A modular add-on approach for patients with comorbid depression and a history of childhood maltreatment

虽然针对障碍的抑郁症治疗方法已被证明有效，但有很大比例的患者没有达到缓解或缓解，这很可能是由于抑郁症的病因机制的个体间的异质性。此外，抑郁症的共病发生率很高，特别是在早期虐待或忽视的患者中，这一点没有通过专门针对障碍的方法来解决。解决这些问题的一个有希望的方法是通过以跨诊断方式针对典型功能障碍的限定心理治疗模块来补充对抑郁症的干预。根据患者出现的问题和功能障碍，选择特定的模块。因此，与传统的标准化治疗相比，干预更加灵活和个性化。本文提出的基于模块的心理治疗(MBP)模型是对抑郁症标准认知行为治疗(CBT)的补充，其模块汇编了心理治疗的认知行为分析系统、基于心智的治疗和基于正念的治疗的具体策略，所有这些都得到了先前的试验支持。这些单元侧重于与儿童期虐待密切相关的三个受干扰的系统：负值系统(急性、潜在和持续威胁)、社会过程系统(理解心理状态)和唤醒系统(情绪意识和情绪调节)。这项双中心研究的目的是评估在患有抑郁症和儿童期虐待的患者中，CBT+MBP单独治疗在减轻抑郁症状方面是否优于标准CBT。70名有发作性或持续性重度抑郁症、轴I和/或II共病、有儿童期虐待史的门诊患者将被随机分为CBT+MBP 20个单独疗程或标准CBT 20个单独疗程，为期16周。如果药物在随机分组前至少四周稳定，则允许使用SSRI或SNRI进行额外治疗。主要的假设是，在16周的治疗后，MBP作为标准CBT的附加模块比单独使用标准CBT在减少抑郁症状方面更有效。

While disorder-specific approaches for the treatment of depression have proven efficacy, there is a large proportion of patients not reaching response or remission most likely due to the inter-individual heterogeneity of etiological mechanisms of depression. In addition, there is a high rate of comorbid disorders in depression, particularly in patients with early abuse or neglect, which is not addressed by disorder-specific methods. A promising approach to address those issues is to complement interventions for depression by circumscribed psychotherapy modules targeting typical dysfunctions in a transdiagnostic way. Depending upon the patients’ presenting problems and disturbed functions, specific modules are selected. Thus, the intervention is more flexible and personalized than traditional standardized treatment. The Modular Based Psychotherapy (MBP) model proposed here complements standard Cognitive Behavioral Therapy (CBT) for depression with modules compiling specific strategies from Cognitive Behavioral Analysis System of Psychotherapy, mentalization-based therapy, and mindfulness-based treatment, all supported by previous trials. The modules focus on three disturbed systems critically related to childhood maltreatment: the negative valence system (acute, potential, and sustained threat), the system of social processes (understanding mental states), and the arousal system (emotion awareness and emotional regulation). The aim of this bi-centric study is to assess whether in patients with comorbid depression and childhood maltreatment an individual treatment with CBT+MBP is superior to standard CBT in reducing depressive symptoms. Seventy outpatients with episodic or persistent major depression, comorbidity on axis I and/or II, and a history of childhood maltreatment will be randomized to either 20 individual sessions of CBT+MBP or 20 individual sessions of standard CBT over 16 weeks. Additional treatment with SSRI or SNRI is allowed if medication has been stable for at least four weeks before randomization. The primary hypothesis is that MBP as an add-on module to standard CBT is more effective than standard CBT alone in reducing depressive symptoms after 16 weeks of treatment.