An Open Trial of a New Acceptance-Based Behavioral Treatment for Major Depression With Psychotic Features

Abstract

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of Behavioral Activation and Acceptance and Commitment Therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to six months of Acceptance-based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through post-treatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

Challenges in the Treatment of Major Depressive Disorder With Psychotic Features

“…Several studies suggest the potential utility of psychosocial interventions for the treatment of psychotic depression. [67][68][69][70][71][72][73][74][75][76][77] Behavioral activation (BA) 78 and Acceptance and Commitment Therapy (ACT) 79 are 2 new approaches that show considerable promise for treating patients with depression or psychosis. BA involves the identification of an individual's behavioral avoidance patterns via functional analysis (ie, examining antecedents and consequences of behavior) and the development of a goal-oriented plan for changing these behavioral deficits using a stepwise process.…”

“…79 Acceptance-Based Depression and Psychosis Therapy (ADAPT) is an integration of the BA and ACT approaches and was developed specifically for patients experiencing severe depression with co-occurring hallucinations or delusions. 67 A recent open-label study of 14 patients with psychotic depression treated with ADAPT showed promise when combined with pharmacotherapy.…”

Acceptance-based Behavior Therapy for Depression With Psychosis

“…Readers are referred to the report of our previous open trial for a more detailed description of ADAPT. 36 The original protocol used in the open trial involved 24 sessions over 6 months, but it was reduced to 16 sessions over 4 months in this study to improve the feasibility of implementation and to test the effects of a shortened protocol. The same overall content was delivered.…”

“…We had earlier conducted an open trial of acceptance-based depression and psychosis therapy (ADAPT), which integrates behavioral activation and acceptance and commitment therapy for psychotic depression. 36 Results of the open trial showed large, clinically significant and sustained treatment effects on depression, psychotic symptoms, and psychosocial functioning, and that the processes targeted by the intervention (eg, experiential avoidance, behavioral activation) were associated with improvement. The open trial provided the initial “proof-of-concept” and suggested the utility of examining ADAPT further in a randomized design.…”

“…To continue working toward this broader goal, the small pilot randomized controlled trial described here was a feasibility study designed to serve as a logical next step after the open study 36 to further refine treatment conditions and procedures in preparation for future larger clinical trials of ADAPT. We randomized a small number of patients to medication treatment as usual plus ADAPT versus an enhanced assessment and monitoring condition (EAM).…”