Associations of antidepressant medication consumption with changes in personality pathology and quality of life among community-dwelling adults

BACKGROUND

Although antidepressant medication (ADM) has produced small advantages over pill placebo in randomized controlled trials, consuming ADM has predicted prospectively increasing depressive symptom severity in samples of community-dwelling adults.

OBJECTIVE

We extended the community literature by testing ADM's relations to changes in personality and quality of life that may underpin depression.

METHOD

In this longitudinal, observational study, community-dwelling adults (N = 601) were assessed twice, 8 months apart on average. Assessments included depressive symptoms, personality, life satisfaction and quality, and prescription medication consumption.

RESULTS

Consuming ADM at time 1 predicted relative increases in depressive symptoms (dysphoria), maladaptive traits (negative affect, negative temperament, disinhibition, low conscientiousness), personality dysfunction (non-coping, self-pathology), and decreases in life satisfaction and quality from time 1 to 2, before and after adjustment for age, gender, race, income, education, physical health problems, and use of other psychotropics. In no analysis did ADM use predict better outcomes.

CONCLUSION

Among community-dwelling adults, ADM use is a risk factor for psychosocial deterioration in domains including depressive symptoms, personality pathology, and quality of life. Until mechanisms connecting ADM to poor outcomes in community samples are understood, additional caution in use of ADM and consideration of empirically supported non-pharmacologic treatments is prudent.

Disinhibition domain and facets uniquely predict changes in depressive symptoms and psychosocial functioning

This study aimed to understand the role of disinhibition (low conscientiousness)-in conjunction with the other major personality traits of negative affectivity, detachment, antagonism, and psychoticism-in predicting changes in depressive symptoms and psychosocial functioning. Both the disinhibition trait domain and its primary facets (i.e., irresponsibility, impulsivity, and distractibility) were examined. In a large sample (Time 1 N = 605, Time 2 N = 497) of psychiatric outpatients and high-risk community residents, personality traits, depressive symptoms (both self-reported and interviewer-rated), and psychosocial functioning levels (i.e., daily functioning, interpersonal functioning, health-related quality of life, and global quality of life) were collected across two time points. Results showed that the disinhibition domain was the strongest predictor of changes in depressive symptoms and general quality of life levels. Disinhibition facets also predicted changes in depressive symptoms but showed a less consistent pattern compared to the broader trait domain. Finally, the irresponsibility and distractibility facets significantly and uniquely explained changes in interpersonal functioning. The study highlights the importance of assessing the disinhibition trait rather than only negative and positive affectivity (which are well-known correlates of depression), for understanding changes in depressive symptoms and psychosocial functioning. The findings identify potential targets in psychotherapy for individuals with disinhibition traits and depressive disorders.

Evaluating a Comprehensive Model of Euthymia

INTRODUCTION

In research and treatment of mood disorders, "euthymia" traditionally denotes the absence of clinically significant mood disturbance. A newer, expanded definition of euthymia also includes positive affect and psychological well-being.

OBJECTIVE

We aimed to test this comprehensive model of euthymia and estimate the coherence and predictive power of each factor in the model.

METHODS

Community-dwelling adults (N = 601), including both mental health outpatients and non-patients at high risk for personality pathology, completed a battery of interviews and questionnaires at time 1. Most (n = 497) were reassessed on average 8 months later (time 2). We modeled euthymia using standard mood, personality, and psychosocial functioning assessments rather than measures designed specifically for euthymia.

RESULTS

The hypothesized model of euthymia was supported by confirmatory factor analysis: specific measures loaded on three lower order factors (mood disturbance, positive affect, and psychological well-being) that reflected general euthymia at time 1. Each factor (general euthymia plus lower order factors) demonstrated moderately strong concurrent (time 1) and predictive (time 1-2) correlations with outcomes, including employment status, income, mental health treatment consumption, and disability. Compared to positive affect and psychological well-being, mood disturbance had stronger incremental (i.e., nonoverlapping) relations with these outcomes.

CONCLUSIONS

Support for a comprehensive model of euthymia reinforces efforts to improve assessment and treatment of mood and other disorders. Beyond dampening of psychological distress, euthymia-informed treatment goals encompass full recovery, including enjoyment and meaning in life.

Predictors of attrition in an interdisciplinary pain management program

PURPOSE/OBJECTIVE

This study sought to investigate the extent to which demographic and clinical characteristics predict which patients drop out of an interdisciplinary pain management program (IPP).

RESEARCH METHOD/DESIGN

Participants (N = 178 outpatients, 18-75 years of age) received treatment for various chronic pain conditions in an IPP (including biopsychosocial assessment, cognitive-behavioral, and physical therapies). Separate logistic regression analyses identified the demographic and clinical variables most predictive of attrition across five domains: (a) demographics, (b) number of medical and non/psychiatric diagnoses, (c) opioid use (yes versus no)/risk of misuse, (d) pain-related cognition and behavior, and (e) physical, social, and mental well-being. Significant predictors from the five domains were integrated in a final multivariable logistic regression model.

RESULTS

Among patients exposed to a 4-week IPP, 34% dropped out. In the final model, significant predictors of higher odds of attrition included younger age or being unemployed. Also, patients on opioids at preintervention had higher odds of completing the IPP than patients not on opioids at preintervention. Follow-up analyses revealed 24 of 37 completers (65%) on opioids at preintervention reduced or eliminated use over the course of the IPP.

CONCLUSIONS/IMPLICATIONS

Because findings are limited by sample and design characteristics, they require replication yet offer novel hypotheses for identifying patients at risk of attrition. Specifically, patients with preintervention opioid use (contrasted with opioid dependence) may particularly benefit from an IPP. Patients at highest risk for early dropout can be targeted for specific engagement interventions to promote completion and effectiveness of IPP. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

How can the DSM-5 alternative model of personality disorders advance understanding of depression?

BACKGROUND

The DSM-5 introduced an alternative model of personality disorder (AMPD) that includes personality dysfunction plus maladaptive-range traits. This study clarifies relations of depression diagnoses and symptoms with AMPD personality pathology.

METHOD

Two samples (Ns 402 and 601) of outpatients and community-dwelling adults completed four depression (criteria met for major depressive disorder and dysthymia; dysphoria and low well-being scales), ten trait (two scales for each of five domains-negative affectivity, detachment, disinhibition, antagonism, psychoticism), and eight dysfunction (four scales for each of two domains-self- and interpersonal pathology) measures. Diagnoses were made using a semi-structured interview; other measures were self-reports. We quantified cross-sectional relations between depression and personality pathology with correlation and multiple regression analyses.

RESULTS

Collectively (median R²; ps < 0.0001), the trait (0.46) and dysfunction (0.50) scales predicted the depression measures strongly, with most predictive power shared (0.41) between traits and dysfunction. However, trait and dysfunction scales altogether predicted depression (median R² = 0.54) more strongly than either domain alone, ps < 0.0001. Participants with depression diagnoses showed elevations on all nonadaptive trait and personality dysfunction measures, particularly negative temperament/affectivity and self-pathology measures.

LIMITATIONS

Generalization of findings to other populations (e.g., adolescents), settings (e.g., primary care), and measures (e.g., traditional personality disorder diagnoses) is uncertain. Cross-sectional analyses did not test changes over time or establish causality.

CONCLUSIONS

The AMPD is highly relevant to depression. Assessment of personality pathology, including both personality dysfunction and maladaptive-range traits, stands to advance understanding of depression in adults.

