Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (CBASP)

Amazon.com showed that over 170 000 copies of this book had been sold some 15 months after its publication. This must make it among the best sellers in the field.

The psychiatric and psychological literature is replete with books on various forms of psychotherapy, but few have an adequate basis in research to support either their theory or their practice, and few withstand the test of time.

Why then should another book on a new psychotherapy be published and be a best seller? Although McCullough has been writing about depression and the cognitive behavioural analysis system of psychotherapy (CBASP) for a number of years, the May 2000 publication in the New England Journal of Medicine of the results of a 12-centre study of 681 outpatients with chronic depression, randomly assigned to nefazodone, CBASP, or both, attracted much attention.1 In this study by Keller et al (McCullough is a coauthor), the overall rate of response (remission or satisfactory response) was 48% in both the nefazodone and CBASP groups, compared with 72% with both treatments combined. For the 519 subjects completing the study, the comparable results were nefazodone 55%, CBASP 52% and combined treatment 85%. Despite some limitations of the study, it represents a considerable advance. In an editorial in the same issue,2 Scott states that before 1998 only 9 studies of psychotherapy for chronic depression had been published, in only 2 of the 9 were the patients randomized, and the combined sample size was only 126. Placebo response in trials of either psychotherapy or pharmacotherapy for chronic depression is about 12%–15%, and other studies have also suggested that combining psychotherapy with medication is more effective than either alone. The Keller et al study used a larger sample than previous studies and a well-documented systematic and standardized psychotherapeutic approach. When considering outcomes, there is a tendency to lump remission and improvement together, which inflates the results. The “remission” results from this study (i.e., omitting the “satisfactory response” group) are: nefazodone alone 22%, CBASP alone 24%, and combined treatment 42%.

With this background, it is not surprising that McCullough's book should be popular. This is the handbook for CBASP. Not only will psychologists and psychiatrists want to be knowledgeable about this form of psychotherapy, but patients will undoubtedly read related articles, explore Internet resources and ask more knowledgeable questions.

In the book, the origins of CBASP are described and comparisons are made with cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT). McCullough obviously considers CBASP to be a considerable improvement over CBT and IPT, and differs from the proponents of these other therapies (principally Beck and Klerman) in his conceptualization of the illness, the illness process, its psychopathology, treatment goals, use of transference and the role of the therapist.

McCullough states: “I make the assumption that each chronic patient is personally responsible for his or her depression,” and goes on to say: “Because there is no depression without stress and the failure to cope with it, the depression experience, as noted above, is best conceptualized as a ‘person x environment’ phenomenon” (p. 16). This obviously differs from the more clearly defined disease or illness model of IPT; indeed, McCullough writes that “arrested maturational development is viewed as the etiological basis of chronic depression.” These opinions, which seem to ignore the biological, neurochemical and genetic bases for depression, are bound to conflict with the views of others.

Many readers, particularly those who have more of a psychoanalytic orientation, will be surprised to learn that in CBASP the therapist is encouraged to become personally involved with the patient in a disciplined way to modify the patient's behaviour.

Much of the book is concerned with technique. Situational analysis is a key component and is intended to exacerbate psychopathology in the therapy session, with a view to increasing the probability of behavioural change. A Coping Survey Questionnaire (p. 107) is part of this technique as well. Included in the book's appendices are various other assessment forms (e.g., Therapist Prompts for Administering Situational Analysis; this form might also be useful for recording systematic observations and information in other therapies.) There are also rating scales for adherence, for evaluating the quality of the interpersonal relationship and for rating therapists.

This book will likely be essential for anyone wanting to practise CBASP. The aims of the therapy include guiding patients to improve their cognitive and emotional function to mitigate and improve the consequences of their behaviours; learning new skills and coping mechanisms is part of this process. Much of this is shared with other systems of brief psychotherapy.

Reports of effectiveness in clinical trials cannot be equated with establishing the theoretical concepts of the therapy or substantiating the origins of the disorder and its psychopathology.

Chronic depression in its various forms is a common and disabling disorder, with a high rate of relapse and relatively poor response to treatment. A number of studies suggest that a combination of antidepressant medication with brief (10–20 sessions) psychotherapy, is superior to either psychotherapy or medication alone, yet the availability of therapists adequately trained in the techniques of brief psychotherapy is quite limited. If this book increases that number, patients will have been well served.

Roger C. Bland, MB ChB

Edmonton, Alberta, Canada