Therapeutic Alliance in Depression Treatment: Controlling for Prior Change and Patient Characteristics.

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-Behavioral Analysis System of Psychotherapy as a Maintenance Treatment for Chronic Depression.

Although the efficacy of maintenance pharmacotherapy for the prevention of recurrence in major depressive disorder (MDD) is well documented, few studies have tested the efficacy of psychotherapy as a maintenance treatment. The authors examined the efficacy of the cognitive-behavioral analysis system of psychotherapy (CBASP) as a maintenance treatment for chronic forms of MDD. Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assessment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time. These findings support the use of CBASP as a maintenance treatment for chronic forms of MDD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Positive psychotherapy.

Positive psychotherapy (PPT) contrasts with standard interventions for depression by increasing positive emotion, engagement, and meaning rather than directly targeting depressive symptoms. The authors have tested the effects of these interventions in a variety of settings. In informal student and clinical settings, people not uncommonly reported them to be "life-changing." Delivered on the Web, positive psychology exercises relieved depressive symptoms for at least 6 months compared with placebo interventions, the effects of which lasted less than a week. In severe depression, the effects of these Web exercises were particularly striking. This address reports two preliminary studies: In the first, PPT delivered to groups significantly decreased levels of mild-to-moderate depression through 1-year follow-up. In the second, PPT delivered to individuals produced higher remission rates than did treatment as usual and treatment as usual plus medication among outpatients with major depressive disorder. Together, these studies suggest that treatments for depression may usefully be supplemented by exercises that explicitly increase positive emotion, engagement, and meaning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Reactance as a Predictor of Outcome in the Treatment of Chronic Depression.

This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude × Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations

BACKGROUND: Few reliable correlates of treatment response in depression have emerged despite nearly 40 years of research. We examined the correlates of recovery in a "mega-analysis," or meta-analysis of original data, of 595 patients with major depressive disorder enrolled in 6 standardized treatment protocols. METHODS: All patients (mean age, 44 years; 31% male and 69% female) met criteria for nonbipolar, nonpsychotic primary major depressive disorder and were treated for 16 weeks with either cognitive behavior therapy or interpersonal psychotherapy alone (psychotherapy alone; n = 243) or interpersonal psychotherapy plus antidepressant pharmacotherapy (combined therapy; n = 352). The impact of treatment type, severity, study, and other covariates on recovery rates or time to recovery were examined by means of chi 2, log-rank tests, the Cox proportional hazards model, and sensitivity analyses. RESULTS: Whereas combined therapy was not significantly more effective than psychotherapy alone in milder depressions, a highly significant advantage was observed in more severe recurrent depressions. Poorer outcomes were also observed in women and older patients, although these effects were dependent on inclusion of particular studies. CONCLUSIONS: Mega-analysis is a powerful method for comparing the efficacy of treatments and examining correlates of response. Using this method, we found new evidence in support of the widespread clinical impression that combined therapy is superior to psychotherapy alone for treatment of more severe, recurrent depressions.     

Stress reactivity following brief treatment for depression: Differential effects of psychotherapy and medication.

Psychotherapy and medication treatments are both effective in reducing depressive symptoms. However, only psychotherapy provides an enduring effect by reducing depressive vulnerability following treatment termination. This differential efficacy may reflect mode-specific effects on the longitudinal relationship between depression and stress. The current study examined posttreatment data from 153 outpatients enrolled in the Treatment of Depression Collaborative Research Program. Longitudinal analyses using the latent difference score (LDS) framework (a structural modeling technique that combines features of latent growth curve and cross-lagged regression models) evaluated the temporal relationship between severity of depression and frequency of stressful life events, assessed by interviewers at treatment termination and at 6, 12, and 18 months following treatment. Results supported a stress reactivity model in that stressful events led to elevations in the rate of depression change. Furthermore, multigroup LDS analysis indicated that this longitudinal stress reactivity occurred only for outpatients in the medication conditions. Results demonstrate that the enduring impact of psychotherapy involves the development of enhanced resiliency to stressful life events. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A pilot study of affect-focused psychotherapy for antepartum depression.

Logically, psychotherapy should be the first-line treatment for depression during pregnancy, yet there have been very few nondrug interventions tested in this patient population. The present study examines the impact of affect-focused psychotherapy as a treatment for antepartum depression. The treatment model was thought to be feasible to test with this population because depressed pregnant women are in need of an integrative model that can engage the client quickly and work rapidly to reduce symptom distress. Participants were 10 pregnant women with major depressive disorder who were treated with five sessions of affect-focused psychotherapy, as outlined in a published treatment manual. All therapy sessions were videotaped. Results indicate that participants experienced significant improvements in depressive symptoms, as well as increased therapeutic alliance and patient-therapist bond. These preliminary results provide promising data that demonstrate the effectiveness of a short-term (five-session) affect-focused psychotherapeutic treatment with a patient population suffering from antepartum depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of telephone psychotherapy and pharmacotherapy for depression: Continuation and durability of effects.

