Sequence of improvement in depressive symptoms across cognitive therapy and pharmacotherapy

BACKGROUND: The authors examined the patterns of improvement in cognitive and vegetative symptoms of major depression in individuals treated with cognitive therapy (CT) or pharmacotherapy (PT). METHOD: Outpatients diagnosed with major depressive disorder (n=180) were randomized to receive either CT or PT. Cognitive and vegetative symptoms of major depression were measured by the Beck Depression Inventory-II at baseline and regularly throughout 16 weeks of treatment. RESULTS: Multivariate hierarchical linear modeling demonstrated the same patterns of change over time for cognitive and vegetative symptoms within CT and within PT. LIMITATIONS: Self-report measures may not be sufficiently specific to capture subtle differences in improvements between vegetative and cognitive symptoms. CONCLUSIONS: These results are consistent with Beck's [Beck, A.T., 1984, November. Cognition and theory [Letter to the editor]. Arch. Gen. Psychiatry 41, 1112-1114.] hypothesis that CT and PT have a similar site of action, which when targeted, results in changes in both cognitive and vegetative features.     

Cognitive–behavioural treatment of first diagnosis bipolar disorder

Cognitive–behavioural therapy can lead to significant improvements in relapse and inter‐episode functioning for individuals with an established course of bipolar disorder. Both psychiatric and psychological models of bipolar disorder suggest that there may be additional benefits in offering this approach earlier in the illness course. This paper reports on the application of a modified cognitive–behavioural approach for individuals after first diagnosis of bipolar disorder using a single case approach across seven participants. Evidence is reported for improvements in mood symptoms and hopelessness following treatment, as well as increased self‐control behaviours, more stable activity patterns and increased ability to detect and coping with early warning signs. Implications of these initial findings for future research are discussed. Copyright © 2008 John Wiley & Sons, Ltd.     

Pharmacotherapy response and diagnostic validity in atypical depression.

BACKGROUND: The validity of diagnostic criteria and the efficacy of tricyclic antidepressant pharmacotherapy for atypical depression were studied in the NIMH Treatment of Depression Collaborative Research Program. METHODS: Outpatients with major depressive disorder (N = 239) entered a 16-week clinical trial and were randomly assigned to interpersonal psychotherapy, cognitive behavior therapy, and imipramine or placebo with clinical management. Features of atypical depression were rated on the SADS and ISI and clinical outcome was measured on the HRSD and GAS. RESULTS: Atypical features of mood reactivity and at least one reversed vegetative symptom of hypersomnia, hyperphagia or weight gain (25.2% patients) were predictive of pharmacotherapy non-responsiveness with imipramine compared to placebo. The additional features of diurnal mood variation, 'leaden paralysis', and 'rejection sensitivity' did not further distinguish animipramine non-responsive subgroup. Imipramine did show significant effectiveness compared to placebo among non-atypical patients on measures of depressive symptom change. LIMITATIONS: The predictive influence of atypical features was not accounted for on the basis of depression severity. CONCLUSIONS: This study provides evidence for the predictive validity of atypical features of major depressive disorder, including mood reactivity and at least one reversed vegetative symptom of either hypersomnia, hyperphagia, or weight gain, supporting the inclusion of atypical depressive features, with these criteria, in the DSM-IV.     

Avoidance and processing as predictors of symptom change and positive growth in an integrative therapy for depression

Depression is a leading cause of disability worldwide and can worsen the course of a variety of medical illnesses. There is a clear need to develop more potent treatments for this debilitating disorder and prevent its return. We are developing a promising psychotherapy that integrates components of current, empirically supported therapies for depression and also teaches healthy lifestyle and emotion regulation habits to promote psychological health. In the 1st open trial, growth curve analyses revealed a significant linear decrease in symptoms of depression in a sample of 29 clients who completed the therapy. Participants wrote essays about their depression each week, and the content was analyzed using a new coding system of change processes. Hierarchical linear modeling (HLM) revealed that peak levels of processing in the essays were associated with more improvement in depression and with the expression of more hope and of both negative and positive views of the self, presumably as clients explored their depressive views of self. Peak levels of avoidance were associated with less improvement in depression and with more hopelessness and negative views of the self. These preliminary results suggest possible targets of change that can facilitate symptom reduction and perhaps also promote psychological health.     

