A comparison of cognitive and dynamic therapy for MDD in community settings

描述(由申请人提供)：本提案的目标是进行一项随机、比较、非劣势的临床试验，以测试一种广泛使用的手动动态心理疗法(支持性表达心理动力疗法)在社区精神卫生环境中用于治疗严重抑郁障碍时不逊于认知疗法的假设。严重抑郁障碍是一种严重的致残障碍，在美国每年有7%的人受到影响，一生中大约有17%的人受到影响(Kessler等人，2005年)。在过去的30年里，认知疗法(Beck等人，1979)已被确立为治疗严重抑郁障碍的最有经验的心理社会疗法(Hollon，Thase，&Markowitz，2002)。在这一点上，正在进行广泛的努力，将认知疗法传播到临床实践环境中。卫生系统和管理保健实体已开始加快向在社区机构工作的现有心理治疗师传播认知疗法。尽管已经进行了大量关于认知疗法的研究，但与精神卫生保健系统和机构相关的一个核心问题从未得到解决，那就是认知疗法是否能提供比许多社区心理治疗师提供的典型形式的心理治疗更好的结果。如果一种在社区中已经普遍的标准形式的心理治疗(即心理动力治疗)产生的结果不逊于认知治疗所产生的结果，那么，为社区治疗师再培训认知治疗所需的大量资金将更好地用于其他质量改进措施，包括聘请新的治疗师来帮助解决社区普遍存在的人手不足的问题。目前建议的具体目标是：1)进行一项随机非自卑试验，比较支持性表达心理动力疗法和认知疗法对重度抑郁障碍患者的疗效；2)评估支持性表达疗法和认知疗法在患者功能和生活质量二级指标上的比较有效性。在社区精神卫生机构工作的治疗师将在协议的第一年接受认知治疗或动态心理治疗的培训。此外，将在整个研究期间同时实施治疗师培训程序，以便在整个研究期间保留适当数量的治疗师。在两个社区心理健康中心寻求服务的消费者将被随机分配接受12次认知治疗或动态心理治疗。所有心理治疗将由受雇于社区机构的治疗师提供，并将在社区机构进行。在精神卫生机构被诊断为严重抑郁障碍的消费者将被允许参与当前的方案。感兴趣的消费者将被同意进行这项研究，并随机接受治疗。所有参与者都将完成基线访谈，并每月对抑郁症状、功能和生活质量进行评估。作为正常临床程序的一部分，所有消费者还将在基线和每次治疗过程中完成基数-24。我们将评估动态心理治疗在HAM-D总分中从基线到急性治疗终点的变化是否不逊于认知治疗。如果心理动力疗法不逊于认知疗法，那么对心理治疗师进行认知疗法再培训的费用可能就不值得了。

DESCRIPTION (PROVIDED BY APPLICANT): The goal of the current proposal is to conduct a randomized, comparative, non-inferiority clinical trial that tests the hypothesis that a widely used form of manualized dynamic psychotherapy (supportive expressive psychodynamic therapy) is not inferior to cognitive therapy when implemented in community mental health settings for the treatment of major depressive disorder. Major depressive disorder is a severe and disabling disorder afflicting 7% of individuals in the United States annually and approximately 17% of individuals across their lifetime (Kessler et al., 2005). Over the past 30 years, cognitive therapy (Beck et al., 1979) has become established as the most empirically-validated psychosocial treatment for major depressive disorder (Hollon, Thase, & Markowitz, 2002). At this point in time, extensive efforts are occurring to disseminate cognitive therapy to clinical practice settings. Health systems and managed care entities have begun to accelerate dissemination of cognitive therapy to existing psychotherapists working in community agencies. Despite the large number of studies that have been done on cognitive therapy, one central question relevant to mental health care systems and agencies that has never been addressed is whether or not cognitive therapy provides superior outcomes to the typical form of psychotherapy provided by many community-based psychotherapists. If a standard form of psychotherapy (i.e., psychodynamic therapy) already common in the community produces outcomes that are not inferior to those produced by cognitive therapy, then the extensive amount of funds needed to re-train community therapists in cognitive therapy would be better spent on other quality improvement initiatives including hiring new therapists to help with the understaffing that is prevalent in the community. The Specific Aims of the current proposal are 1) to conduct a randomized non-inferiority trial to compare supportive-expressive psychodynamic therapy and cognitive therapy for patients with major depressive disorder, and 2) to assess the comparative effectiveness of supportive-expressive therapy and cognitive therapy on secondary measures of patient functioning and quality of life. Therapists working in community mental health agencies will be trained in either cognitive therapy or dynamic psychotherapy during the first year of the protocol. In addition, concurrent therapist training procedures will be implemented across the study period in order to retain the appropriate number of therapists throughout the study. Consumers seeking services at two community mental health centers will be randomized to either receive 12 sessions of cognitive therapy or dynamic psychotherapy. All psychotherapy will be provided by therapists employed at the community agency and will take place at the community agency. Consumers diagnosed with major depressive disorder at the mental health agency will be offered participation in the current protocol. Interested consumers will be consented for the study and randomized to treatment. All participants will complete a baseline interview as well as monthly assessments of depressive symptoms, functioning, and quality of life. As part of normal clinic procedures, all consumers will also complete the BASIS-24 at baseline and at each treatment session. We will evaluate whether dynamic psychotherapy is not inferior to cognitive therapy on change from baseline to endpoint of acute treatment in the HAM-D total score. If psychodynamic therapy is not inferior to cognitive therapy, the cost of re-training psychotherapists in cognitive therapy may not be warranted.