Evaluation of Metacognitive Training for Depression (D-MCT) in Outpatient Care
Condition: Unipolar Depression
MeSH terms: Depression; Depressive Disorder
Study type: Interventional

Summary: 
      Aim of the current study is to investigate the acceptance and efficacy of Metacognitive
      Training for Depression (D-MCT) compared to cognitive remediation in outpatients with major
      depressive disorders in a randomized, controlled, assessor-blind, group trial.
    

Detailed description: 
      Evidence-based treatments for depression include pharmacological and psychological
      interventions. Within psychological interventions, cognitive behavioral therapy (CBT) is one
      of the most extensively researched evidence-based approaches for depression (Cuijpers, 2015).
      However, even if optimal treatment and access to services were available to all patients, the
      burden of depression would be reduced by only 30% (Andrews et al., 2004). Moreover, as
      depression represents the disorder with the highest drop-out rates during CBT treatment
      (36.4%) (Fernandez et al., 2015), and a relapse rate of 54% for treatment responders within
      the two years after treatment termination (Vittengl et al., 2007), it is pivotal to improve
      treatment for depression. It has been argued that this is less a question of developing novel
      psychological treatments as of determining how existing treatments may be improved (Cuijpers,
      2015) and better disseminated to increase retention rates and to use the waiting phase to
      rise interest in therapy (Fernandez et al., 2015). Due to hopelessness and the discouraging
      character of the disorder, this poses a particular challenge.

      To meet this aim, Metacognitive Training for Depression (D-MCT) has been developed as a
      low-threshold, highly standardized and yet easy to administer group concept for the treatment
      of depression. It is conceptualized as a variant of CBT that adopts a metacognitive
      perspective focusing on the modification of cognitive biases, and is compatible with a
      general CBT treatment approach. Use of standardized presentations reduces time needed for
      preparation and administration of the training; moreover, this "packaging" increases the
      accessibility of D-MCT to a wide range of health care providers, and encourages
      standardization across therapists. The training seeks to enable group members to recognize
      and correct the often automatic and unconscious thought patterns that accompany depression.
      To this end, it attempts to challenge cognitive biases through the use of creative and
      engaging exercises supported by a multimedia presentation (e.g., insight based on "aha"
      effects rather than psychoeducation) and to encourage patients to take a metacognitive
      perspective ("think about one's thinking"). The training is highly flexible with regard to
      depth and intensity. Patients do not need to (but may) discuss their own problems, and can
      still experience how cognitive biases work and influence one's mood in a playful atmosphere.
      The training is conceptualized as an open group: New patients can join the group in every
      session. Thus, the threshold for administration of and participation in this intervention is
      low.

      The general structure of and exercises in D-MCT were inspired by Metacognitive Training for
      psychosis (Moritz et al., 2014); however, contents were modified upon to suit the specific
      problems of individuals with depression. Beside depressive thought patterns already targeted
      in CBT (e.g., overgeneralization, "mind reading"), a number of general cognitive biases,
      which have been identified by basic cognitive research, form the core of D-MCT (e.g.,
      mood-congruent memory (Mathews and MacLeod, 2005)). Finally, as in Metacognitive Therapy
      (MCT) sensu Adrian Wells (Wells, 2011) dysfunctional coping strategies (i.e., thought
      suppression, rumination as problem-solving) are challenged. D-MCT thus blends established
      elements from CBT and MCT as well as newly developed and evidence-based exercises in one
      coherent metacognitive approach.

      D-MCT was positively evaluated with regard to feasibility and acceptance in a non-randomized
      pilot study (Jelinek et al., 2013). Moreover, efficacy of D-MCT was suggested in a randomized
      controlled trail (RCT) in comparison to an active control intervention (Jelinek et al.,
      2016). In this trial patients with depressive disorder were completing a psychosomatic
      outpatient treatment program and were randomly assigned to either D-MCT or general health
      training. Severity of depression and cognitive biases were assessed at baseline (t0), post
      treatment (t1) and 6 months (t2) later by raters blind to diagnostic status.
      Intention-to-treat analyses demonstrated that at the end of treatment, as well as 6 months
      later, improvement in depression was significantly greater in the D-MCT relative to the
      health training group at medium effect sizes. A significantly greater number of patients in
      the D-MCT group were in remission at 6-month follow-up. Moreover, the decrease in cognitive
      biases and increase in psychological well-being/quality of life was larger in the D-MCT than
      the health training group over time. Patients' subjective appraisal of D-MCT was also
      positive (Jelinek et al., 2017).

      Aim of the current study is to investigate the acceptance and efficacy of D-MCT in
      outpatients.The Hamilton Depression Rating Scale (HDRS, 17-item version) total score as well
      as the Quick Inventory of Depressive Symptomatology (QIDS) serve as primary outcome.
      Self-assessed depression, dysfunctional beliefs, self-esteem, quality of life, rumination,
      remission rate as well as neuropsychological functioning serve as secondary outcomes.
    

Intervention name(s): D-MCT; Cognitive remediation
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Metacognitive Training for Depression (D-MCT), 8 sessions (60min); once a week over a period of 8 weeks. Metacognitive Training for depression (D-MCT) is a low-threshold, easy to administer group intervention. It aims at the reduction of depressive symptoms by changing cognitive biases; not only biases targeted in cognitive behavioral therapy but also those identified by basic research.; A computerized cognitive remediation program that covers several cognitive domains, such as attention, visuomotor skills, and Memory. The difficulty level adapts automatically to the performance level of each patient. At the end of each session, the patient receives individual feedback on his or her performance; 8 sessions (60min), once a week over a period of 8 weeks
Other intervention name(s): Metacognitive Training for Depression
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Depression; Metacognition; CBT; D-MCT; cognitive bias