Self-assessment of somatic and psychic symptoms during a two months period of hormone replacement therapy in perimenopausal women

Summary The drastic decrease in sex steroids production at menopause is often related to the development of somatic and psychic symptoms in women. We examined the effects of a two months hormone replacement therapy (HRT) on weekly self-assessments of menopausal symptoms, mood and sleep disturbances. In addition, spatial perception and motor performances abilities were measured before and after 8 weeks of HRT. Twentythree healthy perimenopausal women (mean 50 ± 4.8 years of age) with no previous hormone therapy and a Kuppermann-Index ≥15 were included. Before therapy and in weekly intervals during two months of treatment women reported upon their menopausal symptoms (MENOI), their mood state (POMS) and sleep disturbances (VISM). Psychological examinations were done before HRT and two months later under hormone replacement therapy. All 23 patients showed a significant improvement of the self report of climacteric, affective symptoms and of sleep disturbances, and a tendency to improvement in cognitive performance with respect to pretreatment measures. This indicates that hormone replacement therapy in perimenopausal women is associated with clinical improvement in somatic and psychic symptoms and a cognitive enhancement in some aspects. These benefits of the HRT must play a role in cost-effectiveness analyses of HRT.     

Correspondence Between Teacher Ratings of Childhood Depression and Child Self-ratings

Previous research has reported a low correspondence between teacher ratings and child self-ratings of depression. It was hypothesized that this finding was due to the teachers using a single, global rating which masked knowledge of more specific symptoms of depression in children. Twelve elementary school teachers rated 62 male and female elementary school children on affective, cognitive, motivational/withdrawal, and vegetative symptoms of depression. Students completed the Childhood Depression Inventory (CDI). Items of the CDI were divided into affective, cognitive, motivational/withdrawal, and vegetative categories. Correlations between teacher ratings and CDI component scores were either nonsignificant or were in the opposite direction predicted. Results are discussed in terms of possible reasons for the poor correspondence between teacher and child ratings.     

Group cognitive behavior therapy for bipolar disorder can improve the quality of life

Bipolar disorder (BD) can have an impact on psychosocial functioning and quality of life (QoL). Several studies have shown that structured psychotherapy in conjunction with pharmacotherapy may modify the course of some disorders; however, few studies have investigated the results of group cognitive behavior therapy (G-CBT) for BD. Our objective was to evaluate the effectiveness of 14 sessions of G-CBT for BD patients, comparing this intervention plus pharmacotherapy to treatment as usual (TAU; only pharmacotherapy). Forty-one patients with BD I and II participated in this study and were randomly allocated to each group (G-CBT: N = 27; TAU: N = 14). Thirty-seven participants completed the treatment (women: N = 66.67%; mean age = 41.5 years). QoL and mood symptoms were assessed in all participants. Scores changed significantly by the end of treatment in favor of the G-CBT group. The G-CBT group presented significantly better QoL in seven of the eight sub-items assessed with the Medical Outcomes Survey SF-36 scale. At the end of treatment, the G-CBT group exhibited lower scores for mania (not statistically significant) and depression (statistically significant) as well as a reduction in the frequency and duration of mood episodes (P < 0.01). The group variable was significant for the reduction of depression scores over time. This clinical change may explain the improvement in six of the eight subscales of QoL (P < 0.05). The G-CBT group showed better QoL in absolute values in all aspects and significant improvements in nearly all subscales. These results were not observed in the TAU control group.     

Integrated motivational interviewing and cognitive-behavioural therapy for bipolar disorder with comorbid substance use

Although comorbid substance use is a common problem in bipolar disorder, there has been little research into options for psychological therapy. Studies to date have concentrated on purely cognitive-behavioural approaches, which are not equipped to deal with the ambivalence to change exhibited by many towards therapy designed to change substance use. This paper provides the first report of an integrated psychological treatment approach for bipolar disorder with comorbid substance use. The intervention reported combines motivational interviewing and cognitive-behavioural therapy to address ambivalence and equips individuals with strategies to address substance use. Across five individual case studies, preliminary evidence is reported to support the acceptability and the feasibility of this approach. Despite most participants not highlighting their substance use as a primary therapy target, all but one exhibited reduced use of drugs or alcohol at the end of therapy, sustained at 6 months' follow-up. There was some evidence for improvements in mood symptoms and impulsiveness, but this was less clear-cut. The impact of social and relationship issues on therapy process and outcome is discussed. The implications of the current findings for future intervention research in this area are considered.     

