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Am J Psychiatry 1996; 153:886-891
Copyright © 1996 by American Psychiatric Association
Hypothalamic-pituitary-adrenocortical activity and response to cognitive behavior therapy in unmedicated, hospitalized depressed patients
ME Thase, S Dube, K Bowler, RH Howland, JE Myers, E Friedman and DB Jarrett
Department of Psychiatry, University of Pittsburgh School of Medicine, PA 15213, USA.
OBJECTIVE: Surprisingly little research supports the hypothesis that
depressions characterized by objective measures of neurobiological
dysregulation respond poorly to psychotherapy. Moreover, relevant studies
testing this hypothesis have been compromised by low rates of
neurobiological abnormality in outpatient samples. The authors therefore
investigated response to cognitive behavior therapy in relation to
pretreatment measures of hypothalamic-pituitary- adrenocortical (HPA)
activity in hospitalized, yet unmedicated, patients. METHOD: The subjects
were 29 unmedicated, hospitalized patients with major depression (DSM-III-R
and Schedule for Affective Disorders and Schizophrenia/Research Diagnostic
Criteria), nonpsychotic/nonbipolar subtype. After a 7- to 14-day
evaluation, urinary free cortisol levels and dexamethasone suppression
tests (DSTs) were obtained. Patients were treated for an average of 3 weeks
with intensive individual cognitive behavior therapy. Response was assessed
in relation to clinical severity of illness and pretreatment HPA
parameters. RESULTS: Response to inpatient cognitive behavior therapy was
inversely associated with pretreatment urinary free cortisol
concentrations, although not strongly correlated with DST results. Overall,
12 (92%) of 13 cortisol suppressors on the DST who had normal urinary free
cortisol concentrations responded to treatment, compared with only seven
(44%) of the 16 patients characterized by nonsuppression of cortisol and/or
elevated urinary free cortisol excretion. The relation between response to
cognitive behavior therapy and HPA activity was not explained by clinical
measures of symptom severity. CONCLUSIONS: Results are consistent with the
hypothesis that patients with increased HPA function are less responsive to
psychotherapy and, hence, might require somatic interventions. It is
proposed that the negative impact of hypercortisolism on neurocognitive
function mediates this relationship.
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