Efficacy and moderators of cognitive therapy versus behavioural activation for adults with depression: study protocol of a systematic review and meta-analysis of individual participant data

BACKGROUND

Cognitive therapy and behavioural activation are both widely applied and effective psychotherapies for depression, but it is unclear which works best for whom. Individual participant data (IPD) meta-analysis allows for examining moderators at the participant level and can provide more precise effect estimates than conventional meta-analysis, which is based on study-level data.

AIMS

This article describes the protocol for a systematic review and IPD meta-analysis that aims to compare the efficacy of cognitive therapy and behavioural activation for adults with depression, and to explore moderators of treatment effect. (PROSPERO: CRD42022341602).

METHOD

Systematic literature searches will be conducted in PubMed, PsycINFO, EMBASE and the Cochrane Library, to identify randomised clinical trials comparing cognitive therapy and behavioural activation for adult acute-phase depression. Investigators of these trials will be invited to share their participant-level data. One-stage IPD meta-analyses will be conducted with mixed-effects models to assess treatment effects and to examine various available demographic, clinical and psychological participant characteristics as potential moderators. The primary outcome measure will be depressive symptom level at treatment completion. Secondary outcomes will include post-treatment anxiety, interpersonal functioning and quality of life, as well as follow-up outcomes.

CONCLUSIONS

To the best of our knowledge, this will be the first IPD meta-analysis concerning cognitive therapy versus behavioural activation for adult depression. This study has the potential to enhance our knowledge of depression treatment by using state-of-the-art statistical techniques to compare the efficacy of two widely used psychotherapies, and by shedding more light on which of these treatments might work best for whom.

Cognitive behavioural therapy can be effective in treating anxiety and depression in persons with dementia: a systematic review

Dementia is a neurocognitive disorder that affects a person's abilities in daily functioning. Anxiety and depression symptoms are common among persons with dementia. Cognitive behavioural therapy (CBT) has been tested to manage their depression and anxiety symptoms. However, the purpose of CBT in managing these symptoms is unclear. Therefore, this paper aims to clarify whether CBT can be used to reduce depression and anxiety symptoms in persons with dementia. The electronic databases PubMed, PsycINFO, MEDLINE, and CINAHL were used to locate relevant studies. Eleven studies, which involved a total of 116 older adults, were identified. The findings suggest that CBT can be effective in reducing depression and anxiety symptoms. Based on our current review, the findings from previous studies form a promising foundation on which to conduct a major randomized controlled trial with a larger sample size. This review discusses some of the most important considerations in applying CBT to persons with dementia, and these may be beneficial for future studies that explore this area and seek more conclusive evidence on the use of CBT.

The intergenerational transference of alcohol use behaviour from parents to offspring: a test of the cognitive model

The current study tested the model proposed by Campbell and Oei (2010), and assessed the separate components of the model to best explain the intergenerational transference of alcohol use behaviour. Results revealed an adequate fit of all three models with significant differences between the Cognitive and Behavioral Models, and the Full Cognitive Model. Results suggest that cognitions are not a direct means by which parental drinking behaviour is transferred to their offspring however the parental behaviour impacted on their children's behaviour via their alcohol cognitions.

A cognitive model for the intergenerational transference of alcohol use behavior

A family history of alcoholism has shown to be one of the greatest consistent risk factors in the intergenerational transference of alcohol problems. Whereas a large number of studies have attempted to identify the processes responsible for this interfamilial transfer, the mechanisms remain unclear. Family, twin and adoption studies, and environmental theories have resulted in a number of unanswered questions regarding the extent that these factors influence the transmission of alcohol behavior. Recently, cognitive theories have suggested that the observation of parental drinking habits contributes to the child's beliefs and expectations of alcohol's effects. A hypothesised cognitive model will be proposed suggesting that the mechanism for the transference of particular drinking styles from parent to offspring may be further explained by the transference of alcohol cognitions, in particular, alcohol expectancies and drinking refusal self-efficacy. This review focuses on research of bio/psycho/social factors that perpetuate alcohol misuse across generations, and will delineate the proposed cognitive mechanisms for the interfamilial transference of alcohol problems and discuss the implications of the proposed model.

Management of co-morbid anxiety and alcohol disorders: parallel treatment of disorders

Co-morbid alcohol-related disorders and anxiety disorders have been found to occur in alcohol treatment populations, anxiety treatment populations and the general community. People suffering from co-occurring alcohol-related and anxiety disorders are more prone to relapse to alcohol abuse, and more likely to re-enter the treatment system for either disorder than sufferers of either disorder without a co-morbid disorder. To review the current state of the management of this disorder, evidence of the prevalence of this co-morbid condition in clinical and community populations is examined, then the theoretical mechanisms that might explain this connection are reviewed. A comparison of the few treatment studies of co-morbid alcohol and anxiety disorders shows a limited number of pharmacological treatment trials and no psychotherapy outcome trials. This review shows that it is no longer sustainable to conceptualize co-morbidity of alcohol and anxiety disorders as a unitary concept, i.e. lumping alcohol-related and anxiety disorders as one global condition, but as separate distinct combinations of particular anxiety disorders, e.g. alcohol dependence and panic disorder, alcohol dependence and generalize anxiety disorder. The recommended treatment approach, supported by the evidence, is to offer separate and parallel therapy for the alcohol-related and anxiety disorder, until empirical evidence from treatment outcome studies suggest otherwise. There is an urgent need to conduct treatment outcome research for the subtypes of co-morbid alcohol and anxiety disorders.