Early increase in vegetative symptoms predicts IFN-alpha-induced cognitive-depressive changes

BACKGROUND: The vegetative symptoms of depression resemble the symptoms of malaise associated with activation of the inflammatory response system (IRS), and can be regarded as an expression of a central motivational state that resets the organism's priorities to promote recovery from infection. Early vegetative symptoms, however, may also contribute to the high rates of depression seen later in the course of immune activation. We hypothesized that the onset of vegetative-depressive symptoms early in the treatment with the pro-inflammatory cytokine IFN-alpha in chronic hepatitis C patients would increase the risk for subsequent depressive cognitions. METHOD: Sixteen patients eligible for IFN-alpha treatment and free of psychiatric disorders were recruited. The DSM-IV, the Multidimensional Fatigue Inventory, and the Montgomery-Asberg Depression Rating Scale (MADRS) were administered at baseline and 1, 2, 4, 8, 12 and 24 weeks after treatment was initiated. Cognitive-depressive and vegetative-depressive symptom clusters were constructed. RESULTS: Fatigue and depression scores increased significantly during IFN-alpha treatment. Depression scores were highest at week 8 of treatment. First week increase in vegetative-depressive symptom score predicted cognitive-depressive symptom score at week 8 and at week 24. CONCLUSIONS: During IFN-alpha treatment, vegetative symptoms of depression appear earlier than, and are predictive of, their cognitive counterparts. This finding suggests that low mood state may in part be driven by the increase in early vegetative-depressive symptoms in the course of IFN-alpha-induced immune activation.     

Does adjunctive family therapy enhance recovery from bipolar I mood episodes?

BACKGROUND: Family therapy is sometimes used as adjunctive treatment to pharmacotherapy to help patients recover from mood episodes of bipolar I disorder. However, the efficacy of this practice is not known. METHODS: Ninety-two patients meeting criteria for a current bipolar I mood episode were randomly assigned to family therapy plus pharmacotherapy, multifamily psychoeducational group therapy plus pharmacotherapy, or pharmacotherapy alone. Time to recovery was analyzed with survival analysis. RESULTS: The proportion of subjects within each treatment group who recovered did not significantly differ, nor did time to recovery. LIMITATIONS: The analyses did not include other outcomes such as psychosocial functioning, prophylaxis against recurrences of mood episodes, or compliance with pharmacotherapy. CONCLUSIONS: Neither adjunctive family therapy nor adjunctive multifamily psychoeducational group therapy significantly improves the rate of recovery from mood episodes of bipolar I disorder, compared to treatment with pharmacotherapy alone.     

Meditation for treating adults with bipolar disorder II: A multi‐city study

There is a need to generate evidence on whether meditation's core aspect of building and nurturing calm and peace serves as a mood stabilizer for current and recurrent episodes of depression through the acute and maintenance phases of treating bipolar disorder II affected patients. A 2‐year longitudinal multi‐city randomized controlled trial experiment was conducted comprising 311 bipolar disorder II affected patients in the intervention and control group respectively across eight African and Asian cities. The Bipolar Depression Rating Scale (BDRS) was administered with the intervention and control groups that were equal at baseline. Meditation had a positive impact on the intervention group. Post intervention BDRS scores were significantly lower for patients from Asian cities, men, Hindus and Buddhists, middle class, and married patients as well as those who attended all the meditation rounds and regularly self‐practiced. Within the BDRS outcome measure, depressive symptoms were impacted the most as compared with mixed symptoms. Meditation helped alleviate guilt, depressed mood, and helplessness–hopelessness. The meditation programme can be used as a combination therapy along with pharmacological treatment to treat mood instability and depression among patients with bipolar disorder II.     

An examination of congruency hypothesis in hopelessness theory of depression

A longitudinal study was conducted to test two hypotheses, congruency and hopelessness-mediation, in hopelessness theory of depression. Three cognitive diatheses (attributional style, and inferential styles for consequences as well as the self), symptoms of depression, and hopelessness were measured in a survey of 279 men and women. About three months later, symptoms and hopelessness were measured again, along with negative life events in the interim. Some support was obtained for congruency hypothesis. Women with depressogenic attributional style in interpersonal domain became depressed when they experienced negative events in the domain, while men with depressogenic attributional style in achievement domain similarly became depressed. However, no comparable effect was found for the other diatheses: inferential styles. Hopelessness-mediation hypothesis was partly supported in interpersonal domain.     

A meta-analysis of the efficacy of cognitive therapy for depression

In meta-analysis format the effectiveness of Beck's cognitive therapy for depression was reviewed. Twenty-eight studies were identified that used a common outcome measure of depression, and comparisons of cognitive therapy with other therapeutic modalities were made. The results document a greater degree of change for cognitive therapy compared with a waiting list or no-treatment control, pharmacotherapy, behavior therapy, and other psychotherapies. The degree of change associated with cognitive therapy was not significantly related to the length of therapy or the proportion of women in the studies, and although it was related to the age of the clientele, a lack of adequate representativeness of various age groups renders these results equivocal. Implications for further outcome and process studies in cognitive therapy are discussed.     

