Treatment and Prevention of Depression

The Longitudinal Structure of the Children's Depression Inventory: Testing a Latent Trait-State Model

In a 6-wave longitudinal study, children (Grades 4-6, n = 648), adolescents (Grades 7-9, n = 1,489), and their parents completed child-adolescent or parent versions of the Children's Depression Inventory (CDI; M. Kovacs, 1981). Using structural equation modeling, the authors conducted latent trait-state analyses to distinguish between a stable trait dimension of depression (in which individual differences are stable over time) and an autoregressive dimension (in which individual differences are less stable over time). Children's CDIs reflected the autoregressive dimension more than a stable trait dimension, whereas parents' CDIs reflected a stable trait dimension more than an autoregressive dimension. Reports from adolescents and their parents reflected a stable trait dimension more than an autoregressive dimension of depressive symptoms. Results suggest that the longitudinal structure of the CDI varies considerably depending on the age of the target and the type of informant.

In praise of clinical judgment: Meehl's forgotten legacy

Although Paul E. Meehl demonstrated the limits of informal aggregation of data and prognostication by presumed experts, he remained convinced that clinical experience confers expertise of some kind. The authors explore this forgotten side of Meehl's legacy by reconsidering the validity of clinical judgment in its natural context, everyday clinical work. Three domains central to clinical practice are examined: diagnosis, interpretation of meaning, and intervention. It is argued that a more sanguine picture of clinical expertise emerges when the focus shifts from prediction at high levels of inference to (a) judgments at a moderate level of inference, (b) contexts for which clinical training and experience are likely to confer expertise, and (c) conditions that optimize the expression of that expertise (e.g., use of instruments designed for expert observers). The authors conclude by examining domains in which clinical judgment could prove useful in knowledge generation (e.g., hypothesis generation, identification of falsifying instances, item development).

Empirically Supported Psychotherapies: Comment on Westen, Novotny, and Thompson-Brenner (2004)

D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) suggested that efforts to identify empirically supported treatments are misguided because they are based on assumptions that are not appropriate for some types of treatment and patients. The authors of this comment argue that Westen and colleagues are simply incorrect when they assert that empirically supported treatments require that psychopathology must be highly malleable, that treatments must be brief, or that the samples studied are unrepresentative of the kinds of patients typically encountered in clinical practice--comorbidity is common in many clinical trials. Randomized controlled trials remain the most powerful way to test notions of causal agency.

Psychological treatments

Psychology has recently identified itself as a health care profession and codified this change in the bylaws of the American Psychological Association. Although psychologists make a number of contributions to the nation's health--and mental health--the most identifiable activity focuses on treating physical or psychological pathology with psychological interventions. Recently, health care policymakers have established that evidence supporting the efficacy of these interventions is more than sufficient for their inclusion in health care systems around the world. To promote faster and more widespread dissemination of these interventions specifically targeting problems severe enough to be included in health care systems and to solidify the identification of psychology as a health care profession, perhaps it is time for a change in terminology. It is proposed that psychologists label these procedures psychological treatments so as to differentiate them from more generic psychotherapy, which is often used outside of the scope of health care systems.

The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care

Epidemiological studies have identified high prevalence rates of anxiety and depression in North America [e.g., J. of Nerv. Ment. Dis. 182 (1994) 290]. However, only a small percentage of these individuals access effective treatment. The undertreatment of anxiety and depression is a major public health issue and is associated with significant personal, social, and economic burden. This article describes the existing discrepancy between prevalence of anxiety and depression and access to effective treatment for adults and children, the contributors to this discrepancy, and suggests various means through which access to effective treatment may be enhanced. We begin with a brief overview of the prevalence and associated personal, societal, and systemic burdens of anxiety and depression. This is followed by a review of current rates of access to treatment and possible individual, provider, and systemic barriers to accessing treatment. Recommendations for bridging the gap between the high rates of these disorders and limited accessibility of effective care are then presented.

Does Psychology make a significant difference in our lives?

The intellectual tension between the virtues of basic versus applied research that characterized an earlier era of psychology is being replaced by an appreciation of creative applications of all research essential to improving the quality of human life. Psychologists are positioned to "give psychology away" to all those who can benefit from our wisdom. Psychologists were not there 35 years ago when American Psychological Association (APA) President George Miller first encouraged us to share our knowledge with the public. The author argues that psychology is indeed making a significant difference in people's lives; this article provides a sampling of evidence demonstrating how and why psychology matters, both in pervasive ways and specific applications. Readers are referred to a newly developed APA Web site that documents current operational uses of psychological research, theory, and methodology (its creation has been the author's primary presidential initiative): www.psychologymatters.org.

Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma

Major depressive disorder is associated with considerable morbidity, disability, and risk for suicide. Treatments for depression most commonly include antidepressants, psychotherapy, or the combination. Little is known about predictors of treatment response for depression. In this study, 681 patients with chronic forms of major depression were treated with an antidepressant (nefazodone), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or the combination. Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. Our results suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma.

Science and Philosophy: Comparison of Cognitive Therapy and Rational Emotive Behavior Therapy

Aaron T. Beck’s Cognitive Therapy (CT) and Albert Ellis’ Rational Emotive Behavior Therapy (REBT) are compared. A major difference between these therapies is that CT is an empirically based therapy and REBT is philosophically based. The origins and subsequent development of the therapies are reviewed with this difference highlighted. Comparisons between CT and REBT practice are made regarding attitudes toward client beliefs, use of guided discovery, types of cognition addressed, and the nature of the client-therapist relationship. The scientific foundations of CT are summarized in terms of the specificity of its conceptual models, the construction of targeted treatment protocols, and empirical findings that support both CT conceptualizations and treatments.