Structure of the MAST with an Australian sample of alcoholics

The dimensionality of the Michigan Alcoholism Screening Test (MAST) was examined utilizing an Australian sample (n = 196) of alcoholics. This study was specifically designed to overcome some of the problems with sampling and analytic techniques used in previous studies. Three moderately intercorrelated factors were revealed which covered (a) alcohol-related disabilities; (b) help-seeking behaviour and (c) recognition of a drinking problem. These factors were found to be internally consistent as shown by moderate to high alpha coefficients. Results indicate that the additive system of scoring all 24 items may result in an underestimation of the information afforded by the MAST.

Cognitive and biochemical processes in depressed adult outpatients: a test of the circular process model

The circular process model is a psychobiological model of depression, in which it is postulated that catecholamines and negative cognitions interact to influence depression. Since its publication, there have been no empirical tests to support or refute the model. This study tested the model in 92 depressed adult outpatients with non-bipolar non-psychotic depression. There were no significant bivariate correlations among the biochemical and cognitive measures. However, the interactive model was supported by results of two out of three hierarchical regression analyses, in which the biochemical-by-cognitive interactive terms significantly predicted depression after the main effects of each variable were accounted for. These findings show sufficient evidence in support of the Circular Process Model to warrant further testing over the treatment period.

Alcohol expectancy and drinking refusal self-efficacy: a test of specificity theory

Although alcohol expectancy (expectations about the effects of drinking alcohol on one's behavior and mood) and drinking refusal self-efficacy (one's perceived ability to resist drinking in high-risk situations) have consistently been demonstrated to be useful to our understanding of alcohol use and abuse, the specificity of these constructs to alcohol consumption has not been previously demonstrated. Using 161 first-year psychology students and multiple regression analyses this study indicated that alcohol expectancies and drinking refusal self-efficacy were specifically related to quantity of alcohol consumption, but not to caffeine or nicotine intake. These results provide empirical evidence to confirm the theoretical and practical utility of these two cognitive constructs to alcohol research and serve to strengthen the theoretical foundations of alcohol expectancy theory.

The predictive utility of drinking refusal self-efficacy and alcohol expectancy: a diary-based study of tension reduction

The potential tension reduction effects of alcohol may be most appropriately tested by examining the role of alcohol related beliefs regarding alcohol's anxiolytic properties. The relationship between affective change drinking refusal self-efficacy, tension reduction alcohol expectancies, and ongoing drinking behavior was examined amongst 57 regular drinkers. Alcohol consumption, antecedent, and consequent mood states were monitored prospectively by diary, Social learning theory hypothesizes that low drinking refusal self-efficacy when experiencing a negative mood state should be associated with more frequent drinking when tense. Strong alcohol expectancies of tension reduction were hypothesized to predict subsequent tension reduction. Contrary to this hypothesis, the present study found that alcohol expectancies were more strongly related to antecedent mood states. Only a weak relationship between drinking refusal self-efficacy and predrinking tension, and between alcohol expectancy and subsequent tension reduction, was evident.

Development of a Satisfaction with Therapy and Therapist Scale

OBJECTIVE

While much work has gone into developing measures of specific factors in psychotherapy for depression, measures for non-specific factors have been lacking. This paper aims to develop a scale for a non-specific factor called 'Satisfaction with Therapy and Therapist Scale'.

METHOD

Sixty-seven patients with major depression completed the questionnaires during the fourth session of cognitive therapy. The patients went through an assessment clinical interview using a SCID. They also completed the ATQ, BDI and DAS questionnaires during the fourth session.

RESULTS

Principal component factor analysis with varimax rotation showed that the scale possesses two factors, 'Satisfaction with Therapy' and 'Client Evaluation of Therapist', accounting for 64.7% of the total variance. The alpha Cronbach for the two factors is 0.91 and 0.80 with the total scale alpha at 0.90. The scale also possesses good concurrent and discriminant validity.

CONCLUSION

The Satisfaction with Therapy and Therapist Scale is an adequate measure for measuring a non-specific factor in psychotherapy.

Cognitive changes following recovery from depression in a group cognitive-behaviour therapy program

OBJECTIVE

We report on the changes in cognitions as a result of cognitive-behaviour therapy (CBT), in 35 recovered and 32 non-recovered mood disordered patients who had undergone a 12-week group CBT program for depression.

METHOD

An end-of-therapy cut-off score of 10 on the BDI was used to define recovered and non-recovered patients. ANOVA analyses were conducted to explore possible main effects of recovery status and time on various clinical measures, including cognitions and activity levels.

RESULTS

Mean mood and activity self-rating measures were significantly higher for the recovered as compared to the non-recovered patients over the course of the program. Similarly, scores on the Automatic Thoughts Questionnaire (ATQ) for recovered patients were within the non-clinical range, in contrast to their non-recovered counterparts. In addition, recovered patients improved significantly in their Hopelessness scores, and there was a change in the expected direction in their Dysfunctional Attitudes Scale scores, although this was not significant.

CONCLUSION

These results are consistent with the proposition of cognitive theory (i.e. the remediation of negative cognition plays a significant role in recovery from depression during CBT).

