The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a relatively new approach in the treatment of chronic depression (CD). Adapted as group psychotherapy for inpatients, CBASP is attracting increasing attention. In this naturalistic multicenter trial, we investigated its feasibility after 10 sessions of CBASP group therapy over a treatment time of at least 5 to a maximum of 10 weeks. Treatment outcome was additionally assessed. Across four centers, 116 inpatients with CD (DSM-IV-TR) attended CBASP group psychotherapy. Feasibility was focused on acceptance, and evaluated for patients and therapists after five (t1) and ten sessions (t2) of group psychotherapy. Observer- and self-rating scales (Hamilton Depression Rating Scale—24 items, HDRS24; Beck Depression Inventory-II, BDI-II; World Health Organization Quality of Life assessment, WHOQOL-BREF) were applied before group psychotherapy (t0) and at t2. Dropouts were low (10.3%). Patients’ evaluation improved significantly from t1 to t2 with a medium effect size (d = 0.60). Most of the patients stated that the group had enriched their treatment (75.3%), that the size (74.3%) and duration (72.5%) were ‘optimal’ and 37.3% wished for a higher frequency. Patients gave CBASP group psychotherapy an overall grade of 2 (‘good’). Therapists’ evaluation was positive throughout, except for size of the group. Outcome scores of HDRS24, BDI-II, and WHOQOL-BREF were significantly reduced from t0 to t2 with medium to large effect sizes (d = 1.48; d = 1.11; d = 0.67). In this naturalistic open-label trial, CBASP, when applied as inpatient group psychotherapy, was well accepted by patients and therapists. The results point towards a clinically meaningful effect of inpatient treatment with CBASP group psychotherapy on depression and quality of life. Other potential factors that could have promoted symptom change were discussed. A future controlled study could investigate the safety and efficacy of CBASP group psychotherapy for inpatients.

BACKGROUND:The Cognitive Behavioral Analysis System of Psychotherapy (CBASP), initially developed as an outpatient treatment for chronic depression (CD), has been adapted as a multidisciplinary 12-week inpatient program for CD. METHODS:Seventy inpatients with CD and treatment resistance were included in a noncontrolled trial. The Hamilton Depression Rating Scale served as the primary outcome measure. Prospective naturalistic follow-up assessments were conducted 6 and 12 months after discharge. RESULTS:Dropout rate was 7.1%; 90.4% perceived the program as helpful. Pre-post comparisons yielded strong effect sizes; 75.7% of the intention-to-treat sample responded, and 40.0% remitted. Nonremission was associated with experiencing temporary deterioration of symptoms during treatment. After 6 months 75.0% and after 12 months 48.0% of patients sustained response. CONCLUSIONS:The CBASP program appears as a feasible acute treatment for treatment-resistant CD inpatients with promising outcome. However, the continuation of treatment after discharge should be optimized especially for patients with subjective deterioration during treatment.

Hintergrund: Aufbauend auf einer ambulanten CBASP-Behandlung wurde ein stationäres multidisziplinäres Konzept zur Behandlung chronischer Depression entwickelt. Eine Pilotstudie zeigte positive Ergebnisse hinsichtlich der Wirkung dieses Konzepts, jedoch berichteten einige Patienten, dass die 12-wöchige Therapie zu kurz und die Zeit unmittelbar nach Entlassung schwierig sei. Daher wurde CBASP@home als ein internetbasiertes Situationsanalysen (SA)-Training zur Stabilisierung des erzielten Behandlungserfolgs konzipiert. CBASP@home ist eine 3-monatige Step-down-Onlineintervention. Die Patienten werden dabei unterstützt, die erlernten SA zu Hause fortzuführen und in den Alltag zu transferieren. An insgesamt 9 Terminen füllten die Patienten das SA-Formular über einen Sicherheitsserver aus und erhielten von ihrem stationären Psychotherapeuten zeitnah Rückmeldung. Fallbericht: In der vorliegenden Phase-I-Studie wurde die Akzeptanz und Durchführbarkeit von CBASP@home an 2 Einzelfällen untersucht. CBASP@home wurde von beiden Patienten sehr gut angenommen und als sinnvolle Unterstützung bewertet. Zudem konnte bei beiden Patienten eine zunehmende Leistungssteigerung in der SA-Durchführung bei gleichzeitig rückläufiger depressiver Symptomatik bis zur Remission beobachtet werden. Schlussfolgerungen: Die beiden Einzelfallauswertungen liefern Hinweise, dass CBASP@home Transferprozesse vom stationären Setting in den Alltag erleichtern, Behandlungserfolge beibehalten bzw. Rückfällen vorbeugen kann. Wenn sich diese positiven Erfahrungen in zukünftigen Studien bestätigen sollten, kann CBASP@home wesentlich zur Verbesserung der langfristigen Versorgung chronisch depressiver Patienten beitragen.

