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Original Investigation
March 2017

Effect of Disorder-Specific vs Nonspecific Psychotherapy for Chronic DepressionA Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry, Faculty of Medicine, University of Freiburg, Freiburg, Germany
  • 2Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
  • 3Psychology School at the Fresenius University of Applied Sciences Berlin, Berlin, Germany
  • 4Central Institute of Mental Health, Department of Clinical Psychology, Medical Faculty Mannheim/University Heidelberg, Heidelberg, Germany
  • 5Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
  • 6Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Heidelberg, Germany
  • 7Institute of Clinical Psychology, Hospital Stuttgart, Stuttgart, Germany
  • 8Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
  • 9Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
  • 10Department of General Psychiatry, University Hospital Heidelberg, Heidelberg, Germany
  • 11Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Klinik Hamburg Eilbek, Hamburg-Eppendorf, Germany
  • 12Department of Psychology, Clinical Psychology, and Psychotherapy, Eberhard Karls University Tübingen, Tübingen, Germany
JAMA Psychiatry. 2017;74(3):233-242. doi:10.1001/jamapsychiatry.2016.3880
Key Points

Question  Is a disorder-specific psychotherapy (the Cognitive Behavioral Analysis System of Psychotherapy) superior to a nonspecific, bona fide psychological condition (supportive psychotherapy) in patients with early-onset chronic depression?

Findings  In this randomized clinical trial of 268 adults, patients not taking antidepressant medication who were treated with the Cognitive Behavioral Analysis System of Psychotherapy reported significantly less severe depressive symptoms after 20 weeks than those who received nonspecific psychotherapy.

Meaning  A highly structured, disorder-specific psychotherapy is more effective than nonspecific therapy in outpatients with early-onset chronic depression who are not taking antidepressant medication.


Importance  Chronic depression is a highly prevalent and disabling disorder. There is a recognized need to assess the value of long-term disorder-specific psychotherapy.

Objective  To evaluate the efficacy of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared with that of nonspecific supportive psychotherapy (SP).

Design, Setting, and Participants  A prospective, multicenter, evaluator-blinded, randomized clinical trial was conducted among adult outpatients with early-onset chronic depression who were not taking antidepressant medication. Patients were recruited between March 5, 2010, and October 16, 2012; the last patient finished treatment on October 14, 2013. Data analysis was conducted from March 5, 2014, to October 27, 2016.

Interventions  The treatment included 24 sessions of CBASP or SP for 20 weeks in the acute phase, followed by 8 continuation sessions during the next 28 weeks.

Main Outcomes and Measures  The primary outcome was symptom severity after 20 weeks (blinded observer ratings) as assessed by the 24-item Hamilton Rating Scale for Depression (HRSD-24). Secondary outcomes were rates of response (reduction in HRSD-24 score of ≥50% from baseline) and remission (HRSD-24 score ≤8), as well as self-assessed ratings of depression, global functioning, and quality of life.

Results  Among 622 patients assessed for eligibility, 268 were randomized: 137 to CBASP (96 women [70.1%] and 41 men [29.9%]; mean [SD] age, 44.7 [12.1] years) and 131 to SP (81 women [61.8%] and 50 men [38.2%]; mean [SD] age, 45.2 [11.6] years). The mean (SD) baseline HRSD-24 scores of 27.15 (5.49) in the CBASP group and 27.05 (5.74) in the SP group improved to 17.19 (10.01) and 20.39 (9.65), respectively, after 20 weeks, with a significant adjusted mean difference of –2.51 (95% CI, –4.16 to –0.86; P = .003) and a Cohen d of 0.31 in favor of CBASP. After 48 weeks, the HRSD-24 mean (SD) scores were 14.00 (9.72) for CBASP and 16.49 (9.96) for SP, with an adjusted difference of –3.13 (95% CI, –5.01 to –1.25; P = .001) and a Cohen d of 0.39. Patients undergoing CBASP were more likely to reach response (48 of 124 [38.7%] vs 27 of 111 [24.3%]; adjusted odds ratio, 2.02; 95% CI, 1.09 to 3.73; P = .03) or remission (27 of 124 [21.8%] vs 14 of 111 [12.6%]; adjusted odds ratio, 3.55; 95% CI, 1.61 to 7.85; P = .002) after 20 weeks. Patients undergoing CBASP showed significant advantages in most other secondary outcomes.

Conclusions and Relevance  Highly structured specific psychotherapy was moderately more effective than nonspecific therapy in outpatients with early-onset chronic depression who were not taking antidepressant medication. Adding an extended phase to acute psychotherapy seems promising in this population.

Trial Registration  clinicaltrials.gov Identifier: NCT00970437.