The relationship of positive and negative alcohol expectancies to patterns of consumption of alcohol in social drinkers

Negative alcohol expectancies have recently come to occupy a more important position in the expectancy literature, but recent claims that positive expectancies are unimportant in the consumption of alcohol when compared with negative expectancies are based on potentially flawed methodology. This study investigated the relative contribution of positive and negative expectancies to the consumption of alcohol using an instrument designed to measure both positive and negative expectancies. One hundred ninety-three men and women from the general community participated in the study. Findings showed while negative expectancies accounted for the greater proportion of variance of frequency of consumption, positive expectancies remained an important predictor of consumption, accounting for the greater proportion of variance of quantity consumed per session. The interesting but sometimes counterintuitive directions of these relationships can be explained in terms of social learning principles. The relatively neglected concept of negative expectancies is worthy of further use and investigation.

Psychometric properties of a quitting time for alcohol questionnaire: factor structure, reliability, and validity

Research into the dynamics of alcohol use has traditionally focused on etiological factors, particularly on the reasons an individual engages in drinking behaviours. Although reasons for the permanent cessation of drinking have also been well documented, little is known about the reasons for the episodic cessation of alcohol use that is characteristic of nonproblematic drinking patterns. The purpose of the present study was to develop and validate a questionnaire designed to monitor the reasons an individual temporarily stops drinking at the end of a drinking episode. A 23-item Quitting Time for Alcohol Questionnaire (QTAQ) was developed and distributed to a community based sample of 252 participants. Factor analysis revealed three conceptually distinct factors, QTAQ-IS (Internal Status) QTAQ-AA (Avoidance Adherence) and QTAQ-IC (Immediate Context), which accounted for 36.3% of the variance. Cross-validation on a large sample of undergraduate students (N = 479) confirmed the three-factor solution (accounting for 33% of the variance). Cronbach's alpha coefficients for the factors ranged from .74 to .81 for the community sample and from .62 to .78 for the student sample. The validity of the emergent factors was demonstrated by their ability to classify participants according to self-reported alcohol consumption and alcohol dependence criteria, and also by their significant predictive relationship with these criteria. The present findings suggest that the QTAQ is a useful instrument both for research and for use in clinical practice.

Predictors of career commitment and employment level of tertiary-educated Indonesian women

This study investigated the relationships among education, liberal sex-role values, gender-role orientation (masculinity/femininity), career commitment, and employment level for a sample of 302 married Indonesian women. All participants were tertiary educated and currently employed either as teachers in tertiary institutions or as managers in government or private enterprise. Multiple regression analysis revealed that liberal sex-role values and masculinity were significant predictors of career commitment, whereas education was the only variable to significantly predict employment level. Results are compared with previous research on predictors of career commitment and employment level in both Asian and Western cultures. Directions for further research are discussed.

Pre-existing antidepressant medication and the outcome of group cognitive-behavioural therapy

OBJECTIVE

This study aimed to investigate the impact of pre-existing medication on the outcome of group cognitive-behavioural therapy (CBT) in the treatment of patients with depression.

METHOD

Of the 71 patients diagnosed with major depression who participated in group CBT, 25 were on medication (CBT-M) and 46 were unmedicated (CBT). The patients received 12 sessions of group CBT over a 3-month period. The dependent measures used were the Beck Depression Inventory, Zung Self-Rating Depression Scale, Automatic Thoughts Questionnaire, Hopelessness Scale, Dysfunctional Attitude Scale, Daily Activity Rating Scale and Daily Mood Rating Scale.

RESULTS

Both the CBT and CBT-M groups showed statistically significant improvement in depression scores and cognitive process measures. However, the rate of improvement for both groups on these measures did not differ.

CONCLUSION

The study indicated that pre-existing antidepressant medication did not enhance or detract from the positive treatment outcome of depressed patients receiving a group CBT treatment.

Is there evidence to show that fetal alcohol syndrome can be prevented?

Fetal Alcohol Syndrome (FAS) is currently the major cause of mental retardation in the Western world. Since FAS is not a natural phenomenon and is created by mixing alcohol and pregnancy, the solution to decreasing the incidence of all alcohol-related birth defects is therefore entirely preventable. To date, little is known about the effectiveness of prevention programs in reducing the incidence of FAS. Therefore, it is the intention of this article to review the effectiveness of prevention programs in lowering the incidence of FAS. The present review revealed that prevention programs, to date, have been successful in raising awareness of FAS levels across the groups examined. However, this awareness has not been translated into behavioral changes in "high risk" drinkers as consumption levels in this group have decreased only marginally, indicating prevention programs have had minimal or no impact in lowering the incidence of FAS. Urgent steps must now be taken to fully test prevention programs, and find new strategies involving both sexes, to reduce and ultimately eliminate the incidence of FAS.

The differential role of alcohol expectancies and drinking refusal self-efficacy in problem and nonproblem drinkers

OBJECTIVE

The present study aimed to examine the discriminatory ability of alcohol expectancies and drinking refusal self-efficacy and to identify the differential role of these constructs in social and problem drinkers.

METHOD

Drinkers (N = 276) were self-selected from general (n = 185) and clinical (n = 91) populations to complete a 40-minute questionnaire that asked about alcohol expectancies, drinking refusal self-efficacy, consumption, degree of dependence and demographics.

RESULTS

The results showed that in social drinkers both the expectancy and self-efficacy constructs were reliably able to discriminate between types of drinker. Expectancy was related to consumption in social drinkers, but did not appear to account for a significant proportion of the variance in problem drinkers.