Mindful Self-Care for Caregivers: A Proof of Concept Study Investigating a Model for Embedded Caregiver Support in a Pediatric Setting

We conducted an open-trial proof of concept study to determine the safety, acceptability, and feasibility of Mindful Self-Care for Caregivers (MSCC) for parents of children with Autism Spectrum Disorders (ASD) (N = 13). The intervention was offered as a co-located care model in a pediatric specialty center where the participants' children received care. Results demonstrated that the intervention was: highly acceptable to all stakeholders (i.e., participants, the group facilitator, and center administration) and could be conducted safely by a masters-level practitioner with minimal resources. Further, secondary measures support a hypothesized interventional model of MSCC, demonstrating gains in mindfulness skills and sense of competency in the parenting role reduced perceived stress and depression in parents of children with ASD.

Does Symptom Linkage Density Predict Outcomes in Cognitive Therapy for Recurrent Depression?

Background

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but how CT helps patients is incompletely understood. As a potential means to clarify CT mechanisms, we defined "symptom linkage density" (SLD) as a patient's mean time-lagged correlation among nine depressive symptoms across 13 weekly assessments. We hypothesized that patients with higher SLD during CT have better outcomes (treatment response, and fewer symptoms after response), and we explored whether SLD correlated with other possible CT processes (growth in social adjustment and CT skills).

Method

Data were drawn from two clinical trials of CT for adult outpatients with recurrent MDD (primary sample n = 475, replication sample n = 146). In both samples, patients and clinicians completed measures of depressive symptoms and social adjustment repeatedly during CT. In the primary sample, patients and cognitive therapists rated patients' CT skills. After CT, responders were assessed for 32 (primary sample) or 24 (replication sample) additional months to measure long-term depression outcomes.

Results

Higher SLD predicted increases in social adjustment (both samples) and CT skills (primary sample) during CT, CT response (both samples), and lower MDD severity for at least 2 years after CT response (both samples). Analyses controlled patient-level symptom means and variability to estimate SLD's incremental predictive validity.

Conclusions

These novel findings from two independent samples with longitudinal follow-up require further replication and extension. SLD may reflect or facilitate generalization of CT skills, improvement in social functioning, or other processes responsible for CT's shorter and longer term benefits.

Using quantitative sensory testing to predict attrition in an interdisciplinary pain management program: a pilot study

Aim: To determine the extent to which quantitative sensory testing (QST) predicted attrition in an interdisciplinary pain program (IPP). Patients & methods: Participants (n = 53) enrolled in an IPP completed pretreatment assessments of QST and the PROMIS-29 quality of life survey. Results & conclusion: Compared with completers, non-completers (24.5%) reported significantly higher pain intensity (7.1, 95% CI [5.8, 8.4] versus 5.4, 95% CI [4.8, 6.1]) and cold hyperalgesia (14.6°C, 95% CI [8.8, 20.4] versus 7.5°C, 95% CI [4.8, 6.1]), with both variables also predicting attrition. This finding highlights a potentially novel and clinically significant use of QST. Higher overall pain intensity and the presence of remote cold hyperalgesia may identify patients at risk for dropping out of an IPP.

Levels of depressed mood and low interest for two years after response to cognitive therapy for recurrent depression

BACKGROUND

Major depressive disorder (MDD) involves depressed mood (high negative affect, predominantly) and low interest/pleasure (low positive affect). In past research, negative affect has improved more than positive affect during acute-phase antidepressant medication or cognitive therapy (CT). We extended this literature by differentiating depressed mood and two dimensions of low interest (general and sexual), assessing persistence of symptom differences after acute-phase CT response, and testing whether continuation treatment acted differently on depressed mood versus low interest.

METHODS

We analyzed data from two randomized controlled trials. Patients with recurrent MDD first received acute-phase CT. Then, responders were randomized to 8-month continuation treatments and assessed for 16-24 additional months.

RESULTS

Depressed mood and low general interest improved more than low sexual interest during acute-phase CT. Among responders, these symptom differences persisted for at least 2 years and were not changed by continuation CT or antidepressant medication.

LIMITATIONS

Generalization of findings to other patient populations and treatments is uncertain. Depressed mood and low interest scales were constructed from standard symptom measures and overlapped empirically.

CONCLUSIONS

Less improvement during CT, and persistent low sexual interest despite continuation treatment, highlights the need for MDD treatments more effectively targeting this positive affective symptom.

Improved symptoms of complex regional pain syndrome after novel lymphatic treatment and interdisciplinary pain management

INTRODUCTION

Complex regional pain syndrome (CRPS) is a pain syndrome with no singular mechanism and no specific cure. The aim of this case report is to study the impact of Lymphatic Enhancement Technology (LET) treatment on CRPS-related symptoms.

METHODS

A 51 year-old female presented with a chief complaint of severe, refractory ankle pain and CRPS related to a tibial and fibular fracture sustained three years earlier. The patient completed twelve cognitive behavioral therapy sessions over a 4-week period, and eleven physical therapy sessions over a four-month period, six of which utilized LET.

RESULTS

Pain and swelling were largely unchanged with interdisciplinary treatment before the introduction of LET. A within-session change of 37.5% in pain intensity and 87.5% in ankle girth was observed immediately after the first application of LET. Three months after beginning LET treatment, the patient maintained a 43.8% improvement in pain intensity and 100% improvement in measurements of lower extremity girth and ankle range of motion. No side effects or adverse events were associated with the LET treatment.

CONCLUSION

Swelling, pain, and mobility loss are common symptoms and features of CRPS. LET is a novel, non-invasive treatment that appears to be quite safe and effective for improving pain, swelling, and mobility loss related to CRPS.

Advancing health through research: A scoping review of and model for adjunctive psychosocial interventions to improve outcomes for perinatal women with bipolar disorder

BACKGROUND

We aimed to identify randomized clinical trials (RCTs) which evaluated the efficacy of adjunctive psychosocial interventions to improve outcomes during the perinatal period for women with bipolar disorder (BD).

METHODS

We scanned the literature to identify RCTs evaluating the efficacy of adjunctive psychosocial therapies or interventions provided during the perinatal period to women with BD. We searched from 1946 to July 2020 using Embase, Ovid Medline, PsycINFO, and Scopus. We then searched for future, current, and recently completed RCTs described on www.ClinicalTrials.gov.

RESULTS

This scoping review (1946 - July 2020) revealed no published RCTs for this population. The findings expose an important gap in research and knowledge, as well as a health disparity.

CONCLUSION

We heuristically tied a mechanistic stress reduction model to relevant findings. The initial hypotheses are informed by effective stress reducing psychosocial interventions for: a) people with BD outside the perinatal period and b) perinatal women with major depressive disorder (MDD may improve the health of perinatal women with BD). We hypothesize that the perinatal trajectory of health for women with BD will improve by adding psychosocial interventions or therapies to treatment as usual. We propose maternal stress reduction as a potential mediator/mechanism.

LIMITATIONS

Findings reported are limited to the methods of a scoping review. Reproductive status tends to be a missing variable; we highlight the need for its inclusion. Interdisciplinary, collaborative research to improve the treatment outcome for perinatal women with BD is warranted and ripe for advancement.

