Winter 2024 Issue

Research Brief: Augmented Depression Therapy (ADepT)
By Sue Coyle, MSW
Social Work Today
Vol. 24 No. 1 P. 28

ADepT may offer another treatment modality for individuals struggling with depression.

Worldwide, depression affects an estimated 5% of adults and 5.7% of adults older than age 60, according to the World Health Organization. In the United States alone, that number is even higher, with an estimated 8%, or 21 million adults, struggling with depression each year.

Treatment for major depressive disorder is complex; there’s no one-size-fits-all approach. However, the most commonly implemented modality is cognitive behavioral therapy (CBT). While CBT (and treatments like it) often shows positive outcomes, it’s not successful for everyone. “Meta-analyzed [data] show about half of individuals offered therapies like CBT will reach clinical remission at the end of therapy, half of whom will experience a relapse/recurrence of depression in the next two years,” explains Barney Dunn, a professor of clinical psychology at the University of Exeter in the United Kingdom.

“We need to improve treatments,” he says, “and one way to do so is to target clinically important features of depression that are neglected in current therapies.”

Dunn led a pilot study of a treatment that does just that—augmented depression therapy (ADepT)—to determine if it could be both clinically effective and cost effective in the treatment of depression.

ADepT
ADepT is a form of therapy that targets both an individual’s persistent depressive mood and anhedonia, which is defined as a loss of interest and pleasure. Dunn notes that anhedonia “is linked to broader changes in how our brains and minds process reward. Individuals experiencing depression say reconnecting to pleasure and well-being is key to recovery from depression. Epidemiological studies show that anhedonia features predict a poor future depression course, and our current treatments have shown to be relatively ineffective at rebuilding pleasure and broader well-being.

“The focus of therapies like CBT has predominantly been on targeting negative thoughts and behaviors to bring down negative mood, and they are effective at doing so. However, relatively less emphasis and time is spent on building positive thoughts and behaviors to build positive mood,” he continues.

Dunn’s study, which was published in The Lancet in July 2023 and entitled “Preliminary Clinical and Cost Effectiveness of Augmented Depression Therapy versus vs Cognitive Behavioral Therapy for the Treatment of Anhedonic Depression (ADepT): A Single-Centre Open-Label, Parallel-Group, Pilot, Randomized Controlled TriaI,” further indicates that there are other treatments targeting anhedonia. However, these treatments focus solely on one’s ability to feel pleasure and interest. ADepT is unique in that it targets both the depressive mood and anhedonia at once.1

ADepT treatment consists of 15 acute sessions and five additional sessions and is described as solution focused. The individuals identify goals as well as barriers to those goals, working to improve their overall well-being. They are encouraged to identify their core values across different domains in their life and take steps that are in line with those values.

“Building well-being (capacity to experience pleasure, meaning, and social connection in life) and functional recovery is the primary focus, with depression conceptualized as patterns of thinking, feeling, and behaving that serve as barriers to achieving the goal,” according to the study.

Clinical and Economic Impact
The study, which is the first randomized controlled trial to assess ADepT’s impact, aimed to identify whether the treatment modality would be effective clinically and economically.

Clinically, the researchers wanted to see not only how ADepT affected individuals with depression—the ways in which it improved markers of depression, such as anhedonia—but also whether the treatment would be comparative to modalities such as CBT.

Similarly, the study aimed to identify the cost of ADepT delivery, as financial factors influence the availability and accessibility of a treatment. “In the UK (United Kingdom),” where the study took place, Dunn says, “we are lucky to have a publicly funded National Health Service (NHS) that provides free at the point of access treatment for depression and anxiety via the NHS Talking Therapies initiative. There is limited funding available, and care needs to be taken to spend taxpayer money efficiently to lead to the greatest social gain. Therefore, before a new therapy is adopted, our National Institute of Clinical Excellence (NICE) needs to be convinced that the treatment is effective and represents value for money for the gains achieved in quality of life relative to usual care.” NICE has a willingness to pay a threshold of £20,000. As defined by the World Health Organization, such a threshold is an estimate of the amount a consumer may be willing to pay for a health benefit. It is often connected to a country’s per capita gross domestic product.