CONCLUSIONS

The findings are discussed in terms of a two-process model of drinking behavior that suggests that expectancies operate differently in social and problem drinkers.

Biological and psychological processes in recovery from depression during cognitive therapy

This study investigated the relationship between biological and psychological processes in the recovery phase of depression during treatment with cognitive therapy. In particular, we tested the hypothesis that biological and psychological processes are independent; the hypothesis that they are related in a linear or sequential process; and the hypothesis that there is a circular relationship between them. 35 depressed patients completed a 12 week program of cognitive therapy. Changes in measures of negative thinking and amine dysfunction over the course of therapy were compared for those who improved and those who did not. There was a significant relationship between improvement in symptoms and change for ATQ scores, DAS scores, and epinephrine levels. There was significant change in metanephrine levels during therapy which was not related to improvement. The changes were not consistent across indices. Although the results did not provide definite support for any of the four models of the relationship between biological and psychological variables during recovery from depression, the finding that there was some change in some of the indices of amine dysfunction during cognitive therapy indicates that the interface between biological and psychological processes in depression should continue to be studied.

Effects of maternal cigarette smoking during pregnancy on long-term physical and cognitive parameters of child development

The negative impact of maternal cigarette smoking during pregnancy on the growth and development of the foetus has been well documented. However, the long-term effects of the subsequent cognitive and physical development of the child are less clearly understood. This article presents a critical review of the literature on this topic. The review shows that the effects of prenatal exposure to smoking on children's physical development are mediated by a dose-response relationship. Although the observed effects are long term, they are small and may have no major functional importance. The evidence on the long-term consequences of intellectual function is still unclear. One reason is that very few studies have looked at the long-term consequences of maternal smoking on both physical and cognitive development. More effort is needed to investigate this important issue.

Depression after traumatic brain injury: conceptualization and treatment considerations

The understanding and treatment of depression that develops following traumatic brain injury (TBI) is still unclear and likely to be the result of a complex variety of interacting factors. Past researchers have developed ways to classify important variables related to patients' depression into broad domains such as: Pre-injury assets and liabilities, the nature and severity of brain injury; and reaction to difficulties. However, a better conceptualization of the problem is required in order to guide the assessment and treatment considerations for depressed patients with TBI. This review provides this conceptualization by postulating six theoretical relationships between depression and TBI. The degree of empirical support provided in the literature for these links is indicated. Research findings suggested that an individual with TBI is the most susceptible to depression when any of the following conditions exist: a pre-existing psychiatric disturbance is exacerbated; the injury sustained involved the left anterior region of the brain; and when her individual has poor insight into her deficits, attempts to resume her pre-injury roles and experiences significant failure. For each relationship, a likely outcome is predicted if the recommended treatment plan is not conducted. The present conceptualization and treatment considerations will be of substantial benefit to clinicians working in the area.

A comparison of estimates of the prevalence of heavy drinkers in local regions of Queensland

OBJECTIVE

This study developed and compared separate estimates of the number of heavy drinkers (the in-need population for alcohol treatment interventions) across eight local regions in Queensland.

METHOD

Estimates were based on: (i) a self-report population survey of alcohol consumption; and (ii) an application of the Ledermann log-normal distribution of consumption model to liquor sale figures.

RESULTS

Estimates based on the 1989-1990 National Health Survey (NHS) data indicated that 10.98% (n = 83,880) of adult male drinkers and 1.25% (n = 6581) of adult female drinkers in Queensland (total = 90,461) were on average drinking the equivalent of six or more standard drinks a day in the week prior to the survey (4.74% of Queensland adult drinkers, n = 90,461). Estimates based on the Ledermann model indicated that 12.18% of adult Queensland drinkers (n = 232,283) were drinking six or more standard drinks a day. Estimates based on the Ledermann model were 157% larger than estimates based on NHS data (i.e. a difference of 141,821 heavy drinkers), with large variations in the two estimates across local regions.

CONCLUSION

The NHS data appears to underestimate the population of heavy drinkers, whereas the Ledermann model overestimates it. In this situation, it seems preferable to use the more conservative self-report survey estimates.

A review of systematic and quantifiable methods of estimating the needs of a community for alcohol treatment services

The purpose of this paper was to review a variety of systematic and quantifiable methodologies for planning and evaluating the provision of alcohol treatment services for communities. These methods include: (a) developing and evaluating indicators of alcohol-related harm in and across defined geographic areas, to assess the relative need for services; (b) demand-oriented techniques that involve the prediction of future demand for services based on the previous utilisation of treatment facilities; (c) comprehensive systems approaches to planning services; and (d) the estimation of the prevalence of individuals who need or would benefit from an intervention for their alcohol problem. In practice, service planners may incorporate a combination of approaches that could be compared and contrasted to assess the convergent validity of results. These methodologies can also be used to provide information for planning and evaluating prevention/health promotion and early intervention initiatives.

Catastrophic cognitions in panic disorder with and without agoraphobia

The cognitive models of panic disorder with (PDA) or without (PD) agoraphobia are now widely recognised. These models propose that patients misinterpret external or internal cues in a catastrophic manner and as a result of these catastrophic cognitions the symptoms are maintained. There is now a large body of empirical evidence for this proposal and the aim of this paper is to systematically review the literature to evaluate whether the empirical evidence supports the contribution of catastrophic cognitions to PD and PDA. Empirical studies using different methodologies, such as interview, questionnaire, self-monitoring, and in vivo techniques are reviewed. The results indicate there is substantial empirical evidence in support of the central role of catastrophic cognition in cognitive models. Different methodologies provided convergent support for the importance of catastrophic cognitions in the maintenance of panic disorder and agoraphobia. Limitations in the interpretation of the existing research are highlighted and future research directions are proposed.

