Group Cognitive Behavioural Analysis System of Psychotherapy (CBASP) for persistently depressed outpatients:a retrospective chart review

BACKGROUND: Cognitive behavioural analysis system of psychotherapy (CBASP) is an effective individual treatment for persistent depressive disorder (PDD), but evidence on group treatment (Group-CBASP) is limited. Our aim was to review the effect of Group-CBASP on self-report depression severity in outpatients with PDD, overall and by age of depression-onset. METHODS: A retrospective chart review study (November 2011-March 2017) in 54 patients with PDD (29 late-onset, 25 early-onset). Patients were previously treated by pharmacotherapy (92.6%), psychotherapy (98.1%) and/or electroconvulsive therapy (11.1%). Group-CBASP involved 24 weekly sessions during 6 months, followed by individual appointments over 6 months. The Inventory of Depressive Symptoms -self rating(IDS-SR) was used at baseline and after 3, 6, 9 and 12 months, computing mean differences and response rates. RESULTS: The mean IDS-SR score decreased significantly from 39.83 at baseline to 33.78 at 6 months: a decrease from severe to moderate depression after 24 weeks of Group-CBASP, with a medium effect size (Cohen's d = .49). At 12 months, the mean IDS-SR score was 32.81, indicating moderate symptom levels remained. At 6 and 12 months, mean IDS-SR scores were similar among late- versus early-onset patients, but at 12 months response rates were higher among late-onset patients. LIMITATIONS: Although results of our study provide valuable input for future prospective studies, limitations were the use of a retrospective design and the small group size. CONCLUSION: Group-CBASP offered to an outpatient population with PDD was associated with clinically relevant decrease in self-reported symptom severity, and with sustained response particularly in patients with late onset of depression. PRACTITIONER POINTS: Group-CBASP seems to be a good alternative for CBASP in individual setting. Patients with late age of depression-onset seem to benefit more from Group-CBASP. This study shows that clinical relevant effects of Group-CBASP, followed by individual contacts, remain at least for 6 months. Research on personalizing treatment strategies is needed to improve patient assignment for Group-CBASP

Cognitive Functioning in Patients with Bipolar Disorder: Association with Depressive Symptoms and Alcohol Use

BACKGROUND: Cognitive dysfunction is clearly recognized in bipolar patients, but the degree of impairment varies due to methodological factors as well as heterogeneity in patient populations. The goal of this study was to evaluate cognitive functioning in bipolar patients and to assess its association with depressive symptoms. Post hoc the relationship with lifetime alcohol use disorder was explored. METHODOLOGY/PRINCIPAL FINDINGS: The study included 110 bipolar patients and 75 healthy controls. Patients with severe depressive symptoms, (hypo)manic symptoms and current severe alcohol use disorder were excluded. Diagnoses were evaluated via the Mini-International Neuropsychiatric Interview. Cognitive functioning was measured in domains of psychomotor speed, speed of information processing, attentional switching, verbal memory, visual memory, executive functioning and an overall mean score. Severity of depression was assessed by the Inventory of Depressive Symptomatology-self rating. Patients were euthymic (n = 46) or with current mild (n = 38) or moderate (n = 26) depressive symptoms. Cognitive impairment was found in 26% (z-score 2 or more above reference control group for at least one domain) of patients, most prominent in executive functioning (effect size; ES 0.49) and speed of information processing (ES 0.47). Depressive symptoms were associated with dysfunction in psychomotor speed (adjusted beta 0.43; R(2) 7%), speed of information processing (adjusted beta 0.36; R(2) 20%), attentional switching (adjusted beta 0.24; R(2) 16%) and the mean score (adjusted beta 0.23; R(2) 24%), but not with verbal and visual memory and executive functioning. Depressive symptoms explained 24% of the variance in the mean z-score of all 6 cognitive domains. Comorbid lifetime alcohol use (n = 21) was not associated with cognitive dysfunction. CONCLUSIONS/SIGNIFICANCE: Cognitive dysfunction in bipolar disorder is more severe in patients with depressive symptoms, especially regarding speed and attention. Therefore, interpretation of cognitive functioning in patients with depressive symptoms should be cautious. No association was found between cognitive functioning and lifetime comorbid alcohol use disorder

Can Variation in Hypothalamic-Pituitary-Adrenal (HPA)-Axis Activity Explain the Relationship between Depression and Cognition in Bipolar Patients?