Stability and Change in Relations Between Personality Traits and the Interpersonal Problems Circumplex During Cognitive Therapy for Recurrent Depression

Both personality impairment and maladaptive-range traits are necessary for diagnosis in the alternative model of personality disorder. We clarified personality impairment-trait connections using measures of the interpersonal problems circumplex and personality traits among adult outpatients (N = 351) with major depressive disorder receiving cognitive therapy (CT). The trait scales' circumplex projections were summarized by elevation (correlations with general interpersonal problems), amplitude (specific relations to the circumplex dimensions of dominance and affiliation), and angle (predominant orientation in the two-dimensional circumplex). Most trait scales showed hypothesized circumplex relations, including substantive elevation (e.g., negative temperament, mistrust), amplitude (e.g., aggression, detachment), and expected angles (e.g., positive temperament and manipulativeness oriented toward overly nurturant/intrusive or domineering/vindictive problems, respectively), that were stable across time during CT. These results revealed meaningful and consistent impairment-trait connections, even during CT when mean depressive affect decreased substantially.

Quality of life after response to acute-phase cognitive therapy for recurrent depression

BACKGROUND

Adults with major depressive disorder (MDD) often experience reduced quality of life (QOL). Efficacious acute-phase treatments, including cognitive therapy (CT) or medication, decrease depressive symptoms and, to a lesser degree, increase QOL. We tested longer-term changes in QOL after response to acute-phase CT, including the potential effects of continuation treatment for depression and time-lagged relations between QOL and depressive symptoms.

METHODS

Responders to acute-phase CT (N = 290) completed QOL and depressive symptom assessments repeatedly for 32 post-acute months. Higher-risk responders were randomized to 8 months of continuation treatment (CT, fluoxetine, or pill placebo) and then entered a 24-month follow-up. Lower-risk responders were only assessed for 32 months.

RESULTS

On average, large gains in QOL made during acute-phase CT response were maintained for 32 months. Continuation CT or fluoxetine did not improve QOL relative to pill placebo. Controlling for residual depressive symptoms, higher QOL after acute-phase CT response was a protective factor against MDD relapse and recurrence. Higher QOL predicted subsequent reductions in depressive symptom severity, but depressive symptom severity did not predict subsequent changes in QOL.

LIMITATIONS

Generalization of results to other patient populations, treatments, and measures is uncertain. The clinical trial was not designed to test relations between QOL and depression. Replication is needed before clinical application of these results.

CONCLUSIONS

Gains in QOL made during response to acute-phase CT are relatively stable and may help protect against relapse/recurrence. Continuation CT or fluoxetine may not further improve QOL among acute-phase CT responders.

Assessment of patient and provider attitudes towards therapeutic drug monitoring to improve medication adherence in low-income patients with hypertension: a qualitative study

OBJECTIVES

Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM.

DESIGN

Prospective analysis of responses to a set of questions during semistructured interviews.

SETTING

Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population.

PARTICIPANTS

Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics.

PRIMARY AND SECONDARY OUTCOME MEASURES

Attitudes towards TDM and the potential impact on physician-patient relationship.

RESULTS

We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician-patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks.

CONCLUSION

The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient-physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.

Do patients' cognitive therapy skills predict personality change during treatment of depression?

BACKGROUND

Psychological interventions can change personality, including increasing positive temperament (extraversion) and decreasing negative temperament (neuroticism), but why these changes occur is unclear. The current study tested the extent to which patients' acquisition and use of skills taught in cognitive therapy (CT) correlated with changes in positive and negative temperament during treatment of depression.

METHOD

Outpatients (N = 351) with recurrent major depressive disorder (MDD) were enrolled in a 12-week CT protocol. Temperament (early and late in CT), patient skills (mid and late in CT), and depressive symptoms (early, mid, and late in CT) were measured repeatedly.

RESULTS

Patients with greater acquisition and use of CT skills showed significantly larger increases in positive temperament and larger decreases in negative temperament in path analyses. Effect sizes were small, median standardized |beta| = 0.13. Models controlled depressive symptom levels and changes.

CONCLUSIONS

Skills taught in CT for recurrent depression correlate with personality change during this efficacious treatment. The absence of measures of CT skills at baseline and personality mid-CT allows several interpretations of the current findings. Future research is needed to clarify whether patients' use of CT skills facilitates adaptive changes in personality during CT.

Do Cognitive Therapy Skills Neutralize Lifetime Stress to Improve Treatment Outcomes in Recurrent Depression?

Cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but not all patients respond. Past research suggests that stressful life events (SLE; e.g., childhood maltreatment, emotional and physical abuse, relationship discord, physical illness) sometimes reduce the efficacy of depression treatment, whereas greater acquisition and use of CT skills may improve patient outcomes. In a sample of 276 outpatient participants with recurrent MDD, we tested the hypothesis that patients with more SLE benefit more from CT skills in attaining response and remaining free of relapse/recurrence. Patients with more pretreatment SLE did not develop weaker CT skills, on average, but were significantly less likely to respond to CT. However, SLE predicted non-response only for patients with relatively weak skills, and not for those with stronger CT skills. Similarly, among acute-phase responders, SLE increased risk for MDD relapse/recurrence among patients with weaker CT skills. Thus, the combination of more SLE and weaker CT skills forecasted negative outcomes. These novel findings are discussed in the context of improving CT for depression among patients with greater lifetime history of SLE and require replication before clinical application.

Psychometric properties of the Marital Adjustment Scale during cognitive therapy for depression: New research opportunities

Poor dyadic adjustment in marital or similar relationships is common among patients seeking individual cognitive therapy (CT) for major depressive disorder (MDD). Here we examined the psychometric properties of the marital adjustment subscale (MAS) of the Social Adjustment Scale-Self-report (SAS-SR; Weissman & Bothwell, 1976). Among married or cohabiting patients receiving individual CT for recurrent MDD (N = 306) in the context of two randomized controlled trials, the MAS demonstrated moderate internal consistency and test-retest reliability, strong convergence with the Dyadic Adjustment Scale (Spanier, 1976), and moderate relations with interpersonal problems and depressive symptoms. Controlling baseline depressive symptom severity, greater pre-CT relationship discord on the MAS predicted less reduction in depressive symptom severity and lower odds of depression remission during CT. These results support the reliability, validity, and potential utility of the MAS. Using the MAS may help investigators "mine" existing data sets including the SAS-SR to further understanding of dyadic functioning and its potential impact on depression treatment and other health outcomes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry

BACKGROUND

Antidepressant medication (ADM) and psychotherapy are effective treatments for major depressive disorder (MDD). It is unclear, however, if treatments differ in their effectiveness at the symptom level and whether symptom information can be utilised to inform treatment allocation. The present study synthesises comparative effectiveness information from randomised controlled trials (RCTs) of ADM versus psychotherapy for MDD at the symptom level and develops and tests the Symptom-Oriented Therapy (SOrT) metric for precision treatment allocation.

METHODS

First, we conducted systematic review and meta-analyses of RCTs comparing ADM and psychotherapy at the individual symptom level. We searched PubMed Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, a database specific for psychotherapy RCTs, and looked for unpublished RCTs. Random-effects meta-analyses were applied on sum-scores and for individual symptoms for the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) measures. Second, we computed the SOrT metric, which combines meta-analytic effect sizes with patients' symptom profiles. The SOrT metric was evaluated using data from the Munich Antidepressant Response Signature (MARS) study (n = 407) and the Emory Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study (n = 234).

RESULTS

The systematic review identified 38 RCTs for qualitative inclusion, 27 and 19 for quantitative inclusion at the sum-score level, and 9 and 4 for quantitative inclusion on individual symptom level for the HAM-D and BDI, respectively. Neither meta-analytic strategy revealed significant differences in the effectiveness of ADM and psychotherapy across the two depression measures. The SOrT metric did not show meaningful associations with other clinical variables in the MARS sample, and there was no indication of utility of the metric for better treatment allocation from PReDICT data.