Factors associated with dropout in a group cognitive behaviour therapy for mood disorders

The high prevalence of premature attrition from psychotherapy is a phenomenon which has been well recognized in the psychological literature. The pressing concern that a number of clients may not be benefiting from treatment because they are dropping out has led to a plethora of research in the area of individual psychotherapy. No studies, however, have attempted to investigate the characteristics of dropout in group cognitive behaviour therapy for depression. To address this gap in research, the present study examined the factors associated with dropout in a group cognitive behaviour therapy for depression, using 131 Ss who went through the group therapy for 12 weeks. The results showed that sociodemographic measures (e.g. age) and measures of depressive symptoms (e.g. depression scores) did not discriminate dropouts from completers. An investigation of patterns of mood changes in the course of the therapy also failed to find significant differences between the dropouts and completers. However, weekly therapist rating of client participation revealed that dropouts participated significantly less than completers during the therapy sessions. The results are discussed in light of the findings of current literature and future research in premature attrition.

Does concurrent drug intake affect the long-term outcome of group cognitive behaviour therapy in panic disorder with or without agoraphobia?

The present study investigated the impact of pre-existing pharmacotherapy regimes on the long-term outcome of brief intensive group cognitive-behavioural therapy (BIGCBT) in the treatment of panic disorder with or without agoraphobia in 106 patients (74 females). Forty patients were allocated to BIGCBT without medication, 40 to BIGCBT plus anti-anxiety medication, 10 to BIGCBT plus anti-depressant medication and 16 to BIGCBT plus combined anti-anxiety and anti-depressant medications. The mean follow-up period was 3.2 yr and ranged from 1.1 to 6.2 yr. The results demonstrated that patients who received BIGCBT concurrent with pre-existing medication regimes did not differ significantly (P > 0.001) from each other or from patients who underwent BIGCBT without medication on any of the dependent measures either at pre-treatment assessment or long-term follow-up. However, BIGCBT (with or without pharmacotherapy) was associated with significant (P < 0.001) long-term improvements in frequency of panic attacks, avoidance behaviour and questionnaire measures of anxiety, depression and agoraphobia. Furthermore, the large majority (80%) of patients in the BIGCBT without medication group remained medication-free at long-term follow-up. Of those patients who underwent BIGCBT concurrent with pre-existing pharmacotherapy, a large percentage (44%) reported no longer taking medication for their condition at long-term follow-up. Overall, it is concluded that pre-existing medication regimes (anti-anxiety, anti-depressant or combinations of these) do not significantly enhance or detract from the long-term outcome of a BIGCBT program used in the treatment of panic disorder and agoraphobia.

Comparison of specific and nonspecific factors in a group cognitive therapy for depression

Research into the efficacy of psychotherapy has often reported equivalence in treatment outcome when comparing different therapies. These findings have been interpreted as evidence for what are variously termed placebo, common or nonspecific processes. We suggested that this issue is best examined in comparison of specific and nonspecific processes in the action of a specified therapy and disorder. No comparisons of this nature have yet been reported in relation to cognitive therapy for depression. This study compared specific processes (automatic thoughts and dysfunctional attitudes) and major common processes (satisfaction with therapy and client evaluation of therapist) in the action of a group cognitive therapy for depression. Sixty patients suffering from major depression received a 12 week course of group cognitive therapy. Results from hierarchical regression suggested that the specific processes of cognitive therapy were more associated with reduction in depression than common processes which contributed to the prediction of reduction in depression via specific processes.

Is alcohol a cofactor of HIV and AIDS? Evidence from immunological and behavioral studies

The authors aim to critically examine empirical research on the effects of alcohol on HIV and AIDS from the immunological and behavioral fields. In vitro immunological studies demonstrate that social drinking increases the susceptibility of human cells to HIV infection. Animal studies show that acute and chronic alcohol ingestion increases rate of progression from retrovirus to clinical illness. In humans with HIV, no experimental evidence shows that alcohol is a cofactor of AIDS. Findings from behavioral studies show that a link between social drinking and risk of HIV is weak. No experimental evidence demonstrates that chronic drinking influences rate and course of disease progression to AIDS in humans who are HIV+. It is premature to promote the role of alcohol as a cofactor in HIV and AIDS.

The efficacy of cognitive behaviour therapy in treating premenstrual dysphoric changes

This study assesses the efficacy of cognitive behaviour therapy (CBT) in treating premenstrual dysphoric changes. The CBT condition (n = 24) aimed to modify dysfunctional thinking as a means of impacting on negative premenstrual symptoms and changes. The components of CBT were cognitive restructuring and assertion training. A comparison condition called 'information-focused therapy' (IFT) (n = 9) aimed to present information only and did not address belief restructuring. The components were relaxation training, nutritional and vitamin guidelines, dietary and lifestyle recommendations, aspects of child management training and assertion training. Results indicated that the amelioration of anxiety, depression, negative thoughts and physical changes can be effectively addressed by either CBT or IFT. The extent to which a women's belief system is critical in the experience of premenstrual distress requires further empirical investigation.

