Divergent outcomes in cognitive-behavioral therapy and pharmacotherapy for adult depression

Jeffrey R. Vittengl*, Robin B. Jarrett, Erica Weitz, Steven D. Hollon, Jos Twisk, Ioana Cristea, Daniel David, Robert J. DeRubeis, Sona Dimidjian, Boadie W. Dunlop, Mahbobeh Faramarzi, Ulrich Hegerl, Sidney H. Kennedy, Farzan Kheirkhah, Roland Mergl, Jeanne Miranda, David C. Mohr, A. John Rush, Zindel V. Segal, Juned SiddiqueAnne D. Simons, Pim Cuijpers

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

41 Scopus citations


Objective: Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. Method: Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatmentmoderators of any deterioration (increase≥1HAM-Dor BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease≥ 95%), and superior response (posttreatmentHAM-D or BDI score of 0) using multilevel models. Results: About5%27%of patients showedany deterioration, 1% reliable deterioration, 4%25% extreme nonresponse, 6%210% superior improvement, and 4%25% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels. Conclusions: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.

Original languageEnglish (US)
Pages (from-to)481-490
Number of pages10
JournalAmerican Journal of Psychiatry
Issue number5
StatePublished - May 1 2016

ASJC Scopus subject areas

  • Psychiatry and Mental health


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