Recurrence in major depression: A conceptual analysis.

[Correction Notice: An erratum for this article was reported in Vol 118(4) of Psychological Review (see record 2011-23298-002). An incorrect version of Figure 2 was published, and Figure 3 was published in color instead of Figure 4. Also, in Table 1, the acronym “(FLED)” should not have been included in the Recurrence section, under Confusion to avoid, following “Not to be confused with a first lifetime recurrence.” All versions of this article have been corrected.] Theory and research on major depression have increasingly assumed a recurrent and chronic disease model. Yet not all people who become depressed suffer recurrences, suggesting that depression is also an acute, time-limited condition. However, few if any risk indicators are available to forecast which of the initially depressed will or will not recur. This prognostic impasse may be a result of problems in conceptualizing the nature of recurrence in depression. In the current paper we first provide a conceptual analysis of the assumptions and theoretical systems that presently structure thinking on recurrence. This analysis reveals key concerns that have distorted views about the long-term course of depression. Second, as a consequence of these theoretical problems we suggest that investigative attention has been biased toward recurrent forms of depression and away from acute, time-limited conditions. Third, an analysis of how these theoretical problems have influenced research practices reveals that an essential comparison group has been omitted from research on recurrence: people with a single lifetime episode of depression. We suggest that this startling omission may explain why so few predictors of recurrence have as yet been found. Finally, we examine the reasons for this oversight, document the validity of depression as an acute, time-limited disorder, and provide suggestions for future research with the goal of discovering early risk indicators for recurrent depression. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

"Internalization of interpersonal process in time-limited dynamic psychotherapy": Erratum.

Reports an error in "Internalization of interpersonal process in time-limited dynamic psychotherapy" by R. Steven Harrist, Stephen M. Quintana, Hans H. Strupp and William P. Henry (Psychotherapy: Theory, Research, Practice, Training, 1994[Spr], Vol 31[1], 49-57). This article contained, as Figure 1, an SASB model. The authorship and copyrights for the model were not acknowledged. The following acknowledgement should have been included: "Adapted from Benjamin (1984). Principles of Prediction using Structural Analysis of Social Behavior (SASB). In R. A. Zucker, J. Aronoff, and A. J. Rabin (Eds.), Personality and the Prediction of Behavior (pp. 121- 174). New York: Academic." An apology is offered to the author, Dr. Lorna Smith Benjamin. The particular version used in the article was developed in collaboration with Clinton W. McLemore. (The following abstract of the original article appeared in record 1994-46214-001.) Investigated the internalization of positive aspects of therapist–patient (TP) interactions among 70 patients and their 16 therapists who participated in a 5-yr study (H. H. Strupp et al, unpublished) of time-limited dynamic psychotherapy. Patients sought help for anxiety, depression, or other problems with a clear interpersonal component and qualified for an Axis I or Axis II diagnosis on the DSM-III. Instruments included the Structural Analysis of Social Behavior and outcome measures of depression, anxiety, and psychological functioning. Patients' intrapsychic functioning became more similar to interpersonal activity in the TP relationship over the course of psychotherapy. Intrapsychic movement toward interpersonal activity in the TP relationship was associated with positive outcome on measures of depression, anxiety, and on independent clinician ratings of patient psychological functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dose–effect relations in time-limited psychotherapy for depression.

Criteria for reliable and clinically significant improvement were applied to standard and individually tailored outcome measures data from 212 depressed clients who had been randomly assigned to receive either 8 or 16 sessions of time-limited psychotherapy. The data were used to address 2 questions: (a) Is the dose-effect curve for psychological symptoms negatively accelerated? and (b) is there a differential rate of response for acute, chronic, and characterological/interpersonal components of depression? The results supported the differential rate of response of different components of depression and suggested qualifications to the acute, chronic, and characterological/interpersonal components and evidence that both supported and qualified previous suggestions that the dose effect curve is negatively accelerated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing Relapse/Recurrence in Recurrent Depression With Cognitive Therapy: A Randomized Controlled Trial.

This article reports on the outcome of a randomized controlled trial of cognitive group therapy (CT) to prevent relapse/recurrence in a group of high-risk patients diagnosed with recurrent depression. Recurrently depressed patients (N = 187) currently in remission following various types of treatment were randomized to treatment as usual, including continuation of pharmacotherapy, or to treatment as usual augmented with brief CT. Relapse/recurrence to major depression was assessed over 2 years. Augmenting treatment as usual with CT resulted in a significant protective effect, which intensified with the number of previous depressive episodes experienced. For patients with 5 or more previous episodes (41% of the sample), CT reduced relapse/recurrence from 72% to 46%. Our findings extend the accumulating evidence that cognitive interventions following remission can be useful in preventing relapse/recurrence in patients with recurrent depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recurrence of MDD: A prospective study of personality pathology and cognitive distortions.