Correlates of premenstrual dysphoria in help-seeking women

Comparisons were made between the premenstrual changes reported by nontreatment-seekers (NTS) (n = 32) and those of treatment-seekers (TS) (n = 52). The Premenstrual Assessment Form Luteal Phase and Follicular Phase versions were completed and the Beck Depression Inventory, the Automatic Thoughts Questionnaire and the State-Trait Anxiety Inventory were completed at both the luteal and follicular phases. Prospective daily ratings were made for two treatment cycles on the Daily Ratings Form and TS were screened for a mood-disorder history. Using the commonly cited 30% decrease in dysphoric levels from the pre- to postmenstrual phases as the criterion of prospective confirmation, women with prospectively confirmed dysphoria (PMD +) were not significantly more symptomatic than those without prospective dysphoric confirmation (PMD -). However, TS were more symptomatic than NTS on measures of depression, anxiety and frequency of negative automatic thoughts but not on mood behaviour and physical changes reflected in the PAF scales. No demographic differences were found between TS and NTS. Results did not support the issue of requiring 'confirmation' of self-reports within a help-seeking group or the use of the 30% criterion in particular. Findings further suggest that the 95-item PAF may be inadequate in differentiating TS from others.

Expectancy theory: a two-process model of alcohol use and abuse

In recent years, cognitive-behavioral approaches to drinking behavior have postulated the importance of alcohol expectancy and drinking refusal self-efficacy in the development and maintenance of problem drinking. However, despite a growing number of publications, the structure and role of these constructs have not been clearly explicated in theoretical terms to date. This article proposes a two-process theory of alcohol use and abuse. It is suggested that the acquisition and maintenance phases of drinking behavior are governed by different principles of learning and involve different decision-making processes. The acquisition phase is though to be a time of instrumental learning, in which decision making involves controlled processing by means of a kind of "mental algebra". The maintenance phase is described as subject to the principles of classical conditioning, with automatic processing playing a major role in the making of decisions. Integral to both phases, though differing in structure and function from the first to the second, is the concept of alcohol expectancies. Another cognitive construct, drinking refusal self-efficacy, is also hypothesized to play a role in decisions to drink or not to drink. It is suggested that the development of drinking behavior is best explained in terms of associative models of learning and memory. Implications for prevention and treatment of problem drinking are discussed.

Sociodemographic characteristics of adolescent smokers

In this study we examined the interdependence of a broad range of sociodemographic characteristics in a large sample of 15-year-old smokers and nonsmokers. The most prominent risk factors for smoking included the father figure not being the natural father, low family SES, and the young person having a recent part-time job. In particular, the number of adverse sociodemographic conditions present was associated with an increased likelihood of daily smoking at ages 15 and 18. It is estimated that over a 1-year period the cost of cigarettes consumed by 15-year-olds alone is NZ$4.6 million. Use of sociodemographic characteristics to target adolescents at risk of becoming smokers is discussed.

The importance of alcohol expectancies and drinking refusal self-efficacy in the quantity and frequency of alcohol consumption

Expectancies about alcohol have been shown to be related to and predictive of alcohol consumption. Research to date, however, has often failed to make a clear distinction between expectations about the effects of alcohol (alcohol expectancies) and expectations about one's ability to resist drinking in certain situations (drinking refusal self-efficacy). There is some evidence that alcohol expectancies (AE) and drinking refusal self-efficacy (DRSE) can play differential roles in the prediction of consumption in terms of quantity and frequency of drinking. This study aimed to replicate and extend these findings to the community population. Subjects (N = 185) were recruited from the general community using a peer network system. They were given a booklet comprising six self-report measures, including the Drinking Expectancy Questionnaire (DEQ), the Drinking Self-Efficacy Questionnaire (DSEQ), and the Khavari Alcohol Test (KAT), which produces measures of usual and maximum quantity as well as frequency of the usual and maximum consumed. It was expected that AE would be related to frequency of consumption whereas DRSE would be related to both quantity and frequency. The findings confirmed the differential role of AE and DRSE in drinking, and the role of factors within the two concepts. Results indicated that low DRSE was related to higher frequency of general consumption and a larger maximum quantity on any one occasion. AE was related to frequency, but not to quantity, as expected. The findings are presented with respect to the theoretical constructs; clinical and research implications are also discussed.

An exploration of the relationship between expression of hostility and the anxiety disorders

The purpose of the present study was to investigate differences between four anxiety disorder groups with respect to their levels of hostility. Patients with diagnoses of panic disorder, agoraphobia with panic, generalized anxiety disorder and social phobia were compared as regards their performance on the Hostility and Direction of Hostility Questionnaire (HDHQ). Results showed that while the groups did not differ on their extrapunitiveness, there were significant differences on intropunitive scores, with social phobics showing the most self criticism and guilt, followed in order by the agoraphobics with panic, generalized anxiety disorder and panic disorder subjects. Scores on the Anxiety Symptoms and Consequences Scale were used to predict intropunitiveness and extrapunitiveness for each diagnostic group. Results showed that intropunitiveness was related to anxiety symptoms differently for each diagnostic group. Overall, the study indicates that intropunitive hostility may be an important feature of anxiety disorders, especially panic with and without agoraphobia, and that the finding is worth further exploration with longitudinal studies.

