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Can pharmacotherapists be too supportive? A process study of active medication and placebo in the treatment of depression

Published online by Cambridge University Press:  06 November 2009

D. R. Strunk ,
M. O. Stewart ,
S. D. Hollon ,
R. J. DeRubeis ,
J. Fawcett ,
J. D. Amsterdam  and
R. C. Shelton
D. R. Strunk*
Affiliation:
Department of Psychology, Ohio State University, Columbus, OH, USA
M. O. Stewart
Affiliation:
Department of Psychology, Vanderbilt University, Nashville, TN, USA
S. D. Hollon
Affiliation:
Department of Psychology, Vanderbilt University, Nashville, TN, USA
R. J. DeRubeis
Affiliation:
Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
J. Fawcett
Affiliation:
Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA
J. D. Amsterdam
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
R. C. Shelton
Affiliation:
Department of Psychiatry, Vanderbilt University, Nashville, TN, USA
*
*Address for correspondence: Dr D. R. Strunk, Department of Psychology, Ohio State University, 1835 Neil Avenue, Columbus, OH 43210, USA. (Email: [email protected])
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Abstract

Background

This study examined therapist–patient interactions during clinical management with antidepressant medication and pill-placebo.

Method

The sample consisted of 80 patients on active medication and 40 patients in a pill-placebo condition from a randomized controlled trial for moderate to severe depression. Pharmacotherapist–patient interactions were characterized using observer ratings of the therapeutic alliance, pharmacotherapist-offered facilitative conditions, pharmacotherapist adherence to clinical management treatment guidelines and pharmacotherapist competence. Patients, therapists and raters were blind to treatment condition and outcome.

Results

Provision of greater non-specific support (facilitative conditions) in early sessions predicted less subsequent improvement in depressive symptoms for patients receiving pill-placebo but not those receiving active medications, for which none of the process ratings predicted subsequent change. Early symptom change predicted later alliance and adherence in both conditions and therapist competence in the active condition.

Conclusions

Higher levels of support in early sessions predict poorer subsequent response among placebo patients. It remains unclear whether patients who are likely to be refractory elicit greater non-specific support or whether the provision of such support has a deleterious effect in unmedicated patients. Differences in treatment process variables between conditions late in treatment are likely to be largely a consequence of symptom relief produced by active medications.

Keywords

Antidepressant drugsdepressionfacilitative conditionsplacebos
Type
Original Articles
Information
Psychological Medicine , Volume 40 , Issue 8 , August 2010 , pp. 1379 - 1387
Copyright
Copyright © Cambridge University Press 2009

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References

Barber, JP, Connolly, MB, Crits-Christoph, P, Gladis, L, Siqueland, L (2000). Alliance predicts patient's outcome beyond in-treatment change in symptoms. Journal of Consulting & Clinical Psychology 68, 1027–1032.CrossRefGoogle ScholarPubMed
Campbell, DT, Fiske, DW (1959). Convergent and discriminant validation by the multi-trait multi-method matrix. Psychological Bulletin 56, 81–105.CrossRefGoogle Scholar
Carroll, KM, Nich, C, Rounsaville, BJ (1997). Contribution of the therapeutic alliance to outcome in active versus control psychotherapies. Journal of Consulting & Clinical Psychology 6, 510–514.CrossRefGoogle Scholar
Castonguay, LG, Beutler, LE (eds) (2005). Principles of Therapeutic Change That Work. Oxford University: New York.CrossRefGoogle Scholar
Depression Guideline Panel (1993). Depression in Primary Care: Vol. 2. Treatment of Major Depression (Clinical Practice Guideline No. 5, AHCPR Publication No. 93–0551). US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research: Rockville, MD.Google Scholar
DeRubeis, RJ, Hollon, SD, Amsterdam, JD, Shelton, RC, Young, PR, Salomon, RM, O'Reardon, JP, Lovett, ML, Gladis, MM, Brown, LL, Gallop, R (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry 62, 409–416.CrossRefGoogle ScholarPubMed
Dundon, WD, Pettinati, HM, Lynch, KG, Xie, H, Varillo, KM, Makadon, C, Oslin, DW (2008). The therapeutic alliance in medical-based interventions impacts outcome in treating alcohol dependence. Drug and Alcohol Dependence 95, 230–236.CrossRefGoogle ScholarPubMed
Elvins, R, Green, J (2008). The conceptualization and measurement of therapeutic alliance: an empirical review. Clinical Psychology Review 28, 1167–1187.CrossRefGoogle ScholarPubMed
Fawcett, J, Epstein, P, Fiester, SJ, Elkin, I, Autry, JH (1987). Clinical management-imipramine/placebo administration manual: NIMH Treatment of Depression Collaborative Research Program. Psychopharmacology Bulletin 23, 309–324.Google ScholarPubMed
Fleiss, JL (1981). Balanced incomplete block designs for inter-rater reliability studies. Applied Psychological Measurement 5, 105–112.CrossRefGoogle Scholar
Hamilton, M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery & Psychiatry 23, 56–62.CrossRefGoogle ScholarPubMed
Hill, CE, O'Grady, KE, Elkin, I (1992). Applying the Collaborative Study Psychotherapy Rating Scale to rate therapist adherence in cognitive-behavior therapy, interpersonal therapy, and clinical management. Journal of Consulting and Clinical Psychology 60, 73–79.CrossRefGoogle Scholar
Horvath, AO, Greenberg, LS (1989). Development and validation of the working alliance inventory. Journal of Counseling Psychology 2, 223–233.CrossRefGoogle Scholar
Horvath, AO, Luborsky, L (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting & Clinical Psychology 61, 561–573.CrossRefGoogle ScholarPubMed
Klein, DF (1996). Preventing hung juries about therapy studies. Journal of Consulting & Clinical Psychology 64, 81–87.CrossRefGoogle ScholarPubMed
Kirsch, I, Scoboria, A, Moore, TJ (2002). Antidepressants and placebos: secrets, revelations, and unanswered questions. Prevention and Treatment 5, Article 33.CrossRefGoogle Scholar
Krupnick, JL, Sotsky, SM, Simmens, S, Moyer, J, Elkin, I, Watkins, J, Pilkonis, PA (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting & Clinical Psychology 64, 532–539.CrossRefGoogle ScholarPubMed
Martin, DJ, Garske, JP, Davis, K (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting & Clinical Psychology 68, 438–450.CrossRefGoogle ScholarPubMed
Rogers, CR (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting & Clinical Psychology 21, 95–103.CrossRefGoogle ScholarPubMed
Shrout, PE, Fleiss, JL (1979). Intraclass correlations: uses in assessing rater reliability. Psychological Bulletin 86, 420–428.CrossRefGoogle ScholarPubMed
Wampold, BE (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. Lawrence Erlbaum Associates: Mahwah, NJ.Google Scholar
Weiss, M, Gaston, L, Propst, A, Wisebord, S, Zicherman, V (1997). The role of the alliance in the pharmacologic treatment of depression. Journal of Clinical Psychiatry 58, 196–204.CrossRefGoogle Scholar
Williams, JB (1988). A structured interview guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry 45, 742–747.CrossRefGoogle ScholarPubMed