CONCLUSIONS

This registered report showed no differences of ADM and psychotherapy for the treatment of MDD at sum-score and symptom levels. Symptom-based metrics such as the proposed SOrT metric do not inform allocation to these treatments, but predictive value of symptom information requires further testing for other treatment comparisons.

Development of a Novel Adult Congenital Heart Disease-Specific Patient-Reported Outcome Metric

Background Patient-reported outcome metrics (PROs) quantify important outcomes in clinical trials and can be sensitive measures of patient experience in clinical practice. Currently, there is no validated disease-specific PRO for adults with congenital heart disease (ACHD). Methods and Results We conducted a preliminary psychometric validation of a novel ACHD PRO. ACHD patients were recruited prospectively from 2 institutions and completed a series of questionnaires, a physician health assessment, and a 6-minute walk test. Participants returned to complete the same questionnaires and assessment 3 months±2 weeks later. We tested the internal consistency and test-retest reliability by comparing responses among clinically stable patients at the 2 study visits. We assessed convergent and divergent validity by comparison of ACHD PRO responses to existing validated questionnaires. We assessed responsiveness by comparison with patient-reported clinical change. One hundred three patients completed 1 study visit and 81 completed both. The ACHD PRO demonstrated good internal consistency in each of its 5 domains (Cronbach's α: 0.87; 0.74; 0.74; 0.90; and 0.89, respectively) and in the overall summary score (0.92). Test-retest reliability was good with an intraclass correlation ≥0.73 for all domains and 0.78 for the Summary Score. The ACHD PRO accurately assessed domain concepts based on comparison with validated standards. Preliminary estimates of responsiveness suggest sensitivity to clinical status. Conclusions These studies provide initial support for the validity and reliability of the ACHD PRO. Further studies are needed to assess its sensitivity to changes in clinical status.

Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression?

BACKGROUND

Pre-treatment sleep disturbance has been shown to predict antidepressant treatment outcomes. How changes in sleep disturbance during acute treatment affect longitudinal outcomes, or whether continuation-phase treatment further improves sleep disturbance, is unclear.

METHODS

We assessed sleep disturbance repeatedly in: a) 523 adults with recurrent MDD who consented to 12-14 weeks of acute-phase cognitive therapy (A-CT) and b) 241 A-CT responders at elevated risk for depression relapse/recurrence who were randomized to 8 months of continuation-phase treatment (CCT vs. fluoxetine vs. matched pill placebo) and followed protocol-treatment-free for 24 months. Trajectories of change in sleep and depression during and after A-CT were evaluated with multilevel models; individual intercepts and slopes were retained and input into Cox regression models to predict remission, recovery, relapse, and recurrence of MDD.

RESULTS

Sleep disturbance improved over the course of A-CT, but most patients continued to report clinically significant sleep complaints. Response and remission were more likely in patients with less overall sleep disturbance and those with greater reduction in sleep disturbance during A-CT; these patients also achieved post-A-CT remission and recovery sooner. Sleep improvements endured throughout follow-up but were not enhanced by continuation-phase treatment. Sleep disturbance did not predict relapse or recurrence consistently.

LIMITATIONS

Objective sleep disturbance was not assessed. Analyses were not specifically powered to use sleep changes to predict outcomes.

CONCLUSIONS

Improvements in sleep disturbance during A-CT are linked to shorter times to remission and recovery, supporting consideration of monitoring and targeting sleep disturbance in adults with depression.

Could Treatment Matching Patients' Beliefs About Depression Improve Outcomes?

Patients' beliefs about depression and expectations for treatment can influence outcomes of major depressive disorder (MDD) treatments. We hypothesized that patients with weaker biological beliefs (less endorsement of [a] biochemical causes and [b] need for medication) and more optimistic treatment expectations (greater improvement and shorter time to improvement), have better outcomes in cognitive therapy (CT). Outpatients with recurrent MDD who received acute-phase CT (N = 152), and a subset of partial or unstable responders (N = 51) randomized to 8 months of continuation CT or fluoxetine with clinical management, completed repeated measures of beliefs, expectations, and depression. As hypothesized, patients with weaker biological beliefs about depression, and patients who expected a shorter time to improvement, experienced greater change in depressive symptoms and more frequent response to acute-phase CT. Moreover, responders who received continuation treatment better matched to their biological beliefs (i.e., responders with weaker biological beliefs about depression who received continuation CT, or responders with stronger biological beliefs about depression who received continuation fluoxetine) had fewer depressive symptoms and less relapse/recurrence by 32 months after acute-phase CT than did responders who received mismatched continuation treatment. Specific screening and/or intervention targeting patients' biological beliefs about depression could increase CT efficacy.

The Role of Dyadic Discord in Outcomes in Acute Phase Cognitive Therapy for Adults With Recurrent Major Depressive Disorder

Major depressive disorder (MDD) and relationship discord between cohabiting partners frequently co-occur, with bidirectional effects established. As relationship quality influences understanding and treatment of MDD, the current analyses clarified the relations of pretreatment dyadic discord with outcomes during and at the end of acute phase cognitive therapy (CT) for adults with recurrent MDD. Married or cohabiting patients (n = 219) completed the Dyadic Adjustment Scale (DYS) before and after a 16-20 session, 12-14 week CT protocol. Lower levels of dyadic adjustment indicated higher levels of dyadic discord. Response to CT was defined as the absence of a major depressive episode and ≤ 12 on the 17-item Hamilton Rating Scale for Depression. Pretreatment dyadic discord, whether defined as a continuous or categorical variable (using DYS cutoff score of 97), was not associated with treatment completion or response but was positively associated with levels of depressive symptoms at the end of acute phase CT. Furthermore, CT was associated with declines in dyadic discord, with 23.3% of initially discordant couples moving to nondiscordant status at the end of CT. Depressive symptoms did not significantly mediate changes in dyadic discord. Finally, pre- (but not mid-) treatment dyadic discord was associated with subsequent changes in depressive symptoms, suggesting limited mediation. These findings replicate prior research indicating that individual CT is associated with reductions in depressive symptoms and dyadic discord while clarifying that lower pre-treatment dyadic discord may predict initial improvement in depressive symptoms.

The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis

A recent individual patient data meta-analysis showed that antidepressant medication is slightly more efficacious than cognitive behavioral therapy (CBT) in reducing overall depression severity in patients with a DSM-defined depressive disorder. We used an update of that dataset, based on seventeen randomized clinical trials, to examine the comparative efficacy of antidepressant medication vs. CBT in more detail by focusing on individual depressive symptoms as assessed with the 17-item Hamilton Rating Scale for Depression. Five symptoms (i.e., "depressed mood" , "feelings of guilt" , "suicidal thoughts" , "psychic anxiety" and "general somatic symptoms") showed larger improvements in the medication compared to the CBT condition (effect sizes ranging from .13 to .16), whereas no differences were found for the twelve other symptoms. In addition, network estimation techniques revealed that all effects, except that on "depressed mood" , were direct and could not be explained by any of the other direct or indirect treatment effects. Exploratory analyses showed that information about the symptom-specific efficacy could help in identifying those patients who, based on their pre-treatment symptomatology, are likely to benefit more from antidepressant medication than from CBT (effect size of .30) versus those for whom both treatments are likely to be equally efficacious. Overall, our symptom-oriented approach results in a more thorough evaluation of the efficacy of antidepressant medication over CBT and shows potential in "precision psychiatry" .