Major depressive disorder (MDD) is characterized by a high risk of recurrence, especially among individuals whose initial episode occurs during adolescence. Identifying predictors of recurrence of MDD among young samples is therefore of paramount clinical importance. Survival analytic models were used to evaluate the effects of dysfunctional cognitions and Axis II personality pathology on MDD recurrence in a sample of 130 previously, but not currently, depressed young adults. Participants were initially assessed for depression, dysfunctional attitudes, and personality pathology during their first semester in college and then reevaluated via the Longitudinal Interval Follow-up Evaluation interview every 6 months for 18 months. Baseline level of depressive symptoms significantly (HR-1.07, p = .002) predicted recurrence of MDD. In the survival analyses with baseline level of depression serving as a current mood state covariate, overall personality pathology (HR-1.04, p DSM–IV personality disorder cluster scores uniquely predicted recurrence. We discussed the theoretical, empirical, and clinical implications of these findings, and we noted the limitations of the study. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Children of depressed parents: An integrative review.

Reviews the literature on the adjustment of children of depressed parents, difficulties in parenting and parent–child interaction in these families, and contextual factors that may play a role in child adjustment and parental depression. First, issues arising from the recurrent, episodic, heterogeneous nature of depression are discussed. Second, studies on the adjustment of children with a depressed parent are summarized. Early studies that used depressed parents as controls for schizophrenic parents found equivalent risk for child disturbance. Subsequent studies using better-defined samples of depressed parents found that these children were at risk for a full range of adjustment problems and at specific risk for clinical depression. Third, the parenting difficulties of depressed parents are described and explanatory models of child adjustment problems are outlined. Fourth, important gaps in the literature are identified, and a consistent, if unintentional, "mother-bashing" quality in the existing literature is noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is apathy a valid and meaningful symptom or syndrome in Parkinson's disease? A critical review.

Objective: To review the nearly 30 papers suggesting that apathy may occur frequently in Parkinson's disease (PD) and that it may be a symptom or syndrome that is separate from depression. Method: Literature review. Results: The review revealed three possible explanations for the high rates of apathy found in PD. First, there is much interest in an endogenous explanation of apathy because the basal ganglia and dopamine are implicated in both PD and apathy. Researchers have suggested links between apathy, dopamine depletion, and basal ganglia dysfunction in PD. Second, apathy in PD may be exogenous, resulting from disability and activity restriction. Third, apathy findings are inflated due to conceptual problems and methodological confounds. Indeed, apathy may be consistently confounded with symptoms of PD, including expressive masking, depression, disability, and cognitive decline. Conclusion: Because apathy has not yet been found to relate to meaningful patient outcomes, and it appears that other factors such as depression and cognition are more strongly related to quality of life than apathy, there is not enough evidence to conclude that apathy is a clinically meaningful syndrome in PD. The role of PD in motivation is of theoretical and practical interest and deserves further research. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Biased processing of emotional information in girls at risk for depression.

Researchers have documented that children of depressed mothers are at elevated risk for developing a depressive disorder themselves. There is currently little understanding, however, of what factors place these children at elevated risk. In the present study, the authors investigated whether never-disordered daughters whose mothers have experienced recurrent episodes of depression during their daughters' lifetime are characterized by biased processing of emotional information. Following a negative mood induction, participants completed an emotional-faces dot-probe task. Daughters at elevated risk for depression, but not control daughters of never-disordered mothers, selectively attended to negative facial expressions. In contrast, only control daughters selectively attended to positive facial expressions. These results provide support for cognitive vulnerability models of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Major life events and major chronic difficulties are differentially associated with history of major depressive episodes.

Major life events have been found to precede onsets of a 1st lifetime episode of depression more commonly than subsequent recurrences. Despite general empirical support for this finding, few data directly address how the role of major life events may change over successive recurrences. Further, little research has examined major chronic difficulties in relation to a 1st lifetime episode versus a recurrence of depression. The present study tested the associations between major life events and major difficulties in relation to lifetime history of depressive episodes in a sample of 96 individuals diagnosed with major depression. Using investigator-based measures of life stress, the authors found that, whereas major life events were associated with fewer lifetime episodes, major chronic difficulties were related to more prior episodes. These findings are discussed in terms of underlying mechanisms that may account for the changing role of major life stress over successive recurrences of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Initial symptom levels and the life-event–depression relationship.

