of the three treatment groups. The pharmacotherapy group (n ⫽ 88) received paroxetine, with a mean
dose of 30 mg daily and a range of 10 –50 mg (dosing protocol
adjusted for response and reported adverse effects). The duration
of this medication intervention was 6 months, in line with guidelines for the acute and maintenance phases of depression treatment
(AHRQ, 1993). The study did not offer medication treatment after
6 months, but women could seek continued medication treatment
elsewhere if desired. Paroxetine treatment was managed by primary care nurse practitioners under the supervision of a boardcertified psychiatrist (Joyce Y. Chung). Eighteen (20%) patients
unable to continue paroxetine were switched to bupropion therapy
(mean dose ⫽ 229 mg/day, range ⫽ 100 – 450 mg).
Women in the CBT group (n ⫽ 90) received therapy from
experienced psychotherapists who were previously trained in CBT.
Therapists were supervised by a licensed clinical psychologist with
CBT expertise who conducted weekly group supervision to ensure
adherence to the treatment. The manual-guided treatment was
eight weekly sessions administered in group or individual sessions
(Muñoz, Aguilar-Gaxiola, & Guzman, 1986; Muñoz & Miranda,
1986). All patients in this arm were provided protocol-based CBT
based on the course manual, and treatment involved homework
and monitoring activities. Cognitive-behavior therapy could be
extended an additional 8 weeks if the patient still met criteria for
major depressive disorder and wanted additional therapy (15
[17%] received an additional course of CBT).
Therapists attempted to get each woman randomized to CBT
into group care for cost-effectiveness reasons. When strong preferences or scheduling issues prevented them from joining a group,
women were offered individual CBT. Of the 90 women assigned
to psychotherapy, 32 (35.5%) completed a course of CBT defined
as six or more CBT sessions. Fifteen of the 32 received group
CBT, and 17 received individual CBT. Both groups received the
same manual-guided treatment. Latinas were much more likely to
receive individual CBT compared with African Americans and
Whites. Eighty-three percent of Latinas who completed a course of
CBT received individual CBT, compared with 14% of African
Americans and Whites. Otherwise, there were no significant differences between women who received individual CBT and those
who received group CBT in terms of any of the other baseline
variables in Table 1.
Women in the community referral group (n ⫽ 89) were educated about depression and mental health treatments available in
the community. Clinicians offered to make an appointment for the
997
women at the end of the clinical interview to facilitate the referral
and to speak with the mental health clinician. Approximately one
quarter of the women declined referral. Referred participants were
contacted by the referring clinician within 1–2 weeks of referral to
encourage them to attend the community care program. All women
in the WECare study were followed for 12 months regardless of
whether they continued to receive study treatments.
Measures
Our primary outcome was the Hamilton Depression Rating
Scale (HDRS; Hamilton, 1960). WECare participants completed a
structured version of the HDRS (Williams, 1988) by telephone at
baseline, monthly for 6 months, and at Months 8, 10, and 12. Both
the American Psychiatric Association (APA; 2000) and the National Institute for Health and Clinical Excellence (NICE; 2009)
have recommended using HDRS cutoff values of 7, 13, 18, and 22
to classify subjects into different depression categories. Participants with HDRS scores of 7 or less are referred to as “not
depressed.” Cutoff values of 13, 18, 22, and ⱖ23 are used to
classify participants into “mild,” “moderate,” “severe,” and “very
severe” depression categories, respectively. These are the names
given by the APA. NICE uses different names but the same cutoff
points.
Anxiety was measured at baseline, Month 6, and Month 12
using the Hamilton Anxiety Rating Scale (HAM-A; M. Hamilton,
1959), a 14-item rating scale that measures both psychic and
somatic anxiety. Screening interviews assessed demographics, insurance status, income, and interest in treatment.
Sample
Demographic and clinical characteristics of the sample are presented in Table 1. The sample was made up of young minority
women, the majority of whom were uninsured and living below or
near the poverty level. There were no significant differences at
baseline among the randomly assigned intervention groups on
demographics, baseline depression, baseline anxiety, current diagnoses from the CIDI, and interest in treatment. Women randomly
assigned to medications reported somewhat higher levels of depressive symptoms at baseline than did the other two groups, a
difference that neared significance (p ⫽ .06). Based on diagnoses
from the CIDI, about half the women were experiencing a mild to
moderate episode and 47% a severe episode. Depression severity
was determined based on responses to structured interview questions from the CIDI. In addition to a diagnosis of MDD, 46% of
the women also had panic disorder, agoraphobia, social phobia,
and/or generalized anxiety disorder. Most of the women were
interested in receiving treatment.
Table 2 provides mean HDRS scores, percentage missing, and
cumulative measurement dropout at each time point by treatment
group. By Month 6, approximately 84% of participants had been
retained in the study. By Month 12, the retention rate was 76%.
The difference in dropout rates across the three treatment groups
was not significant (p ⫽ .27).
Growth Mixture Modeling
A frequent characteristic of depression clinical trials (including
the WECare study) is that outcomes over time are subject to
SIDDIQUE, CHUNG, BROWN, AND MIRANDA
998
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Table 1
WECare Variables at Baseline by Treatment Group
Variable
Total (n ⫽ 267)
Age in years, mean (SD)
Marital status, n (%)
Married or living with partner
Widowed or separated/divorced
Never married
No. of children, mean (SD)
Ethnicit …
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