Personality and treatment response in agoraphobia with panic attacks

The present study investigated the association of specific personality characteristics with agoraphobia, and whether they predicted long-term outcome following a group cognitive behavior therapy program. Thirty-three patients with agoraphobia with panic attacks, 18 with social phobia, and 26 "normals" were used in the study. Personality factors were measured with the Maudsley Personality Inventory (MPI), the Hostility and Direction of Hostility Questionnaire (HDHQ), and the Fundamental Interpersonal Relations Orientation-Behavior Scale (FIRO-B). The results showed that (1) agoraphobics are more extroverted and more likely to include others in their activities than are social phobics; however, they are less extroverted, more neurotic, more hostile and intropunitive, and less likely to include others in their activities than are normals; (2) social phobics are similarly less extroverted, more neurotic, and more hostile and intropunitive than normals, but, in addition, are less likely to exert control over others, more likely to want to be controlled, and less expressive of affection than normals; and (3) personality characteristics did not predict treatment outcome.

The latent structure of anxiety symptoms in anxiety disorders

OBJECTIVE

Research in the psychopathology of panic and anxiety disorders, particularly agoraphobia, suggests that fear of fear may be the basis of these conditions. However, there is little empirical research on the definition and validity of the concept of fear of fear in a clinical study group. The authors' aims are 1) to determine empirically if particular associations between symptoms and beliefs exist in a group of patients with anxiety disorders and what underlying dimensions of perceived threat they represent and 2) to assess the relative importance of these associations in agoraphobia with panic attacks, panic disorder, social phobia, and generalized anxiety disorder.

METHOD

In an anxiety disorders treatment unit, 390 outpatients with anxiety disorders diagnosed according to DSM-III criteria completed the Anxiety Symptoms and Beliefs Scale.

RESULTS

A principal components analysis of the patients' ratings on the Anxiety Symptoms and Beliefs Scale produced a four-factor solution in which specific sets of anxiety symptoms loaded with specific beliefs. These four factors were interpreted as respiratory symptoms, vestibular symptoms, autonomic arousal, and psychological threat. Respiratory and vestibular symptoms were more associated with panic disorder diagnoses than with social phobia and generalized anxiety disorder diagnoses.

CONCLUSIONS

These findings support a conception of fear of fear in anxiety disorders as fearful beliefs concerning the experience of anxiety symptoms. Associations between symptoms and fear of fear are present across anxiety disorders but are most pronounced in agoraphobia with panic attacks.

A psychosocial profile of women with premenstrual dysphoria

Sixty women from the community were used in this study to identify a profile of women who experience premenstrual dysphoria. Women with prospectively confirmed premenstrual dysphoria (PMD +; N = 24) were compared to women with prospectively unconfirmed premenstrual dysphoria (PMD -; N = 15) and controls (PMD control; N = 21). Over one menstrual cycle daily records of physical, emotional and behavioural symptoms were completed on the Daily Ratings Form. Other self report measures obtained were the Premenstrual Assessment Form, Rotter's Internal External Locus of Control, the Locke-Wallace Marital Adjustment Scale, and the State-Trait Anxiety Inventory. A psychiatric history was obtained during an interview. Analyses showed that premenstrually, PMD + and PMD - groups could be significantly differentiated from controls on reports of premenstrual dysphoric changes and levels of state and trait anxiety. Postmenstrually, they could be significantly differentiated from controls firstly, by history of affective disorder and locus of control and secondly, by premenstrual dysphoric changes. There were no significant differences between the PMD+ and PMD- women on most of the self report measures either at pre or post menstrual assessments. The present findings suggest that the characteristic profile of PMD+ and PMD- women is one of being symptomatic premenstrually in relation to dysphoric changes and levels of state and trait anxiety. Postmenstrually these symptoms appear to be superimposed on a background of a history of affective disorder and an external locus of control orientation.

Change in children's smoking from age 9 to age 15 years: the Dunedin Study

Studies have shown that the rate at which children take up smoking is still very high, particularly for female adolescents. While some progress has been made in determining the factors related to the initiation of smoking, an issue that still requires investigation is the relationship between early smoking patterns and later smoking behaviour. This paper reports the results of a longitudinal study which examined the continuity between smoking at an early age and later smoking behaviour. The smoking behaviour of a cohort of New Zealand children was followed from age 9 to age 15 years. Results showed that children's smoking pattern at age 9 years was not highly related to their smoking behaviour at age 15. The children most likely to become daily smokers by age 15 were those who had smoked within the last year at ages 11 and 13. It was concluded that the formative period for children's daily smoking at age 15 was from 10 to 13 years of age.

Treatment outcome of a group cognitive therapy program for depression

A 12-session group program of cognitive therapy, designed by the first author, was evaluated with 35 persons suffering from major or minor depressive disorders. Effect-size scores were generated using the method of Nietzel, Russel, Hemmings, and Gretter (1987) and compared with cut-off points calculated using the method of Jacobson and Revenstorf (1988) and the norms established by Nietzel et al. (1987) in their meta-analysis. The effects of the Group Cognitive Therapy Program were found to be clinically significant according to the criteria of Jacobson and colleagues (Jacobson and Revenstorf, 1988; Jacobson, Follette and Revenstorf, 1984) for 73% of patients. It is concluded that the Group Cognitive Therapy Program is a clinically efficacious and cost-effective treatment for persons suffering from nonpsychotic, primary, unipolar depression.

