Stress Systems and Psychotherapy in Depression

Study Overview
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Brief Summary
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Dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis as well as maladaptive activation of the autonomic nervous system (ANS) are discussed as relevant factors in the development of a major depressive episode and as a correlate of its clinical manifestation. Preliminary evidence suggests that the hypercortisolaemic pattern in a subgroup of depressed patients may predict non-responses to psychotherapeutic treatment. At the same time, it is conceivable that disorder-related alterations in HPA axis and ANS regulation change in response to effective treatment, such as cognitive behavioural therapy (CBT), and that those changes could parallel changes in depressive symptoms. Identifying such associations may shed light on biological and psychological mechanisms of action underlying successful treatment. However, so far, no studies have investigated depressed patients with regard to dysregulation in both stress systems, HPA axis and ANS, before psychotherapeutic treatment, nor have changes in functioning of both systems been inspected in response to treatment. Moreover, a detailed investigation of depressive symptom trajectories over the course of treatment and its associations with changes in HPA axis and ANS regulation is lacking. It can be speculated that specific techniques of the treatment, e.g., typical CBT elements, such as behavioural activation or cognitive restructuring, might particularly be associated with changes in HPA axis and ANS regulation. The main aims of this project are to investigate: whether diurnal salivary cortisol and alpha-amylase as well as hair cortisol concentrations change from pre- to post-intervention in treatment responders compared to non-responders; whether diurnal salivary cortisol and alpha-amylase concentrations change from pre- to mid-intervention and from mid- to post-intervention in treatment responders compared to non-responders; whether changes in diurnal salivary cortisol, alpha-amylase and hair cortisol concentrations are significantly correlated with changes in depressive symptoms; whether concentrations of diurnal salivary cortisol and alpha-amylase as well as hair cortisol at pre-treatment predict future treatment response (i.e., on a psychological level). On an exploratory level, it will be investigated: which elements of a CBT intervention for depression (behavioural activation vs. cognitive restructuring) are associated with changes in diurnal salivary cortisol and alpha-amylase concentrations. It is hypothesised: that pre- to post-intervention decreases in diurnal salivary cortisol and alpha-amylase as well as hair cortisol concentrations will be more pronounced in responders compared to non-responders. that pre- to mid-intervention and mid- to post-intervention decreases in diurnal salivary cortisol and alpha-amylase will be more pronounced in responders compared to non-responders. that changes in depressive symptoms will significantly correlate with changes in diurnal cortisol and diurnal alpha-amylase as well as hair cortisol concentrations. that pre-intervention diurnal salivary cortisol and alpha-amylase as well as hair cortisol concentrations will be higher in future non-responders, compared to responders.

Detailed Description
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Recruitment: Patients will be recruited from an ongoing project providing an internet-based cognitive behavioral intervention for patients suffering from mild to moderate depression. Protocol: In this study, a total of N=42 patients fulfilling criteria for a current major depressive episode will undergo a 6-week internet-based cognitive behavioural intervention which consists of seven consecutive modules. Diurnal (salivary) and hair cortisol as well as diurnal (salivary) alpha-amylase will be assessed immediately before and after treatment, and at mid-treatment (i.e., after four of seven modules). Saliva samples (six samples per day) will be collected over two consecutive days. One hair sample will be obtained at pre- and post-intervention assessments respectively.

Official Title
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Biological Correlates of an Internet-based Psychological Intervention for Depression

Conditions
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Major Depressive Episode

Intervention / Treatment
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* Behavioral: internet-based intervention for mild to moderate depression


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Current major depressive episode (F32.0, F32.1, F33.0, F33.1) Agreement to participate in the study At least 18 years of age Exclusion Criteria: Diagnosis of schizophrenia, schizotypal and delusional disorders (F20-F29) Acute suicidal patients Acute manic episode Substance related abuse or addiction Pregnancy or lactation Chronic somatic diseases Severe somatic diseases (e.g., endocrinological, neurological, autoimmune diseases) Glucocorticoid medication intake during the last six months Concurrent psychotherapeutic treatment

