1. www.lvn.se Randomized trial of treatment of depression with Interpersonal psychotherapy and Cognitive Behavioural Therapy Psychiatric clinic, Hospital of Sundsvall Västernorrland Linköpings universitet

2. www.lvn.se Depression Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt and low self-worth, disturbed sleep or appetite, low energy and poor concentration At its worst, depression can lead to suicide, associated with the loss of about 850 000 lives every year (WHO)

3. www.lvn.se Depression Depression is the leading cause of disability as measured by YLDs (WHO) By the year 2020, depression is projected to reach 2nd place among DALYs calculated for all ages, for both sexes. Today, depression is the second cause of DALYs in the age category 15-44 for both sexes combined (WHO)

4. www.lvn.se Depression Sweden The Lundby study: 27 % men and 45 % women had at least one episode of depression before the age of 70 The incidence in Sweden is between 4 och 10 %

5. www.lvn.se National Board of Health and Welfare, Sweden In the guidelines from National Board of Health and Welfare in Sweden, CBT and IPT are recommended as first hand choices for treatment of mild and moderate depression. This recommendation is based on studies from other countries. Comparative randomized studies of CBT and IPT have not been published in Sweden

6. www.lvn.se Randomized trial of treatment of depression with Interpersonal psychotherapy and Cognitive Behavioural Therapy In all, 96 patients will take part in the study, during 2 years. Inclusion Patients who seek treatment with a diagnosis of Major Depressive Disorder (MDD), and who indicate mild or moderate depression on Beck’s Depression Inventory will be asked to participate Exclusion Exclusion criteria are psychosis, ongoing drug abuse, serious neuropsychiatric disorder, personality disorder cluster B. We will also exclude patients who have used disability pension and only include patients who have sickness benefit, as psychotherapy with 16 sessions is unlikely to be enough to benefit patients with disability pension.

7. www.lvn.se Background Both CBT and IPT are manualized short term therapies but with different theoretical background Neither CBT nor IPT, using face-to-face treatment, have been studied as treatments for depression in RCTs in Sweden Outcome measured as work performance has not been studied with these treatments.

8. www.lvn.se Hypothesis The main hypotheses in this study is that CBT and IPT are both effective treatments for Major Depressive Disorder, and that they have equal effects with regard to remission from depression A second hypothesis is that CBT is more effective than IPT when return to employment is the outcome measure Three moderator hypotheses will be tested (next slide)

9. www.lvn.se Three moderator hypotheses will be tested The first moderator hypothesis is that patients with avoidant attachment style get better results with CBT, whereas patients with anxious attachment style get better results with IPT The second hypothesis is that patients with higher Reflective Function get better results with IPT than with CBT The third moderator hypothesis is that women respond better to IPT and men to CBT, particularly if relational functioning is considered. In the moderator hypotheses, both remission from depression and return to work will be outcome criteria

10. www.lvn.se The following instruments will be used before and after treatment: Structured Clinical Interview for DSM-IV, I and II, (SCID I (A) and II (after screening); First et al., 1999) Self-rating questionnaire from the Social Insurance Agency for measuring work capacity and presence at the work place (Undersökning om hälsa. Enkätundersökning 2008. Försäkringskassan) MADRS ( Montgomery SA & Åsberg M. Br J Psychiatry 1979; 134:382-9)

11. www.lvn.se Measurements, cont Alcohol Use Disorders Identification test (Audit; Babor, Higgins-Biddle, Saunders & Monteiro, 2001) Adult Attachment Interview (AAI; 11 questions for measuring Reflective function, Main, Caplan & Cassidy, 1985), combined with Sheehan Disability Scale (Sheehan, Harnett-Sheehan & Raj, 1996) Beck Anxiety Inventory (BAI) Beck, Epstein, Brown & Steer, 1988)

12. www.lvn.se Before and after treatment, and after session five, the following instruments will be used: Depressive Experiences Questionnaire (DEQ; Blatt, D'Afflitti & Quinlan, 1976) Experiences in Close Relationships-revised (ECR-R, Brennan, 1998; Broberg & Zahr, 2003) Trail Making Test, TMT A och B Delis-Kaplan Executive Function System, D-KEFS (Delis, Kaplan & Kramer, 2001). Controlled Oral Word Association Test (COWAT; Benton, Hamsher & Sivan, 1976)

13. www.lvn.se Before and after treatment, and after session five, the following instruments will be used, cont: Perceived Social Support Questionnaire (PSS; Procidano & Heller, 1983, translated to Swedish by Ghaderi och Scott, 1997) The interview: The Depression Specific Reflective Function Interview (DSRF, modified after Rudden, 2007), specially adapted for depressive symptoms

14. www.lvn.se Mesurements, cont Before each session (patient): Becks Depression Inventory (BDI 2) (Beck, Steer & Brown, 1996) After each session (patient and therapist): Working alliance Inventory, short version (WAI; Horvath, 2001) Feeling Checklist (Holmqvist & Armelius, 1994)

15. www.lvn.se Adherence All sessions are videotaped A number of therapy sessions from each therapist will be rated to ascertain treatment integrity The Collaborative Study Psychotherapy Rating Scale- 6 (CSPRS-6; Markowitz, Spielman, Scarvalone & Perry, 2000), which is the standard scale for rating adherence to CBT and IPT, will be used

16. www.lvn.se Ethical considerations Ethical approvement has been given by the ethical committee at Linköping University. Patients who do not want to take part in the study will be offered adequate treatment.

17. www.lvn.se Some preliminary results RF/ mentalizing in depression Some characteristics of included patients

18. www.lvn.se Discussion The Allegiance problem – Which therapy is best liked by the researchers and the therapists? The Therapy process – is there a balance to be struck between adherence to the manual and adaptation to the patient’s responsiveness? It is not easy to get the therapists participating – ideas? Outcome measured as work performance has not been studied with these treatments, (workcapacity not often used as measurement) Medication with SSRI?