Unlinking negative cognition and symptoms of depression: evidence of a specific treatment effect for cognitive therapy

In this study, the authors examined whether cognitive therapy alters the association between negative cognition and symptoms of depression. Participants were recruited during psychiatric hospitalization for depression. Following discharge, they were randomly assigned to 6 months of outpatient treatment. Treatment consisted of pharmacotherapy either alone or in combination with cognitive therapy and/or family therapy. Following this 6-month treatment period, negative cognition and symptoms of depression were assessed monthly for 1 year. Hierarchical linear modeling indicated that the association between negative cognition and depression during follow-up was weaker for patients randomized to cognitive therapy than for patients who did not receive cognitive therapy. Cognitive therapy appeared to unlink negative cognition and symptoms of depression to a greater extent than other forms of treatment.     

"No longer Gage": frontal lobe dysfunction and emotional changes.

This review presents the multiple changes in emotional response and personality that occur after damage to the frontal systems, proposes operational definitions, and analyzes the published reports according to these definitions. Neurological causes of frontal lobe damage and associations of frontal dysfunction with psychiatric disturbances are summarized. It is concluded that symptoms of frontal lobe damage that have been labeled as emotional disturbances may be classified as disorders of drive or motivation, mood (subjective emotional experience), and affect (emotional expression). It is proposed that the primary change after frontal lobe pathology is a disorder of personality, a change in the stable response patterns that define an individual as a unique self. Dysfunction of personality includes cognitive abilities, with a disorder of self-reflective awareness as a key deficit.     

Attachment and therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

We examine associations between client attachment style and therapeutic alliance in a 3‐arm randomized controlled trial of brief motivational interviewing and cognitive–behavioural therapy compared with longer term motivational interviewing and cognitive–behavioural therapy or standard care alone. Client self‐report measures of attachment style were completed at baseline, and both clients and therapists in the treatment arms of the trial completed alliance measures 1 month into therapy. We found that insecure–anxious attachment was positively associated with therapist‐rated alliance, whereas clients with insecure–avoidant attachment were more likely to report poorer bond with therapist. There was no evidence that client attachment significantly predicted clinical or substance misuse outcomes either directly or indirectly via alliance. Nor evidence that the length of therapy offered interacted with attachment to predict alliance.     

Chronic mood disorders in depressed outpatients: Diagnosis and response to pharmacotherapy

The current study was devised to assess the utility of Research Diagnostic Criteria (RDC) categories used to classify minor mood disorders. Similar categories are to be used in the APA's Diagnostic and Statistical Manual, 3rd edition. The patient sample consisted of 64 consecutive admissions to a double-blind trial of amitriptyline, perphenazine and the combination as treatment for depression. Patients who met RDC for a current episode of major depressive disorder were given 4 weeks of pharmacotherapy as treatment.Chronic mood disorders were also assessed using RDC criteria. This evaluation revealed that only 34% met criteria for an episode of major depressive disorder alone, while 36% met criteria for intermittent depressive disorder, 14% for cyclothymic personality and 16% for labile personality in addition to being in a current major depressive episode. These 4 diagnostic subgroups were compared on demographic characteristics, childhood history, psychiatric history, presenting patterns of symptoms and social functioning, and response to treatment. Differences were noted in the subgroups in presenting symptom levels and residual impairment. However, there was no differential response to a brief course of antidepressant pharmacotherapy in patients with and without chronic minor mood disorders. Most patients showed an improvement during the brief course of treatment. Thus, the presence of a chronic minor mood disorder does not appear to be a contraindication for use of medication in patients who also are currently experiencing a major depressive episode.     

A randomized clinical trial of a brief, mailed intervention for symptoms of depression

This research evaluated the efficacy of a brief, mailed personalized feedback intervention designed to alleviate depressed mood and antecedents (ineffective coping and hopelessness). College students (N = 177) were randomly assigned to intervention or control group following a baseline assessment. A week after completing the baseline assessment, participants in the intervention condition were mailed feedback and information detailing their mood, coping strategies, as well as suggestions for enhancing mood. Results indicated that feedback was effective in reducing depressive symptoms, hopelessness, and among men, increasing willingness to use coping strategies at the 1-month follow-up. Hopelessness mediated reductions in depressive symptoms. Results support the use of personalized feedback as a low-cost, initial intervention for college students suffering from symptoms of depression.