Patients received optimized pharmacotherapy in addition to the CBASP program in compliance with current national and international guidelines for depression treatment [13, 14] and according to clinical expert supervision ( table 1 ). Ten inpatients with severe chronic depression according to DSM-IV were included in this pilot study. Exclusion criteria were limited to a history of bipolar I disorder, comorbid substance dependence with less than 3 months of abstinence, and mental disorders due to organic factors. The SCID I and II [15, 16] were used for diagnosis. Early trauma and life events were assessed by using the Childhood Trauma Questionnaire (CTQ) [17, 18] . Follow-up data were collected 6 months after discharge. Table 1 summarizes the baseline demographics and characteristics of the 10 inpatients. Concerning feasibility, all patients completed the treatment. Self-rating questionnaires for evaluating the experience and acceptance of the program revealed that patients found the overall concept ‘helpful’ or ‘very helpful’. Satisfaction with the CBASP group therapy was rated as ‘high’ or ‘very high’. In addition, the acceptance of the CBASP concept by the treatment team was high. The CBASP concept proved to be feasible and there were no major difficulties integrating the concept into the daily clinical routine. The 24-item version of the Hamilton Depression Rating Scale (HAMD) [19] served as the primary outcome measure and the Beck Depression Inventory (BDI) [20] as the secondary measure. T tests for paired samples revealed significant improvements and large effect sizes in the primary outcome HAMD-24 (HAMD pre : 31.80 8 4.87; HAMD post : 14.90 8 9.40; ES pre-post : d = 2.26, T(9) = 6.33, p = 0.000) and in the BDI (BDI pre : 35.50 8 6.16; BDI post : 17.88 8 11.21; ES pre-post : d = 1.95; T(7) = 4.75, p = 0.002). Treatment response was defined a priori as a reduction in symptom severity of at least 50% on the HAMD, and remission was defined as a score of 10 or less on the HAMD scale. Figure 1 a illustrates the treatment response for each patient, demonstrating that no patient deteriorated. Six out of the 10 patients were classified as responders and 4 of these fulfilled the remission criterion. Exploratory analyses revealed that the nonresponders had a significantly higher number of personality disorders ( M = 3.25) than responders ( M = 0.66; U = 2.00; p = 0.038). In addition, the Impact Message Inventory (IMI-R) [21, 22] was used to assess the stimulus character of a patient rated by the therapist before and after treatment. The mean scores of the IMI-R are illustrated in figure 1 b and showed that the patients could change their stimulus character to be more friendly and dominant. Finally, the 6-month naturalistic follow-up assessments were completed by 9 out of the 10 patients. Outpatient psychotherapy was continued by 6 patients (CBASP: 3, cognitive-behavioral therapy: 2, schema therapy: 1), 9 patients were still on pharmacotherapy, and 6 patients regularly attended the CBASP support group. In figure 1 a, the HAMD follow-up scores for each patient in relaCognitive behavioral analysis system of psychotherapy (CBASP) was initially developed as an outpatient treatment for chronic depression [1, 2] . It integrates cognitive-emotional, behavioral, interpersonal, and psychodynamic theories and strategies by addressing directly the specific psychopathology of chronic depression. In most of the studies being conducted in outpatient settings CBASP proved to be an effective treatment [3–5] , especially in patients with early onset [5] , early trauma [4] , and in combination with medication [3] . The recently published REVAMP trial found no difference between CBASP, brief supportive therapy, or continued optimized pharmacotherapy for augmentation of antidepressant nonresponse; however, the validity of these findings is limit ed by the low number of therapy sessions used in this study [6, 7] . Given the high degree of suicidality, comorbidity, and therapy resistance in chronic depression [8–11] , however, many of these patients require inpatient treatment [12] . Here, we report on a first specialized program for chronic depression adapting CBASP to an inpatient setting. The aim of this study was to evaluate the feasibility and shortas well as long-term outcome of this program. The CBASP inpatient treatment was established at our department in 2008 and is based on the outpatient CBASP concept by McCullough [1, 2] . However, we modified his approach by implementing a multidisciplinary structured treatment program combining individual and group therapies. The manualized CBASP inpatient treatment is limited to 3 months (24 individual sessions). The new CBASP group therapy focuses on a modified approach for conducting situation analysis and on Kiesler’s circle training with the extensive use of role playing and shaping. The entire treatment team was trained in CBASP; regular workshops and weekly supervisions for both the team and the individual therapists were conducted. Specific CBASP elements were also implemented in other accompanying treatments such as nurse encounters, physiotherapy, music therapy, and occupational group therapy. A patient support group was established to avoid relapse after discharge. Received: February 3, 2010 Accepted after revision: August 26, 2010 Published online: March 10, 2011