93 undergraduates selected for diversity of initial depression levels were studied longitudinally to explore the relation between stressful events and depression. Ss were chosen on the basis of their scores on an information-processing procedure, the Beck Depression Inventory, the Schedule for Affective Disorders and Schizophrenia—Lifetime Version, and the SCL-90. After the initial screening, Ss completed a 2-hr interview covering current and lifetime diagnostic status and stressful life-event occurrence in the previous 12 mo. Following this, they participated in 4 regular monthly follow-ups. Regression analyses and inspection of individual patterns supported the hypothesis that initial depression status is a critical factor in depression–event associations and that concurrent high-impact negative events contribute significantly but modestly to outcomes. It appeared that nonsymptomatic Ss were relatively resistant to onset even when exposed to high-impact stress events, whereas a subset of initially symptomatic Ss continued to have both more depression and more high-impact events over time. It is suggested that future research on event–depression associations should carefully consider these different outcome patterns: symptom resistance and symptom onset in nondepressed persons and symptom remission and symptom maintenance or recurrence in initially depressed persons. (43 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postpartum depression: A critical review.

A review of the literature suggests that there are 3 types of postpartum dysphoric mood states: the maternity blues (a fairly common, transient disorder), postpartum affective psychosis (relatively rare), and postpartum depression (as many as 20% of postpartum women may develop mild to moderate depression). The etiology of postpartum depression remains unclear, although numerous biological, psychological, and sociopsychological factors have been proposed as etiologically relevant. There is some empirical support for these notions, but methodological and conceptual problems hinder the development of a coherent theoretical framework for understanding the etiology, course, and treatment of the disorder. Recent data indicate a relation between stress and depression; future research into postpartum depression is needed to determine the contribution of psychosocial factors (e.g., life events and social support). Medical complications during pregnancy, infant variables, and the effect on the infant–mother relationship also need to be studied. (3 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rumination and cigarette smoking: A bad combination for depressive outcomes?

Ruminative coping has been shown to heighten the risk and severity of depression. The authors hypothesized that ruminators who smoke would experience greater depressive symptoms than ruminators who do not. The rationale is that, by heightening attentional focus, nicotine may increase ruminators' ability to focus on negative thoughts, augmenting depressed mood. Participants (N = 145) self-reported smoking status, rumination, and current and lifetime depressive symptoms, including depressed mood. Results showed that rumination accounted for a larger amount of variance in current and past depressed mood and severity of lifetime depressive symptoms among smokers than nonsmokers. Noncorrelational, experimental research should directly test whether nicotine worsens depressed mood among ruminative smokers. Such evidence would be surprising because it would contradict the assumption that nicotine dispels negative moods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Interpersonal psychotherapy of depression.

Reviews the book, Interpersonal psychotherapy of depression by Gerald L. Klerman, Myrna M. Weissman, Bruce J. Rounsaville, and Eve S. Chevron (1984). The authors state their intention to "describe the theoretical and empirical basis for interpersonal psychotherapy of depression," and also "offer a guide to the planning and conduct of the therapy." They do both, and waste no words. The book is organized into three parts. In the first part, the authors present an overview of the theory of the interpersonal approach of the use of interpersonal psychotherapy for depression, objectively offer both favorable and unfavorable findings from completed studies, and outline several studies in progress. The chapters in Part Two clarify how one conducts interpersonal therapy of depression. Part Three addresses the combination of psychotherapy with pharmacotherapy and the professional requirements of the therapist. This book is clearly written, well referenced, and easily understood by beginners who might not have the perspective, as well as by busy veterans who want to learn something new without plowing through mountains of theory and data. It would be useful for students in training, and extremely valuable to the legions of relatively inexperienced front-line mental health center therapists who are required to use time-limited approaches with depressed patients, often without having much structure for what they are doing. More experienced therapists who treat ambulatory depressed patients will add to their clinical skills and enjoy the process. The authors have turned their manual into a useful book that competes most favorably with other texts on short-term approaches to therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Vulnerability to depression: Cognitive reactivity and parental bonding in high-risk individuals.

Although various conceptual proposals have suggested that disruptions in childhood bonding processes may be linked to the origins of these cognitive structures, little research has tested these proposals. This study assessed the information processing of vulnerable individuals and its relationship to childhood bonding. Formerly depressed (vulnerable) and never depressed (nonvulnerable) individuals participated in a mood induction task followed by an attentional allocation task. Results indicated that vulnerable individuals uniquely diverted attention toward negative stimuli when they were in a negative mood. Furthermore, level of maternal caring was found to be associated with performance on this task for vulnerable individuals in this mood state. These data support the idea that cognitive variables form a pathway between troublesome parental-child/adolescent interactions and depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relative memory deficits in recurrent versus first-episode major depression on a word-list learning task.