Estimating outcome probabilities from early symptom changes in cognitive therapy for recurrent depression

OBJECTIVE

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) producing benefits comparable to pharmacotherapy, but not all patients respond or remit. The purpose of the current analyses was to estimate CT patients' probability of nonresponse and remission from symptom improvement early in treatment.

METHOD

Data from 2 clinical trials of acute-phase CT for recurrent depression were pooled for analysis (N = 679). Adult outpatients received 16- or 20-session CT protocols. Symptoms were measured repeatedly with the clinician-report Hamilton Rating Scale for Depression (HRSD) and Inventory of Depressive Symptomatology-Self-Report (IDS-SR). Outcomes at exit from CT were nonresponse (<50% reduction in HRSD scores) and remission (no MDD and HRSD score ≤6).

RESULTS

The nonresponse rate was 45.7%, and the remission rate was 33.4%. In logistic regression models, improvements on the HRSD or IDS-SR from intake to CT Sessions 3, 5, 7, 9, or 11 significantly predicted both outcomes, with prediction gaining in accuracy in later sessions. Clinician and self-report assessments yielded similar results. Prediction of outcomes replicated across data sets. Patients with no symptom improvement by CT Session 9 (Week 5) had ≤10% probability of remission and >75% probability of nonresponse.

CONCLUSIONS

Outcomes of CT for depression are predictable from early symptom changes. Clinicians may find nonresponse and remission probability estimates useful in the informed consent process and in choosing whether to continue, augment, or switch treatments for CT patients with recurrent MDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Do comorbid social and other anxiety disorders predict outcomes during and after cognitive therapy for depression?

BACKGROUND

Cognitive therapy (CT) improves symptoms in adults with major depressive disorder (MDD) plus comorbid anxiety disorder, but the specific type of anxiety may influence outcomes. This study compared CT outcomes among adults with MDD plus social, other, or no comorbid anxiety disorders.

METHODS

Outpatients with recurrent MDD (N = 523, including 87 with social and 110 with other comorbid anxiety disorders) received acute-phase CT. Higher risk responders (n = 241 with partial or unstable response) were randomized to 8 months of continuation treatment (CT or clinical management plus fluoxetine or pill placebo), followed by 24 months of assessment. Lower risk responders (n = 49) were assessed for 32 months without additional research treatment. Depression, anxiety symptoms, and social avoidance were measured repeatedly.

RESULTS

Other (non-social), but not social, anxiety disorders predicted elevated depression and anxiety symptoms throughout and after acute-phase CT. Social, but not other, anxiety disorder predicted greater reduction in depressive symptoms during acute-phase CT and elevated social avoidance during and after acute-phase CT.

LIMITATIONS

Anxiety disorders were assessed only before acute-phase treatment. The anxiety symptom measure was brief. Generalization to other patient populations and treatments is unknown.

CONCLUSIONS

Non-social comorbid anxiety disorders may reduce the efficacy of acute-phase CT for MDD by diminishing both short- and longer term outcomes relative to depressed patients without comorbid anxiety disorders. Comorbid social anxiety disorder may increase relative reductions in depressive symptoms during acute-phase CT for MDD, but patients with comorbid social anxiety disorder may require specialized focus on social avoidance during CT.

Partner criticism during acute-phase cognitive therapy for recurrent major depressive disorder

Many patients with major depressive disorder (MDD) are married or in marriage-like relationships that could influence treatment process and outcomes. We clarified relations of patient-reported criticism from partners (perceived criticism) and criticism of partners with psychosocial functioning and changes in cognitive therapy (CT) for depression. Partnered outpatients (N = 219) received a 12-week CT protocol and completed measures repeatedly. As hypothesized, perceived criticism and criticism of partners correlated with personality (e.g., perceived criticism: trait mistrust, self-harm; criticism of partners: negative temperament, aggression), social-interpersonal problems (perceived criticism: cold and overly nurturant behavior; criticism of partners: vindictive and domineering behavior; both measures: poor adjustment in partnered and family relationships), cognitive content (both measures: negative failure attributions, dysfunctional attitudes), and depressive symptom intensity (both measures), although effect sizes were small-moderate. Both criticism measures decreased little during CT and remained elevated compared to community norms, despite the fact that relations between the criticism measures and depressive symptoms included both stable trait and more transient state components. From these findings, we speculate that some patients with MDD elicit or amplify criticism in ways that harm their relationships and psychosocial functioning and may benefit from additional or strategic treatment.

Methodological Recommendations for Trials of Psychological Interventions

Recent years have seen major developments in psychotherapy research that suggest the need to address critical methodological issues. These recommendations, developed by an international group of researchers, do not replace those for randomized controlled trials, but rather supplement strategies that need to be taken into account when considering psychological treatments. The limitations of traditional taxonomy and assessment methods are outlined, with suggestions for consideration of staging methods. Active psychotherapy control groups are recommended, and adaptive and dismantling study designs offer important opportunities. The treatments that are used, and particularly their specific ingredients, need to be described in detail for both the experimental and the control groups. Assessment should be performed blind before and after treatment and at long-term follow-up. A combination of observer- and self-rated measures is recommended. Side effects of psychotherapy should be evaluated using appropriate methods. Finally, the number of participants who deteriorate after treatment should be noted according to the methods that were used to define response or remission.

Relations of Shared and Unique Components of Personality and Psychosocial Functioning to Depressive Symptoms

Consistent with theories of depression, several personality (e.g., high neuroticism, low extraversion) and psychosocial (e.g., interpersonal problems, cognitive content) variables predict depressive symptoms substantively. In this extended replication, we clarified whether 13 theoretically relevant personality and psychosocial variables were unique versus overlapping predictors of symptoms among 351 adult outpatients with recurrent major depressive disorder who received acute-phase cognitive therapy (CT). Using factor analysis and regression methods, we partitioned the measures' variance into general components common across the two types of measures (psychosocial and personality), within-type components shared only with other measures of the same type, and scale-specific components. From early to late in CT, and from late in CT through 8 months after response, the general components were the strongest (median r = .23)-and scale-specific components the weakest (median r = .01)-forward predictors of symptoms. We discuss implications for measurement and treatment of depression.

Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder

Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments' effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients' pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16-21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.

Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression

BACKGROUND

Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis.

METHODS

We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses.

RESULTS

In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10).

CONCLUSIONS

We found no indication that melancholic or atypical depressions are significant or relevant moderators or predictors of outcome of CBT and ADM.

Initial severity of depression and efficacy of cognitive-behavioural therapy: individual-participant data meta-analysis of pill-placebo-controlled trials

BackgroundThe influence of baseline severity has been examined for antidepressant medications but has not been studied properly for cognitive-behavioural therapy (CBT) in comparison with pill placebo.AimsTo synthesise evidence regarding the influence of initial severity on efficacy of CBT from all randomised controlled trials (RCTs) in which CBT, in face-to-face individual or group format, was compared with pill-placebo control in adults with major depression.MethodA systematic review and an individual-participant data meta-analysis using mixed models that included trial effects as random effects. We used multiple imputation to handle missing data.ResultsWe identified five RCTs, and we were given access to individual-level data (n = 509) for all five. The analyses revealed that the difference in changes in Hamilton Rating Scale for Depression between CBT and pill placebo was not influenced by baseline severity (interaction P = 0.43). Removing the non-significant interaction term from the model, the difference between CBT and pill placebo was a standardised mean difference of -0.22 (95% CI -0.42 to -0.02, P = 0.03, I² = 0%).ConclusionsPatients suffering from major depression can expect as much benefit from CBT across the wide range of baseline severity. This finding can help inform individualised treatment decisions by patients and their clinicians.