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: iCBT for depression - behavioral activation first (BAF)<br>internet-based intervention for mild to moderate depression: patients receive behavioral activation first, followed by cognitive restructuring | Behavioral: internet-based intervention for mild to moderate depression<br>* The six-weeks, therapist-guided, internet-based intervention for depression includes expressive writing tasks and further consists of key elements of cognitive behavioral therapy (CBT) for depression. In seven consecutive modules, patients receive psychoeducation and instructions for weekly tasks, and an individualized feedback letter of their therapist after each module. The intervention is effective in reducing depressive symptoms (Zagorscak et al., 2018). In the current study, patients will be randomly assigned to two different conditions with varying orders of modules: 1. patients will receive two modules (module 3 and 4) of behavioral activation, followed by two modules (modules 5 and 6) of cognitive restructuring; 2. patients will receive two modules (module 3 and 4) of cognitive restructuring, followed by two modules (modules 5 and 6) of behavioral activation. All other modules (1, 2 and 7) will be identical across conditions.<br>|
| Experimental: iCBT for depression - cognitive restructuring first (CRF)<br>internet-based intervention for mild to moderate depression: patients receive cognitive restructuring first, followed by behavioral activation | Behavioral: internet-based intervention for mild to moderate depression<br>* The six-weeks, therapist-guided, internet-based intervention for depression includes expressive writing tasks and further consists of key elements of cognitive behavioral therapy (CBT) for depression. In seven consecutive modules, patients receive psychoeducation and instructions for weekly tasks, and an individualized feedback letter of their therapist after each module. The intervention is effective in reducing depressive symptoms (Zagorscak et al., 2018). In the current study, patients will be randomly assigned to two different conditions with varying orders of modules: 1. patients will receive two modules (module 3 and 4) of behavioral activation, followed by two modules (modules 5 and 6) of cognitive restructuring; 2. patients will receive two modules (module 3 and 4) of cognitive restructuring, followed by two modules (modules 5 and 6) of behavioral activation. All other modules (1, 2 and 7) will be identical across conditions.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in salivary cortisol concentration | Changes in diurnal profiles (six time points: awakening, +30 min., 11am, 2 pm, 6pm, 9pm) of salivary cortisol concentration (nmol/l), measured on two consecutive days, at mid-intervention and post-intervention in responders compared to non-responders to the psychological intervention (assessed by Patient Health Questionnaire (PHQ-9)) | pre-intervention, mid-intervention (after an average of three weeks), post-intervention (after an average of six weeks) | 
| Differences in salivary cortisol concentration | Differences in diurnal profiles (six time points: awakening, +30 min., 11am, 2 pm, 6pm, 9pm) of cortisol concentration (nmol/l), measured on two consecutive days, at pre-intervention in responders compared to non-responders to the psychological intervention (assessed by PHQ-9) | pre-intervention | 
| Changes in salivary alpha-amylase concentration | Changes in diurnal profiles (six time points: awakening, +30 min., 11am, 2 pm, 6pm, 9pm) of salivary alpha-amylase concentration (U/ml), measured on two consecutive days, at mid-intervention and post-intervention in responders compared to non-responders to the psychological intervention (assessed by Patient Health Questionnaire (PHQ-9)) | pre-intervention, mid-intervention (after an average of three weeks), post-intervention (after an average of six weeks) | 
| Differences in salivary alpha-amylase concentration | Differences in diurnal profiles (six time points: awakening, +30 min., 11am, 2 pm, 6pm, 9pm) of salivary alpha-amylase concentration (U/ml), measured on two consecutive days, at pre-intervention in responders compared to non-responders to the psychological intervention (assessed by PHQ-9) | pre-intervention | 
| Changes in hair cortisol concentration | Changes in hair cortisol concentrations (nmol/l) at post-intervention in responders compared to non-responders to the psychological intervention (assessed by Patient Health Questionnaire (PHQ-9)) | pre-intervention, post-intervention (after an average of six weeks) | 
| Differences in hair cortisol concentration | Differences in hair cortisol concentrations (nmol/l) at pre-intervention in responders compared to non-responders to the psychological intervention (assessed by PHQ-9) | pre-intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sleep quality (self-report) | Changes in Pittsburgh Sleep Quality Index (PSQI); scale ranges from 0 to 21 | pre-intervention, mid-intervention (after an average of three weeks), post-intervention (after an average of six weeks) | 
| Chronic stress (self-report) | Changes in Trier Inventory for the assessment of chronic stress - TICS (Trier Inventar zum chronischen Stress), scale ranges from 0 to 48 | pre-intervention, mid-intervention (after an average of three weeks), post-intervention (after an average of six weeks) | 
| Cognitive biases (self-report) | Changes in Cognitive Styles Assessment (COSTA-21); scale ranges from 0 to 5 per item | pre-intervention, mid-intervention (after an average of three weeks), post-intervention (after an average of six weeks) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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major depressive episode, cortisol, alpha-amylase, psychotherapy