Randomized trial evidence and expert guidelines are mixed regarding the value of combined pharmacotherapy and psychotherapy as initial treatment for depression. This study describes long-term results of a randomized trial (N = 393) evaluating telephone-based cognitive-behavioral therapy (CBT) plus care management for primary care patients beginning antidepressant treatment versus usual care. In a repeated measures linear model with adjustment for baseline scores, the phone therapy group showed significantly lower mean Hopkins Symptom Checklist (HSCL) Depression Scale scores (L. Derogatis, K. Rickels, E. Uhlenhuth, & L. Covi, 1974) from 6 months to 18 months versus usual care, F(1, 336) = 11.28, p = .001. Average HSCL depression scores over the period from 6 months to 18 months were 0.68 (SD = 0.55) in the telephone therapy group and 0.85 (SD = 0.65) in the usual-care comparison group. Addition of a brief, structured CBT program can significantly improve clinical outcomes for the large number of patients beginning antidepressant treatment in primary care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP).

Reviews the book, Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP) by James P. McCullough Jr. (see record 2006-11486-000). The premise of this book is that therapeutic neutrality does not apply to the psychotherapy of chronically depressed individuals, and that disciplined personal involvement is an efficacious and perhaps necessary component of their treatment. Cognitive behavioral analysis system of psychotherapy (CBASP) is a learning model, in which the therapist focuses on teaching patients to recognize the consequences of their behavior. McCullough addresses practical and theoretical objections to this therapeutic approach, which include fears of overinvolvement, and inappropriate behavior, and clinical risks of flooding patients with excessively personal information and content. Ultimately, most readers will finish reading this volume with many open questions, some specific to McCullough's approach, others related to the challenging condition of chronic depression itself. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fluoxetine in depressed alcoholics. A double-blind, placebo-controlled trial

BACKGROUND: The selective serotonergic medication fluoxetine has demonstrated efficacy in the treatment of major depression and has suggested efficacy in the treatment of alcoholism. However, no completed trials with any selective serotonergic medication have been reported in patients who display both major depression and alcoholism, despite previous observations that both depression and alcoholism are associated with low serotonergic functioning. METHODS: Fifty-one patients diagnosed as having comorbid major depressive disorder and alcohol dependence were randomized to receive fluoxetine (n = 25) or placebo (n = 26) in a 12-week, double-blind, parallel-group trial. Weekly ratings of depression and alcohol consumption were obtained throughout the 12-week course of the study. RESULTS: The improvement in depressive symptoms during the medication trial was significantly greater in the fluoxetine group than in the placebo group. Total alcohol consumption during the trial was significantly lower in the fluoxetine group than in the placebo group. CONCLUSIONS: Fluoxetine is effective in reducing the depressive symptoms and the alcohol consumption of patients with comorbid major depressive disorder and alcohol dependence. It is unknown whether these results generalize to the treatment of less depressed and less suicidal alcoholics.     

Therapy processes and outcomes of psychological interventions for women diagnosed with gynecological cancers: A test of the generic process model of psychotherapy.

Objective: Little attention has been paid to the role of nonspecific therapy processes in the efficacy of psychological interventions for individuals diagnosed with cancer. The goal of the current study was to examine the three constructs from the generic model of psychotherapy (GMP): therapeutic alliance, therapeutic realizations, and therapeutic openness/involvement in the treatment outcome of women with gynecological cancers attending either a 7-session supportive counseling intervention or a coping and communication skills intervention. Method: Two hundred and three women completed measures of alliance, realizations, and openness after Intervention Sessions 2, 3, and 6, as well as measures of depressive symptoms after these sessions and 6 months after the pre-intervention assessment (posttreatment). Results: Consistent with the GMP, in early sessions, therapeutic bond predicted openness in terms of positive affect experienced during sessions, and both aspects of openness (positive and negative affect), in turn, predicted more therapeutic realizations. Therapeutic realizations predicted perceptions of greater session progress, and greater therapeutic bond predicted more therapeutic realizations. When early session GMP variables were used to predict later GMP processes and outcomes and posttreatment outcomes, early therapeutic bond predicted later session therapeutic realizations directly and indirectly via emotional arousal, emotional arousal predicted session progress, session progress predicted lower postsession depressive symptoms, and depressive symptoms as rated after Session 6 predicted depressive symptoms 3 months posttreatment. However, a number of additional associations among GMP processes were found. Conclusions: Our results suggest that therapy processes played a role in predicting both short- and long-term treatment outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A review of the neurobiological effects of psychotherapy for depression.