Long term follow-up of agoraphobics treated by brief intensive group cognitive behavioural therapy

This study reports the long term efficacy of a brief intensive (2 days) group cognitive behavioural programme for the treatment of agoraphobia with panic attacks. A total of 97 patients was included in the study. Seventy-four patients were in the treated group and 23 were on the waiting list control group. The Fear Questionnaire (FQ), Fear Survey Schedule (FSS), Maudsley Personality Inventory (MPI), the Hostility and Direction of Hostility Questionnaire (HDHQ) and a clinical assessment based on structured interview to assess current levels of functioning were used as dependent measures. The results show that patients in the treated group show significant improvement on FSS and FQ when compared with the patients in the control group. Clinical rating shows that 85% of the patients were either symptom free or their symptoms had been reduced and these effects of treatment were shown to be maintained at follow-up which was on average 1 year after the treatment.

Behavioral strategies used by long-term successful self-quitters

Smoking-cessation programs have been shown to produce unreliable long-term results. Thus, efficient methods still need to be identified. One way of getting relevant information on successful smoking cessation is to study the quitting methods of unaided, long-term, successful quitters. A structured questionnaire was designed specifically for this purpose. Results from 70 self-quitters indicated that self-quitters typically had high motivation before attempting to quit and used aversive and operant methods currently stressed in the literature. Graded habituation and nicotine-based methods were used by some self-quitters. The findings suggest a two-stage model of quit-smoking program which gives greater attention initially to the systematic development of motivation to quit. This model, it is postulated, might enhance the long-term efficacy of smoking cessation programs.

Cognitive processes and cognitive behavior therapy in the treatment of problem drinking

Cognitive behavior Therapy has been shown to be an effective therapy for a wide range of clinical problems. However, the efficacy of CBT on addictive behavior is still unknown. This paper reviews the evidence for the efficacy of cognitive behavior therapy treatment for problem drinkers and examines its relationship with cognitive models of problem drinking. A computer search of the literature showed that only 13 studies met the criteria for inclusion in this review. This review indicated that there is evidence to show that cognitive behavior therapy can be successfully applied to addictive behaviors, in particular, problem drinking. However, there is lack of evidence to show that cognitive behavior therapy supports cognitive models of problem drinking. Future direction for research in this area is suggested.

Differences in reasons for smoking between younger and older smokers

The reasons why older people smoke have not been examined in the literature. This paper attempted to examine the differences in motivation and maintenance factors of elderly and young smokers using the Horn-Waingrow Why do you smoke questionnaire. One hundred and thirteen clinical patients and 112 non-patient controls were used in this study. The clinical group was divided into an elderly group (n = 58) and a younger group (n = 55). The results of a discriminant analysis showed that patients significantly differed from non-patients on 'automatic habit and stimulation', and 'crutch/tension reduction' factors. Elderly patients were found to be significantly differentiated from both younger patients and the control group on the 'pleasurable relaxation' factor. These findings offer support for the US Surgeon Generals' report that elderly smokers do have different motivating factors for their smoking behaviours from younger smokers.

Utility and validity of the STAI with anxiety disorder patients

Factor analytic studies of the State-Trait Anxiety Inventory (STAI) have provided support for the concepts of state and trait anxiety. This article reports the factor structure of the STAI (Form X) using 205 panic-disordered patients with and without agoraphobia. Results show that a two-factor oblique solution is the most appropriate, accounting for 41.1 per cent of the variance. Eighteen of the A-State items had salient loadings on factor 1 (state anxiety) and all 20 of the A-Trait items had salient loadings on factor 2 (trait anxiety). This study demonstrates the utility of the STAI in measuring anxiety in clinical populations and further supports the theoretical distinction between state and trait anxiety.

Neuroticism and age of onset for agoraphobia with panic attacks

The study of the age of onset of psychiatric conditions can provide some clues to the aetiology of these disorders. A number of studies have examined the age of onset in agoraphobia but results have varied. This may be associated with small sample sizes or differences in populations. There has been very little work examining the factors determining age of onset. The present study examines age of onset in relation to sex and personality. Results indicate no sex differences in age of onset, but an association with age and high levels of neuroticism.

The in vivo manipulation of alcohol-related beliefs in male social drinkers in a naturalistic setting

Earlier research shows that alcohol expectancies are related to alcohol consumption. However, how the alcohol expectancies are related to drinking in a public bar is still unknown. This paper examines this relationship in 10 moderate-heavy male social drinkers attending alternatively to both alcohol dependent and non-dependent cognitive sets of alcohol use. When discussing the alcohol dependent expectancies, these drinkers consumed significantly less alcohol compared with their consumption when discussing non-alcohol dependent expectancies. This group effect was also corroborated by a within-subject analysis of the data. The implications of the relationship between beliefs and drinking behaviour in terms of a cognitive behaviour model of alcohol use are briefly discussed.

Differences between personal and general alcohol-related beliefs

The discrepancy between personal alcohol-related statements and general beliefs regarding alcohol was investigated in a community sample of 283 social drinkers. Discriminant analysis showed that subjects perceived themselves as significantly less dependent than others. "Self" statement responses accurately predicted drinking behavior, as measured by consumption; however, general statements did so less effectively. Medium-heavy drinkers considered others to be dependent on alcohol to change aversive events, suggesting that a self-fulfilling bias may have distorted their perception. For most drinkers the self-other discrepancy seemed best explained by media and societal influences rather than by a self-fulfilling bias model.