Treatment Utility of Response Class Assessment in Heterosocial Difficulties

College-student males ( n = 27) with self-reported heterosocial difficulties received treatment that was either matched or mismatched to their identified (by questionnaires) problematic response class of social anxiety, social skills deficits, or irrational cognitions. Both matched and mismarched treatments produced significant pre-post changes on the questionnaire measures, but only marched treatment produced significant pre-post changes on the role-playing and self-monitoring measures.

Defined symptom-change trajectories during acute-phase cognitive therapy for depression predict better longitudinal outcomes

BACKGROUND

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but responders experience varying post-acute outcomes (e.g., relapse vs. recovery). Responders' symptom-change trajectories during response to acute-phase CT may predict longer term outcomes.

METHOD

We studied adult outpatients (N = 220) with recurrent MDD who responded to CT but had residual symptoms. Responders with linear (steady improvement), log-linear (quicker improvement earlier and slower later), one-step (a single, relatively large, stable improvement between adjacent assessments), or undefined (not linear, log-linear, or one-step) symptom trajectories were assessed every 4 months for 32 additional months.

RESULTS

Defined (linear, log-linear, one-step) versus undefined acute-phase trajectories predicted lower depressive symptoms (d = 0.36), lower weekly probability of being in a major depressive episode (OR = 0.46), higher weekly probabilities of remission (OR = 1.93) and recovery (OR = 2.35), less hopelessness (d = 0.41), fewer dysfunctional attitudes (d = 0.31), and better social adjustment (d = 0.32) for 32 months after acute-phase CT. Differences among defined trajectory groups were nonsignificant.

CONCLUSIONS

Responding to acute-phase CT with a defined trajectory (orderly pattern) of symptom reduction predicts better longer term outcomes, but which defined trajectory (linear, log-linear, or one-step) appears unimportant. Frequent measurement of depressive symptoms to identify un/defined CT response trajectories may clarify need for continued clinical monitoring and treatment.

Longitudinal social-interpersonal functioning among higher-risk responders to acute-phase cognitive therapy for recurrent major depressive disorder

BACKGROUND

Social-interpersonal dysfunction increases disability in major depressive disorder (MDD). Here we clarified the durability of improvements in social-interpersonal functioning made during acute-phase cognitive therapy (CT), whether continuation CT (C-CT) or fluoxetine (FLX) further improved functioning, and relations of functioning with depressive symptoms and relapse/recurrence.

METHOD

Adult outpatients (N=241) with recurrent MDD who responded to acute-phase CT with higher risk of relapse (due to unstable or partial remission) were randomized to 8 months of C-CT, FLX, or pill placebo plus clinical management (PBO) and followed 24 additional months. We analyzed repeated measures of patients' social adjustment, interpersonal problems, dyadic adjustment, depressive symptoms, and major depressive relapse/recurrence.

RESULTS

Large improvements in social-interpersonal functioning occurring during acute-phase CT (median d=1.4) were maintained, with many patients (median=66%) scoring in normal ranges for 32 months. Social-interpersonal functioning did not differ significantly among C-CT, FLX, and PBO arms. Beyond concurrently measured residual symptoms, deterioration in social-interpersonal functioning preceded and predicted upticks in depressive symptoms and major depressive relapse/recurrence.

LIMITATIONS

Results may not generalize to other patient populations, treatment protocols, or measures of social-interpersonal functioning. Mechanisms of risk connecting poorer social-interpersonal functioning with depression were not studied.

CONCLUSIONS

Average improvements in social-interpersonal functioning among higher-risk responders to acute phase CT are durable for 32 months. After acute-phase CT, C-CT or FLX may not further improve social-interpersonal functioning. Among acute-phase CT responders, deteriorating social-interpersonal functioning provides a clear, measurable signal of risk for impending major depressive relapse/recurrence and opportunity for preemptive intervention.

Divergent Outcomes in Cognitive-Behavioral Therapy and Pharmacotherapy for Adult Depression

OBJECTIVE

Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes.

METHOD

Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models.

RESULTS

About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels.

CONCLUSIONS

Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.

Predictors of longitudinal outcomes after unstable response to acute-phase cognitive therapy for major depressive disorder

After patients with major depressive disorder (MDD) respond to acute-phase cognitive therapy (CT), continuation-phase treatments may be applied to improve long-term outcomes. We clarified which CT responders experience remission, recovery, relapse, and recurrence by testing baseline demographic, clinical, and personality variables. The sample of CT responders at higher risk of relapse (N = 241) was randomized to 8 months of continuation-phase CT, double-blinded fluoxetine, or pill placebo, and followed 24 months (Jarrett & Thase, 2010). Patients with lower positive emotionality and behavioral activation at the end of acute-phase CT showed increased risk for relapse/recurrence of MDD. In addition, patients with lower positive emotionality and behavioral activation, as well as higher residual depression (including emotional, cognitive, and social facets), showed decreased probability of remission (≥6 continuous weeks of minimal or absent symptoms) after acute-phase CT. Finally, patients with greater residual depression, as well as younger age and earlier MDD onset, showed decreased probability of recovery (≥35 continuous weeks of minimal or absent symptoms) after acute-phase CT. Moderator analyses did not reveal differential prediction across the continuation phase treatment arms. These results may help clinicians gauge the prognoses and need for continuation treatment among MDD patients who respond to acute-phase CT.

Quantifying and qualifying the preventive effects of acute-phase cognitive therapy: Pathways to personalizing care

OBJECTIVE

To determine the extent to which prospectively identified responders to cognitive therapy (CT) for recurrent major depressive disorder (MDD) hypothesized to be lower risk show significantly less relapse or recurrence than treated higher risk counterparts across 32 months.

METHOD

Outpatients (N = 523), aged 18-70, with recurrent MDD received 12-14 weeks of CT. The last 7 consecutive scores from the Hamilton Rating Scale for Depression (HRSD-17) were used to stratify or define responders (n = 290) into lower (7 HRSD-17 scores of less than or equal to 6; n = 49; 17%) and higher risk (n = 241; 83%). The lower risk patients entered the 32-month follow-up. Higher risk patients were randomized to 8 months of continuation-phase CT or clinical management plus double-blind fluoxetine or pill placebo, with a 24-month follow-up.

RESULTS

Lower risk patients were significantly less likely to relapse over the first 8 months compared to higher risk patients (Kaplan-Meier [KM] estimates; i.e., 4.9% = lower risk; 22.1% = higher risk; log-rank χ2 = 6.83, p = .009). This increased risk was attenuated, but not completely neutralized, by active continuation-phase therapy. Over the subsequent 24 months, the lower and higher risk groups did not differ in relapse or recurrence risk.

CONCLUSIONS

Rapid and sustained acute-phase CT remission identifies responders who do not require continuation-phase treatment to prevent relapse (i.e., return of an index episode). To prevent recurrence (i.e., new episodes), however, strategic allocation and more frequent "dosing" of CT and/or targeted maintenance-phase treatments may be required. Longitudinal follow-up is recommended.

Improved cognitive content endures for 2 years among unstable responders to acute-phase cognitive therapy for recurrent major depressive disorder

BACKGROUND

The cognitive model of depression suggests that cognitive therapy (CT) improves major depressive disorder (MDD) in part by changing depressive cognitive content (e.g. dysfunctional attitudes, hopelessness). The current analyses clarified: (1) the durability of improvements in cognitive content made by acute-phase CT responders; (2) whether continuation-phase CT (C-CT) or fluoxetine (FLX) further improves cognitive content; and (3) the extent to which cognitive content mediates continuation treatments' effects on depressive symptoms and major depressive relapse/recurrence.