Although randomized, controlled clinical trials have shown that different forms of psychotherapy may be efficacious for depression, psychotherapy has not been widely reported to have effects upon the neurobiological concomitants of depression in similar ways as medication. Neuroendocrinal changes that occur during depression (principally hypercortisolaemia) produce structural and functional alterations to the prefrontal cortex, hippocampus, and amygdala, plus the connectivity between these regions of the brain. This article reviews the evidence to date regarding the neurobiological effects of psychotherapy for depression and suggests a hypothetical pathway linking the nurturing effects of the therapist–patient “bond” and restoration of neuroendocrinal “balance.” This pathway may provide a neurobiological causal link between psychotherapy and alleviation of depression in the same way as that which exists for pharmacological treatments, and argues for a model of depression that includes both biological and psychological effects of psychotherapy when considering treatment choice and application. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of depression in low-income older adults.

The purpose of this study was to compare cognitive-behavioral group therapy (CBGT), clinical case management (CCM), and their combination (CBGT + CCM) to treat depression in low-income older adults (60+). Sixty-seven participants with major depressive disorder or dysthymia were randomly assigned and entered into 1 of the 3 treatment conditions for 6 months. They were followed for 18 months after treatment initiation on depression and functional outcomes. CCM and CBGT + CCM led to greater improvements in depressive symptoms than CBGT, but CBGT led to greater improvements in physical functioning. All 3 conditions resulted in similar reduction of needs. Findings suggest that disadvantaged older adults with depression benefit from increased access to social services either alone or combined with psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of an intensive depression-focused intervention for smoking cessation in pregnancy.

Objective: The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. Method: Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies–Depression Scale (Radloff, 1977). Results: At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. Conclusions: The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effectiveness of psychotherapy: The Consumer Reports study.

Consumer Reports (1995, November) published an article which concluded that patients benefitted very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Differential effects of treatments for chronic depression: A latent growth model reanalysis.

Objective: Psychotherapy–pharmacotherapy combinations are frequently recommended for the treatment of chronic depressive disorders. Our aim in this novel reanalysis of archival data was to identify patient subgroups on the basis of symptom trajectories and examine the clinical significance of the resultant classification on basis of differential treatment effects to psychotherapy (cognitive behavioral analysis system of psychotherapy), pharmacotherapy (nefazodone), and their combination. Method: We selected data for 504 patients diagnosed with chronic depression from archival data of a clinical trial (N = 681) and analyzed treatment courses (as assessed by the Hamilton Rating Scale for Depression) using growth mixture models, a contemporary exploratory analysis technique. Results: Three patient subgroups were identified from the typical patterns of change of depression severity during 12-week acute-phase treatment. Within these patient subgroups, differential treatment effects were evident: combination treatment clearly outperformed the 2 monotherapies in the largest patient subgroup, characterized by moderate depression severity, but not in the remaining 2 subgroups, characterized by low and severe depression at baseline. Patient characteristics prior to initiation of treatment enabled allocation of 61% of patients to these subgroups. Conclusions: Research on patient subgroups with different change patterns may support classifications of patients that indicate which treatment is most effective for which type of patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal styles of chronically depressed outpatients: Profiles and therapeutic change.

Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of the longitudinal course of postpartum depression following interpersonal psychotherapy.

Objective: We examined the course and predictors of postpartum depression in the 18 months following interpersonal psychotherapy (IPT). Method: We enrolled 120 community women with major depression in a 12-week randomized trial of individual IPT during the postpartum period (O'Hara, Stuart, Gorman, & Wenzel, 2000). At 6, 12, and 18 months posttreatment, women participated in clinical interviews to establish the course of depression over the previous 6 months. We used survival analyses to characterize recovery and recurrence in the follow-up and growth curve modeling techniques to identify predictors of change in depression during the follow-up period. Potential predictors included severity, chronicity, and personal history of depression. Results: Of 35 women who recovered with acute treatment, 20 (57%) achieved sustained recovery during follow-up; average time to recurrence was 33.40 weeks (SD = 18.43 weeks). Over 80% of women who did not recover with acute treatment experienced recovery at some point during follow-up; average time to recovery was 28.60 weeks (SD = 17.51 weeks). Time depressed each month decreased over the follow-up period. Posttreatment depressive severity and length of the index episode predicted changes in depression over time. Posttreatment depression severity, personal history of depression, and weeks of treatment in the follow-up were significant predictors of time depressed during follow-up. Conclusions: IPT resulted in long-term benefits past the termination of acute treatment, even for women who did not initially recover. Though the vast majority of women who did not recover with acute treatment did recover during the follow-up period, continuation of IPT may accelerate the process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of drug solubility, drug loading, and polymer molecular weight on drug release from Polyox tablets

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.