Anxiety Therapy Better for Depression Than CBT?

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Metacognitive therapy (MCT), a psychotherapeutic approach that targets persistent rumination and negative thought processes, has a large effect size when used to treat depression and may offer a viable alternative to mainstay cognitive-behavioral therapy (CBT), results from a new randomized control trial show.

“The results of this trial of MCT for depression are encouraging with large and statistically significant reductions both for depressive and anxious symptoms following 10 sessions of treatment. These improvements were sustained at 6 months follow-up,” the authors, led by Roger Hagen, PhD, Norwegian University of Science and Technology, Trondheim, Norway, write.

The study was published online January 24 in Frontiers in Psychiatry. Adrian Wells, PhD, is the senior author of the study.

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With the most common approaches to the treatment of depression, such as CBT or antidepressants, recovery rates are often low and relapse rates are high, so MCT is being eyed as a potential alternative
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MCT was originally developed in the 1990s for the treatment of generalized anxiety disorder. It focuses on shifting maladaptive rumination, or “overthinking,” which can occur with psychiatric disorders.

As opposed to analyzing and challenging thoughts, as is practiced with CBT, MCT focuses on reducing the thought process that drives persistent ruminating thoughts, said Dr Hagen.

“In CBT, we focus on thought content, with [the clinician] and the patient working together to examine the validity of the content, asking, for instance, ‘What is really the evidence that you are stupid?’

“With MCT, we try to instead focus on reducing rumination and changing maladaptive metacognitions, such as, ‘I have to analyze why I became depressed,’ or ‘I need to find out what is wrong with me in order to snap out of my depression,’ ” he told Medscape Medical News.

Edge Over CBT?

Although numerous studies have shown the benefits of MCT for patients with anxiety, only a few, including a study published in 2009, have looked at the approach in depression.

The lead author of that study, Jennifer Jordan, PhD, senior research fellow and clinical psychologist with the Department of Psychological Medicine at the University of Otago, Christchurch, New Zealand, told Medscape Medical News that the 2009 findings suggest “MCT may have an advantage over CBT, given that there is increasing recognition that neuropsychological impairments seen in the acute state of depression often don’t remit with mood recovery with standard treatment, as was previously assumed.”

For the current study, investigators randomly assigned 39 patients with depression to receive 10 sessions of MCT, either immediately or after a 10-week waiting period.

The sessions focused on increasing meta-awareness by identifying thoughts that triggered rumination and worry; challenging beliefs about uncontrollability of rumination and dangers of rumination; and modifying positive beliefs about rumination and worry.

The results, assessed using the Beck Depression Inventory, showed that those who received MCT had significant improvements in symptoms of depression and anxiety compared to the wait-list group (Cohen’s d = 2.51 and Cohen’s d = 1.92, respectively).
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The analyses of clinical significance showed that 70% to 80% of the total sample of patients achieved recovery, as measured by the Hamilton Rating Scale for Depression–17. This result, the researchers note, is consistent with results from previous uncontrolled studies of MCT.

A core focus of the MCT approach is what the therapy’s developers call the cognitive attentional syndrome (CAS), consisting of persistent rumination, threat monitoring, and ineffective coping. With depression, a key component can include repeated analysis of negative feelings and past failures, the authors note.

Depression is understood as an extension of low mood resulting from a problem of overthinking (eg, worry and rumination) and withdrawal of active coping. (eg, social withdrawal and reduction in activity),” they write.

Specific strategies of MCT to tackle symptoms of CAS include verbal reattribution and behavioral experiments, such as an attention training technique, detached mindfulness, and postponement of rumination.

“The CAS is driven by metacognitions, both positive: ‘To ruminate about my problems can help me find a solution,’ and negative: ‘My rumination is uncontrollable’,” Dr Hagen said.

“In therapy, we try to help the patient to see that rumination is not uncontrollable and that there are no benefits in using rumination to self-regulate.”

Another recent study that compared MCT with CBT showed interesting differences in some cognitive functions, but not mood. For that study, 48 patients with depression were randomly assigned to receive 12 weeks of treatment with either MCT or CBT.

After the 12 weeks, those in the MCT group demonstrated significantly greater improvements in executive functioning, including spatial working memory and attention tasks, compared to the CBT group.

Importantly, an earlier randomized study conducted by Dr Jordan and her colleagues showed no difference between CBT and MCT in terms of depression scores.

“It was noteworthy that MCT delivered by our team was no less effective than CBT, given the extent of training that we had in MCT was far less than our training and experience with CBT, which is the core training model in clinical psychology training in New Zealand,” said Dr Jordan.

She added, however, that an important limitation of some MCT research, including the current study, is that the treatment was administered by experts who developed the therapy or who are working directly with the developers.

“The effect sizes in the studies published by the core MCT researchers with Adrian Wells are incredibly large,” Dr Jordan said.

“This speaks to the promise of MCT when administered by those with a high degree of training and supervision by the originator(s).

“However, there is an allegiance literature that suggests that it can be difficult to achieve similar levels of effectiveness as the therapies are disseminated. Thus, there is a need for further independent research.”

One Size Doesn’t Fit All
Philip Muskin, MD, professor of clinical psychiatry at Columbia University Center for Psychoanalytic Training and Research, in New York City, agreed that the findings are encouraging but that larger studies are needed.

“It’s a small study with a robust finding, and it’s an interesting approach because it goes beyond the process of thinking with CBT,” he told Medscape Medical News.

“MCT appears to be unique in delving more into how one’s mind is working – asking not, ‘Where did this come from in your childhood?’ but, ‘How is your mind working to process it and how is that affecting you?’ “

He noted that the approach of addressing rumination in depression is important.

“We know that people who are depressed do ruminate about negative things. Patients will tell you that at night they have racing thoughts, which makes you think they may be bipolar, but they’re not – they’re just lying in bed and going over the whole day and all of the things they think they did poorly.”

Because some patients experience such symptoms more than others, the proposal of an alternative to CBT for patients who do not respond to that approach could be highly useful, Dr Muskin added.

“The reality is there are patients who either don’t want to take antidepressant medications or don’t respond well to certain psychotherapies, so we want as many treatments as we can.

“Everyone is different, and you want to have choices of a treatment that is best – one size doesn’t fit all.”
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