METHOD

Out-patients with recurrent MDD who responded to acute-phase CT (n = 241) were randomized to 8 months of C-CT, FLX or pill placebo (PBO) and followed for an 24 additional months. Cognitive content was assessed approximately every 4 months using five standard patient-report measures.

RESULTS

Large improvements in cognitive content made during acute-phase CT were maintained for 32 months, with 78-90% of patients scoring in normal ranges, on average. Cognitive content varied little between C-CT, FLX and PBO arms, overall. Small, transient improvements in cognitive content in C-CT or FLX compared with PBO patients did not clearly mediate the treatments' effects on depressive symptoms or on major depressive relapse/recurrence.

CONCLUSIONS

Outpatients with recurrent MDD who respond to acute-phase CT show durable improvements in cognitive content. C-CT or FLX may not continue to improve patient-reported cognitive content substantively, and thus may treat recurrent MDD by other paths.

Baseline Depression Severity as Moderator of Depression Outcomes Between Cognitive Behavioral Therapy vs Pharmacotherapy: An Individual Patient Data Meta-analysis

IMPORTANCE

Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical trials as well as traditional meta-analyses have considerable limitations in testing for moderators of treatment outcomes.

OBJECTIVES

To conduct a systematic literature search, collect primary data from trials, and analyze baseline depression severity as a moderator of treatment outcomes between cognitive behavioral therapy (CBT) and antidepressant medication (ADM).

DATA SOURCES

A total of 14 902 abstracts were examined from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and Cochrane Registry of Controlled Trials from 1966 to January 1, 2014.

STUDY SELECTION

Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included.

DATA EXTRACTION AND SYNTHESIS

Study authors were asked to provide primary data from their trial. Primary data from 16 of 24 identified trials (67%), with 1700 outpatients (794 from the CBT condition and 906 from the ADM condition), were included. Missing data were imputed with multiple imputation methods. Mixed-effects models adjusting for study-level differences were used to examine baseline depression severity as a moderator of treatment outcomes.

MAIN OUTCOMES AND MEASURES

Seventeen-item Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI).

RESULTS

There was a main effect of ADM over CBT on the HAM-D (β = -0.88; P = .03) and a nonsignificant trend on the BDI (β = -1.14; P = .08, statistical test for trend), but no significant differences in response (odds ratio [OR], 1.24; P = .12) or remission (OR, 1.18; P = .22). Mixed-effects models using the HAM-D indicated that baseline depression severity does not moderate reductions in depressive symptoms between CBT and ADM at outcome (β = 0.00; P = .96). Similar results were seen using the BDI. Baseline depression severity also did not moderate the likelihood of response (OR, 0.99; P = .77) or remission (OR, 1.00; P = .93) between CBT and ADM.

CONCLUSIONS AND RELEVANCE

Baseline depression severity did not moderate differences between CBT and ADM on the HAM-D or BDI or in response or remission. This finding cannot be extrapolated to other psychotherapies, to individual ADMs, or to inpatients. However, it offers new and substantial evidence that is of relevance to researchers, physicians and therapists, and patients.

Assessing cognitive therapy skills comprehension, acquisition, and use by means of an independent observer version of the Skills of Cognitive Therapy (SoCT-IO)

The purposes of this study were (a) to describe the adaptation and psychometric properties of the Skills for Cognitive Therapy (SoCT) measure for use by an independent observer (SoCT-IO) who rates the cognitive therapy (CT) skill acquisition, comprehension, and use by depressed adults and (b) to compare ratings of CT skill comprehension, acquisition, and use by independent observers to those by patients and therapists. Like the other SoCT versions, the SoCT-IO consists of 8 items that assess patients' comprehension, acquisition, and use of cognitive and behavioral skills for managing depressive symptoms, using a 5-point Likert-type scale. Four experienced raters (2 doctoral-level CT therapists and 2 bachelor-level nontherapists) used the SoCT-IO to rate 80 CT videotapes from both mid and later sessions in acute-phase CT from a randomized controlled trial for outpatients with recurrent major depression. The SoCT-IO ratings showed excellent internal consistency reliability and moderately high interrater reliability. Concurrent validity was demonstrated by convergence of the SoCT-IO with 2 other versions of the SoCT, 1 completed by therapists (SoCT-O) and the other by patients (SoCT-P). SoCT-IO ratings evidenced good predictive validity: Independent observers' ratings of patient CT skills midphase in therapy predicted treatment response even when the predictive effects of SoCT ratings by therapists and patients were controlled. The SoCT-IO is a psychometrically sound measure of CT skill comprehension, acquisition and use for rating outpatients with recurrent depression. The clinical utility and implications for using the SoCT-IO as a measure of CT skills acquisition are discussed. (PsycINFO Database Record

Cognitive Therapy to Prevent Depressive Relapse in Adults

The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT's preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.

A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence

Major depressive disorder (MDD) is highly disabling and typically runs a recurrent course. Knowledge about prevention of relapse and recurrence is crucial to the long-term welfare of people who suffer from this disorder. This article provides an overview of the current evidence for the prevention of relapse and recurrence using psychological interventions. We first describe a conceptual framework to preventive interventions based on: acute treatment; continuation treatment, or; prevention strategies for patients in remission. In brief, cognitive-behavioral interventions, delivered during the acute phase, appear to have an enduring effect that protects patients against relapse and perhaps others from recurrence following treatment termination. Similarly, continuation treatment with either cognitive therapy or perhaps interpersonal psychotherapy appears to reduce risk for relapse and maintenance treatment appears to reduce risk for recurrence. Preventive relapse strategies like preventive cognitive therapy or mindfulness based cognitive therapy (MBCT) applied to patients in remission protects against subsequent relapse and perhaps recurrence. There is some preliminary evidence of specific mediation via changing the content or the process of cognition. Continuation CT and preventive interventions started after remission (CBT, MBCT) seem to have the largest differential effects for individuals that need them the most. Those who have the greatest risk for relapse and recurrence including patients with unstable remission, more previous episodes, potentially childhood trauma, early age of onset. These prescriptive indications, if confirmed in future research, may point the way to personalizing prevention strategies. Doing so, may maximize the efficiency with which they are applied and have the potential to target the mechanisms that appear to underlie these effects. This may help make this prevention strategies more efficacious.

Gender as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression: an "individual patient data" meta-analysis

BACKGROUND

It has yet to be established whether gender moderates or predicts outcome of psychological and pharmacological treatments for adult depression because: (1) individual randomized trials typically lack sufficient statistical power to detect moderators and predictors and (2) meta-analyses cannot examine such associations directly.

METHODS

We conducted an "individual patient data" meta-analysis with the primary data of 1,766 patients from 14 eligible randomized trials comparing cognitive behavior therapy (CBT) with pharmacotherapy. Five studies also compared CBT and pharmacotherapy with pill placebo. We examined the extent to which gender moderates or predicts outcome, using the Hamilton Rating Scale for Depression-17-item (HAM-D-17), with mixed effects models.

RESULTS

Despite the high statistical power, we did not find any indication (P > 0.05) that gender moderates outcome (i.e., no indication that either men or women respond better or worse to CBT than to pharmacotherapy or vice versa). Gender was neither a nonspecific predictor (indicating whether gender is related to improvement, regardless of comparison or control groups), nor a specific predictor (predicting outcome of CBT and pharmacotherapy compared to pill placebo). The average differences between men and women within three conditions (CBT, pharmacotherapy, and pill placebo) were less than one point on the HAM-D-17.