Background: Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is thought to be associated with more mood symptoms and worse cognitive functioning. This study examined whether variation in HPA axis activity underlies the association between mood symptoms and cognitive functioning. Methodology/Principal Findings: In 65 bipolar patients cognitive functioning was measured in domains of psychomotor speed, speed of information processing, attentional switching, verbal memory, visual memory, executive functioning and an overall mean score. Severity of depression was assessed by the Inventory of Depressive Symptomatology-self rating version. Saliva cortisol measurements were performed to calculate HPA axis indicators: cortisol awakening response, diurnal slope, the evening cortisol level and the cortisol suppression on the dexamethasone suppression test. Regression analyses of depressive symptoms and cognitive functioning on each HPA axis indicator were performed. In addition we calculated percentages explanation of the association between depressive symptoms and cognition by HPA axis indicators. Depressive symptoms were associated with dysfunction in psychomotor speed, attentional switching and the mean score, as well as with attenuation in diurnal slope value. No association was found between HPA axis activity and cognitive functioning and HPA axis activity did not explain the associations between depressive symptoms and cognition. Conclusions/Significance: As our study is the first one in this field specific for bipolar patients and changes in HPA-axis activity did not seem to explain the association between severity of depressive symptoms and cognitive functioning in bipolar patients, future studies are needed to evaluate other factors that might explain this relationship

Characteristics of Participants.

<p>*p<0.05</p>$<p>3 patients were medication-free</p>‡<p>3 patients used 2 types of anticonvulsants</p>£<p>χ² tests were used for categorical data and the unpaired t-test was used for continuous data</p

Raw Data of the Neuropsychological Tests from 110 Bipolar Patients and 75 Healthy Controls.

<p>CPT: Continuous Performance Task; CVLT: Dutch version of California Verbal Learning Test; PRM: Pattern Recognition Memory; SWM: Spatial Working Memory; SOC: Stockings of Cambridge; BADS: Behavioural Assessment of the Dysexecutive Syndrome; msec: milliseconds; nr: number; resp: responses; sd: standard deviation; sec: seconds.</p

Age-adjusted Cognitive Z-scores of 110 Bipolar Patients.

<p>Healthy controls (n = 75) were used as reference score.</p><p>For all cognitive measures: higher values indicate worse performance.</p><p>*p<0.25.</p>†<p>normally distributed</p><p>CPT: Continuous Performance Task; CVLT: Dutch version of California Verbal Learning Test; PRM: Pattern Recognition Memory; SWM: Spatial Working Memory; SOC: Stockings of Cambridge; BADS: Behavioural Assessment of the Dysexecutive Syndrome.</p

Associations between Depressive Symptoms and Cognitive Performance.

<p>For all cognitive measures: Beta's are corrected for age, gender, education and IQ. Higher values indicate worse performance.</p><p>*p<0.05.</p><p>95%CI: 95% confidence interval.</p>†<p>All beta's are regression coefficients indicating the mean change in cognitive performance, associated with an increase of 13 points IDS-SR score.</p><p>R²: explained variance.</p><p>Speed  =  psychomotor speed; Process  =  speed of information processing; Attention  =  attentional switching; Verbal  =  verbal memory; Visual  =  visual memory; Exec/WM  =  executive functioning/working memory; Mean  =  mean z-score of all 6 cognitive domains.</p

Cognitive Performance in the Total Group and Subgroups of Bipolar Patients.

<p>Total group (n = 110; dots), the euthymic subgroup (n = 46; triangle) and depressed subgroup (n = 64; square), with healthy controls (n = 75) used as reference score. Values are effect sizes, corrected for age. Error bars are 95% confidence intervals (95%CI). Statistical significance for group differences between bipolar patients and healthy controls was defined as p<0.05, shown in the figure as 95%CI which does not cross the base-line. Statistical significance (p<0.05) of sub-group differences were marked with an asterix (*) and were based on continuous depression scores. Speed  =  psychomotor speed; Process  =  speed of information processing; Attention  =  attentional switching; Verbal  =  verbal memory; Visual  =  visual memory; Exec/WM  =  executive functioning/working memory; Mean  =  mean z-score of all 6 cognitive domains.</p

Associations between HPA categories and depressive symptoms.

†<p>All values are regression coefficients (beta's) indicating the mean change in IDS-SR total score, divided by 13, associated with an increase of 1 unit HPA value.</p><p>Higher values indicate worse performance.</p><p>Betas are corrected for age, gender, education and IQ.</p><p>IDS-SR = Inventory of Depressive Symptomatology-self rating; CAR = cortisol awakening response; Diurnal = diurnal slope; evening = mean evening cortisol level; DST = cortisol suppression on the dexamethasone suppression test; 95%CI = 95% confidence interval.</p