In the United States, health care delivery is, of course, quite different. However, the financial aspects of treatment remain an important factor in accessibility. Depending on cost, insurance providers may cover limited treatment models or a wide range of options but with other limitations, such as the providers accepted and the number of sessions covered. When insurance does not cover treatment or the entirety of treatment, patients in the United States pay out of pocket. According to the National Survey on Drug Use and Health, 46% of respondents who felt they needed mental health treatment over the course of 2020 but did not receive it failed to do so because they could not afford it.

Dunn states that in designing ADepT, he and his colleagues ensured that it would be essentially cost-neutral when compared with CBT in the United Kingdom. The same professionals who deliver CBT are able to deliver ADepT, and the treatment entails a similar number of sessions. With that in mind, the study aimed to show that ADepT had a greater impact on quality of life, leading to greater cost effectiveness.

Methods
To measure the impact—both clinical and economic— of ADepT, the researchers recruited 82 adults who met the criteria for a current major depressive episode, as determined by the Structured Clinical Interview for Diagnosis (SCID-I). Additionally, depression had to be the individuals’ primary presenting problem, and they had to have demonstrated symptoms of anhedonia. Participants were divided into two groups, with one group receiving up to 20 sessions of ADepT and the other receiving 20 sessions of CBT. ADepT consisted of 15 acute sessions and up to five additional “booster” sessions as needed, as aforementioned.

According to Newswise, “The therapy sessions were conducted at the AccEPT clinic at the University of Exeter and were supported by Devon Partnership NHS Trust, Exeter Collaboration for Academic Primary Care (APEx), and the University of Exeter Psychology Department.”2

After the 20 sessions, participants were followed at six months, 12 months, and 18 months.

Participants rated their treatment, and tapes of the treatment sessions were assessed for the competence of each participating therapist, all of whom are experienced CBT practitioners. The Patient Health Questionnaire (PHQ-9) and the Warwick Edinburgh Mental Wellbeing Scale were used to assess the coprimary self-report outcomes with additional tools used for secondary self-report outcomes. The researchers indicated that “For health economic evaluation, intervention usage was measured from clinical records and information about training, supervision, and other non-face-to-face activities were taken from therapists and trainers. Use of broader health and care services was measured using a modified version of the Adult Service Use Schedule.”

Outcomes and Next Steps
The findings were positive, showing that clinically, ADepT was not inferior to CBT in treating depression. “The pilot trial shows ADepT is not worse and has potential to be better than CBT for addressing depression with adhedonic features with care delivered in a university specialist setting,” Dunn says.

Similarly, ADepT looks to be a financially sound treatment option. “Costs of ADepT care were broadly the same as CBT,” Dunn says, “but it [ADepT] led to greater quality of life gains and so has the potential to be cost-effective at that £20,000 willingness to pay threshold.”

Given the positive results, the next steps are to move from a pilot trial to a large-scale trial “in real-world NHS services,” Dunn says. “We are also simultaneously developing and evaluating adaptations of ADepT, targeting more complex depression cases linked to exposure to complex early life trauma and for young adults early on in their depression trajectory.” He adds that therapists both in the United Kingdom and internationally are being trained on ADepT so that they may both implement and assist in evaluating it down the line.

If the outcomes continue to indicate ADepT’s potential for positive impact, individuals struggling with depression may soon have another option for help.

Additional information about Dunn’s research can be found at https://www.cbtreach.org/barney-dunn.

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.

References
1. Dunn BD, Widnall E, Warbrick L, et al. Preliminary clinical and cost effectiveness of augmented depression therapy versus cognitive behavioural therapy for the treatment of anhedonic depression (ADepT): a single-centre, open-label, parallel-group, pilot, randomised, controlled trial. EClinicalMedicine. 2023;61:102084.

2. New talking therapy for depression could be more effective and cheaper than CBT. Newswise website. https://www.newswise.com/articles/innovative-therapy-for-depression-rivals-cbt-in-efficacy-and-cost. Published July 13, 2023.