Although memory deficits are associated with major depressive disorder, few studies have identified which patient characteristics predict impairment. Because recurrent depression appears related to more severe cerebral dysfunction, the present study tested whether recurrent depressed individuals have worse memory function than first-episode depressed individuals. Two groups of young-adult, nonpsychotic, depressed inpatients (20 single episode [SE] and 46 recurrent episode [RE]) were administered the California Verbal Learning Test within a broader battery of neuropsychological tests. The groups were equivalent in age, education, estimated IQ, severity of depression, and demographic composition. The RE group demonstrated memory deficits relative to both the SE group and published norms, but no other significant difference was found across the battery. Data indicate that abnormal memory performance is associated with recurrent depression, whereas memory deficits are not prominent in first-episode depressed individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative cognitive styles, dysfunctional attitudes, and the remitted depression paradigm: A search for the elusive cognitive vulnerability to depression factor among remitted depressives.

Results from studies using a behavioral high-risk design and approximations to it generally have corroborated the cognitive vulnerability hypothesis of depression, whereas results from remitted depression studies typically have not. Suspecting that design features of previously conducted remitted designs likely precluded them from detecting maladaptive cognitive patterns, the authors conducted a study featuring the remitted design that has been successful in studies of a biological vulnerability for depression. Participants' current depressive symptoms, negative cognitive styles (hopelessness theory), dysfunctional attitudes (Beck's theory), and lifetime prevalence of clinically significant depression were assessed. Participants who had remitted from an episode of clinically significant depression had more negative cognitive styles, but not greater levels of dysfunctional attitudes, than did never depressed individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Performance benefits of depression: Sequential decision making in a healthy sample and a clinically depressed sample.

Previous research reported conflicting results concerning the influence of depression on cognitive task performance. Whereas some studies reported that depression enhances performance, other studies reported negative or null effects. These discrepant findings appear to result from task variation, as well as the severity and treatment status of participant depression. To better understand these moderating factors, we study the performance of individuals—in a complex sequential decision task similar to the secretary problem—who are nondepressed, depressed, and recovering from a major depressive episode. We find that depressed individuals perform better than do nondepressed individuals. Formal modeling of participants' decision strategies suggested that acutely depressed participants had higher thresholds for accepting options and made better choices than either healthy participants or those recovering from depression. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Maternal depressive disorder and contextual risk: contributions to the development of attachment insecurity and behavior problems in toddlerhood

Research has shown that offspring of depressed caregivers are at increased risk for maladaptive development and emotional difficulties. Specifically, infants and toddlers of depressed mothers have been shown to evidence higher percentages of insecure attachments and more behavioral difficulties than offspring of nondisordered mothers. However, even in studies that reveal significant differences between children of depressed and nondepressed caregivers, a substantial number of children with depressed caregivers do not evidence dysfunction. Such findings have resulted in increased attention to the broader social context in which children of depressed mothers develop. This investigation examined the direct influences of maternal depression on child development, as well as the role of contextual risks that may be particularly heightened in families with depressed parents. Toddlers with depressed mothers evidenced significantly more insecure attachments than did toddlers with nondisordered mothers, and this difference was not accounted for by contextual risk. In predicting child behavior problems, contextual risk was found to mediate the relation between maternal depression and child behavior problems. Father-report data on child behavior corroborated the mother report data. Results are discussed in terms of the diversity of functioning in offspring of depressed caregivers that can be attributed to varied levels of contextual risk accompanying depression.     

Youth depression and early childrearing: Stress generation and intergenerational transmission of depression.

Objective: Broadening the concept of stress generation beyond acute life events, the current study explores predictors of the creation of stressful environments—specifically, selection into early childrearing by age 20. It was predicted that youth with early onset depressive disorders would be at higher risk for early childrearing accompanied by greater depression and parenting maladjustment. Additional analyses tested hypotheses about the roles of interpersonal vulnerability and intergenerational transmission of depression and examined gender differences. Method: A community sample of 706 adolescents and their mothers were studied at ages 15 and 20. The sample was originally selected to oversample families with depressed mothers. Results: Results confirmed the hypotheses for women but not men: Young women with depression by age 15 were at greater risk for interpersonal difficulties at age 15 and early childrearing, accompanied by further depression and parenting dysfunction at age 20. The effects of (grand)maternal depression were evident in predicting youth early onset depression and interpersonal difficulties, as well as higher rates of depression among their daughters who had children by age 20. Conclusions: The study expands the definition of stress generation to include the role of past depression and other risk factors as predictors of selection into a stressful childrearing environment. The findings also describe aspects of the intergenerational transmission of depression. The results highlight potentially important targets for interventions in young women to prevent recurrence of major depression and parenting dysfunction. (PsycINFO Database Record (c) 2011 APA, all rights reserved)