CONCLUSIONS

The lack of predictive relations in a this good sized sample suggests that gender does not moderate differential response to CBT versus medication treatment and that it neither predicts nonspecific response across the treatments nor the specificity of response for either treatment with respect to pill placebo.

Are Improvements in Cognitive Content and Depressive Symptoms Correlates or Mediators during Acute-Phase Cognitive Therapy for Recurrent Major Depressive Disorder?

The cognitive model of depression posits that cognitive therapy's (CT) effect on depressive symptoms is mediated by changes in cognitive content (e.g., automatic negative thoughts dysfunctional attitudes, failure attributions). We tested improvement and normalization of cognitive content among outpatients (N = 523) with recurrent major depressive disorder treated with acute-phase CT (Jarrett & Thase, 2010; Jarrett et al., 2013). We also tested whether improvement in cognitive content accounted for subsequent changes in depressive symptoms and vice versa. Five measures of content improved substantively from pre- to post-CT (median d = 0.96), and the proportions of patients scoring in "healthy" ranges increased (median 45% to 82%). Evidence for cognitive mediation of symptom reduction was limited (median r = .06), as was evidence for symptom mediation of cognitive content improvement (median r = .07). We discuss measurement and design issues relevant to detection of mediators and consider alternative theories of change.

Stable remission and recovery after acute-phase cognitive therapy for recurrent major depressive disorder

OBJECTIVE

Continuation-phase cognitive therapy (C-CT) or fluoxetine (FLX) reduces relapse in adults with major depressive disorder (MDD; Jarrett, Minhajuddin, Gershenfeld, Friedman, & Thase, 2013). Among patients at higher risk for relapse, we hypothesized that continuation-phase treatment reduces residual symptoms and facilitates stable remission and recovery.

METHOD

Outpatients (N = 241) with recurrent MDD who responded to acute-phase CT with higher risk for relapse (i.e., had unstable remission defined by any of the last 7 acute-phase scores ≥ 7 using the Hamilton Rating Scale for Depression; Hamilton, 1960) were randomized to 8 months of C-CT, FLX, or pill placebo and followed for 24 additional months. Psychiatric status ratings (Keller et al., 1987) of 1 or 2 (absent or minimal depressive symptoms) for 6 and 35 continuous weeks post-randomization defined stable remission and recovery, respectively.

RESULTS

Actuarial estimates of stable remission (97%) and recovery (94%) by the end of follow-up were high and did not differ among groups. Observed (unadjusted) proportions of patients remitting (70%) and recovering (47%) before relapse or attrition were lower. During the continuation phase, C-CT (d = 0.21) and FLX (d = 0.25) patients had significantly lower mean depressive symptoms than did controls, but C-CT and FLX patients did not differ from each other, nor did the 3 experimental groups differ during follow-up.

CONCLUSION

Many patients who responded to CT with higher relapse risk subsequently remitted and recovered after discontinuation of acute-phase treatment. After discontinuation, C-CT and FLX decreased levels of residual depressive symptoms, but neither significantly increased the likelihood of stable remission or recovery, beyond the moderate to high levels observed among patients who did not relapse.

Extreme nonresponse to acute phase cognitive therapy for depression: an attempt to replicate and extend

As with other interventions for major depressive disorder (MDD), cognitive therapy (CT) results in treatment failure for about half of all participants. In 2007, Coffman and colleagues in Seattle studied this topic by identifying a group of patients who demonstrated an extremely poor response to CT (i.e., posttreatment BDI score≥31). They called these patients "extreme nonresponders" (ENR) and described the pretreatment characteristics that predicted response status. In the current study, we attempt a replication of the Seattle study with a larger sample of adults with recurrent MDD (N=473) who received a 16-20 session (12-14week) course of CT. The rate of ENR in this large sample was only 6.3% (30/473), compared to 22.2% (10/45) in the Seattle sample. Four pretreatment measures of symptom severity and functioning differed significantly among ENR and non-ENR participants. In each case, higher symptoms or poorer functioning were associated with ENR status. However, the combination of these factors in a regression model did not predict actual ENR status with the high degree of sensitivity or specificity observed in the Seattle study. These findings suggest that extreme nonresponse to CT is not as common as previously described and, although poor outcomes are associated with pretreatment clinical status, it is difficult to predict posttreatment symptom severity with a high degree of accuracy across different research samples.

Replication and extension: separate personality traits from states to predict depression

Changes in personality trait levels often parallel episodes of major depressive disorder (MDD), whereas trait factor structures and substantial retest correlations are preserved. The authors explicated this dual state/trait nature of personality assessments among adults with recurrent MDD (N = 351) receiving cognitive therapy (CT) by testing stability and change with the Schedule for Nonadaptive and Adaptive Personality, 2nd Edition (SNAP-2; Clark, Simms, Wu, & Casillas, in press), separating state and trait variance, and predicting depressive symptoms and clinical outcomes. Many SNAP scale scores changed in CT (e.g., positive temperament increased, negative temperament decreased), and decreases in depressive symptoms accounted for most scales' score changes. Nonetheless, SNAP scales' state and trait components predicted depressive symptoms early and late in CT as well as clinical outcomes, and state components predicted changes in symptoms and clinical outcomes. These results support the validity of the SNAP-2 among depressed patients and highlight the salience of personalityrelevant state affect.

Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo

IMPORTANCE

Strategies to improve the course of recurrent major depressive disorder have great public health relevance. To reduce the risk of relapse/recurrence after acute phase cognitive therapy (CT), a continuation phase model of therapy may improve outcomes.

OBJECTIVES

To test the efficacy of continuation phase CT (C-CT) and fluoxetine for relapse prevention in a pill placebo (PBO)-controlled randomized trial and compare the durability of prophylaxis after discontinuation of treatments.

DESIGN

A sequential, 3-stage design with an acute phase (all patients received 12 weeks of CT); 8-month experimental phase (responders at higher risk were randomized to C-CT, fluoxetine, or PBO); and 24 months of longitudinal, posttreatment follow-up.

SETTING

Two university-based specialty clinics.

PATIENTS

A total of 523 adults with recurrent major depressive disorder began acute phase CT, of which 241 higher-risk responders were randomized and 181 subsequently entered the follow-up.

INTERVENTIONS

Cognitive therapy responders at higher risk for relapse were randomized to receive 8 months of C-CT (n = 86), fluoxetine (n = 86), or PBO (n = 69).

MAIN OUTCOMES AND MEASURES

Survival analyses of relapse/recurrence rates, as determined by blinded evaluators using DSM-IV criteria and the Longitudinal Interval Follow-up Evaluation. RESULTS As predicted, the C-CT or fluoxetine groups were significantly less likely to relapse than the PBO group across 8 months. Relapse/recurrence rates for C-CT and fluoxetine were nearly identical during the 8 months of treatment, although C-CT patients were more likely to accept randomization, stayed in treatment longer, and attended more sessions than those in the fluoxetine and PBO groups. Contrary to prediction, relapse/recurrence rates following the discontinuation of C-CT and fluoxetine did not differ.

CONCLUSIONS AND RELEVANCE

Relapse risk was reduced by both C-CT and fluoxetine in an enriched randomization sampling only CT responders. The preventive effects of C-CT were not significantly more durable than those of fluoxetine after treatment was stopped, suggesting that some higher-risk patients may require alternate longer-term interventions.

TRIAL REGISTRATION

clinicaltrials.gov Identifiers: NCT00118404, NCT00183664, and NCT00218764.