Brief CBT Interventions May Stop Depression Before It Starts
Abstract
Researchers have found that just a few months of cognitive-behavioral therapy (CBT) can reduce the risk of depression in high-risk groups, such as older adults with insomnia.
According to data from the National Institute of Mental Health, nearly 1 in 10 Americans had a major depressive episode in 2020, a condition that robs individuals of the joy in life and is a risk factor for cognitive decline, disability, and mortality. Yet studies show that fewer than half of individuals with depression receive treatment and a considerable group of patients do not respond. Relapse rates are high.
A growing body of research is focused on ways to prevent major depressive disorder (MDD) with brief psychological interventions before it develops into the full-blown disease.
Pim Cuijpers, Ph.D., says brief targeted interventions cost only a fraction of that of routine treatment of depression.
“We need to find other methods to reduce the impact of this disease. Prevention is one of the most important possibilities,” Pim Cuijpers, Ph.D., director of the WHO Collaborating Centre for Research and Dissemination of Psychological Interventions and a professor of clinical psychology at Amsterdam Public Health Research Institute, told Psychiatric News.
Cuijpers and colleagues recently completed a meta-analysis of 50 studies comparing depression outcomes in participants assigned to a psychotherapeutic intervention with those assigned to a control group. These interventions included cognitive-behavioral therapy (CBT), interpersonal therapy, behavioral activation therapy, and more. More than 12,000 people participated in these trials, including older adults in care homes, pregnant women receiving public assistance, high school students, and adults with major medical problems. None of the participants were diagnosed with depression at the time of study enrollment.
According to results published in Clinical Psychology Review in February 2021, individuals who received a brief psychotherapeutic intervention were 19% less likely be diagnosed with MDD 12 months later than those who did not receive the intervention.
Previous research has found strong evidence for “indicated” preventions, or those that are aimed at people who already have some depression symptoms but not the full-blown disorder. However, there is also increasing evidence that brief “selective” interventions, which are aimed at individuals deemed high risk for MDD, such as new moms or children of depressed parents, can also reduce the incidence of depressive disorder by about 20%, he said.
In that vein, researchers are now piloting a suite of digital interventions with college students in Holland who present with various risk factors for depression. The project, part of the WHO World Mental Health Surveys International College Student Project led by Harvard University, involves surveying 160,000 students at six universities annually about their experiences with procrastination, worrying, and perfectionism—known risk factors for depression. Students who score high on one of these factors are invited to participate in a corresponding CBT-based digital intervention.
Although the researchers are still collecting and analyzing data on the effectiveness of these interventions, Cuijpers sees great potential. That’s because the prevalence of depression in college students is so high, with 21% of students experiencing major depression, and because the cost of the digital interventions is so low compared with the price tag for routine depression treatment.
Treating Insomnia Halves MDD Risk
Researchers have found another brief psychotherapeutic intervention, this one targeting insomnia in older adults, can also prevent depression. A study published last November in JAMA Psychiatry found that offering cognitive-behavioral therapy for insomnia (CBT-I) cut the risk of depression in half, even in patients who previously had MDD.
Michael R. Irwin, M.D., says that older adults with insomnia who completed cognitive-behavioral therapy for insomina were half as likely to develop depression as those who were given only education about insomnia.
Insomnia, which affects nearly 50% of people 60 years or older, is known to increase the risk of depression, according to study author Michael R. Irwin, M.D., director of the Mindful Awareness Research Center and the Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles, and colleagues. Research shows that nearly 1 in 4 older adults uses over-the-counter or prescription sleep aids.
Irwin and colleagues assigned 291 older adults with insomnia who did not have depression to two months of weekly CBT-I or sleep education therapy. CBT-I is a first-line treatment for insomnia that combines cognitive-behavioral therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. Participants in the sleep education therapy group were taught about behavioral and environmental factors that contribute to poor sleep.
During the three-year follow-up, older adults with insomnia disorder who received CBT-I were 50% less likely than those who received sleep education therapy to develop either new or recurring major depression (12% of the CBT-I group developed depression vs. 26% of the sleep education group). They were also more likely to achieve sustained remission of their insomnia.
“People who rely on sleep aids usually have a relapse in their insomnia once they discontinue their sleep medications,” Irwin told Psychiatric News. “By contrast, CBT-I produces a lasting remission of insomnia disorder because it targets the maladaptive behaviors and cognitions that can lead to it, and because it teaches skills to manage daytime stress and arousal mechanisms. Once these simple cognitive and behavioral strategies are learned, people with insomnia can reach sustained remission.”
The interventions in the study were delivered by a trained psychologist or public health educator. However, apps that deliver CBT-I are gaining increasing attention; for example, the Department of Veterans Affairs offers the CBTi Coach free to the public.
Using CBT-I is “a completely new and innovative way of increasing the effect of preventive interventions on the disease burden of depression,” wrote Cuijpers and Charles F. Reynolds III, M.D., a professor of geriatric psychiatry and director of the Aging Institute at the University of Pittsburgh School of Medicine, in an accompanying JAMA Psychiatry editorial. The study by Irwin and colleagues shows that “depression can be prevented effectively without even using the word ‘depression’ and thus avoid the associated stigma.”
They concluded, “This major finding offers exciting new opportunities for the prevention field and opens a new field of research into indirect preventive interventions for avoiding the stigma of mental disorders.”
The study by Irwin and colleagues was funded by the National Institute on Aging, National Institutes of Health. The study by Cuijpers and colleagues was supported in part by CIBEROBN, an initiative of the Instituto de Salud Carlos (ISCIII). ■
