Early psychotherapeutic empathy,alliance, and client outcome: Preliminary evidence of indirect effects

The association between psychotherapeutic empathy and client outcome is well established, yet the mechanisms underlying this association remain poorly understood. We hypothesized that early experiences of empathy influence outcome through the working alliance. To test this hypothesis, we used archival data collected from 56 clients (mean [M] age = 19.5 years, 83.9% female, 76.8% White) who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments and then received five sessions of evidence‐based psychotherapy. Therapists (M age = 26.0 years, 50% female, 100% White) were six students in a clinical psychology PhD program. Results of bootstrap analyses were consistent with the idea that early experiences of empathy strengthen the alliance (specifically the goals and tasks facets), which in turn facilitates improvements in depressive symptoms and psychological well‐being. While preliminary, these results implicate a specific pathway of change in the treatment of depression.     

Cognitive functioning in young and middle-aged unmedicated out-patients with major depression: testing the effort and cognitive speed hypotheses

BACKGROUND: Cognitive deficits are common in major depressive disorder, but their nature is unclear. The effort hypothesis states that performance on effortful tasks is disproportionately impaired compared with the performance on automatic tasks. The cognitive speed hypothesis states that depression is characterized by cognitive slowness, which is a source of cognitive dysfunctioning. The present study investigated both theories in unmedicated adult depressive patients. It was also investigated whether the cognitive deficits can be attributed to more general physical illness-related factors or specifically to depressive disorder. METHOD: Thirty non-psychotic depressive out-patients were compared with 38 healthy control subjects and 25 patients with severe allergic rhinitis. The effects of group on more automatic and more effortful aspects of cognitive tasks measuring cognitive speed (Concept Shifting Task, Stroop Colour Word Test, Memory Scanning Test) and memory retrieval (Visual Verbal Learning Task, Verbal Fluency Test) were evaluated by MANCOVA. Age, sex, education and pre-morbid intelligence were treated as covariates. RESULTS: The depressive group had cognitive deficits in the automatic processing subtask of the Stroop, memory scanning and memory span. Performance on more effortful tasks was not impaired. CONCLUSIONS: Our results are more consistent with the cognitive speed hypothesis. Cognitive functioning in depressive disorder seems to be characterized by a reduced speed of information processing in automatic subtasks.     

Attributional style and defense mechanisms: a synthesis of cognitive and psychodynamic factors in depression

In a study involving 160 undergraduates, we tested the hypothesis that attributional style and defense style would have interactive effects on depressive symptoms. Consistent with this hypothesis, both negative attributional style and low defense maturity were associated with depressive symptoms, both as main effects and in interaction. Negative attributional style was associated with depressive symptoms primarily when accompanied by low defense maturity. The presence of a positive attributional style reduced the relation between low defense maturity and depressive symptoms, and the presence of high defense maturity reduced the relation between a negative attributional style and depressive symptoms. In addition, high defense immaturity was shown to be a possible mediator of the relation between negative attributional style and depressive symptoms. Clinical implications for psychotherapy integration are discussed.     

Insulin resistance in depressive disorders and Alzheimer's disease: revisiting the missing link hypothesis

Several lines of evidence suggest an association between depressive disorders and Alzheimer's disease (AD). We previously suggested central nervous system (CNS) effects of insulin resistance (IR) to be an important link between depressive disorders and AD. Although the exact mechanism of central IR is not known, it is thought that central IR results in inadequate glucose metabolism in the brain. According to our hypothesis, inadequate glucose utilization resulting from IR underlies neuronal changes in crucial brain regions (i.e. limbic system) observed among patients with depressive disorders, the same brain regions affected in AD. Further, in patients with undetected and/or untreated IR, such changes in glucose utilization, if unresolved, may lead to neurodegeneration. Our studies have demonstrated a high prevalence of IR in patients with depressive disorders, and reciprocally, a high prevalence of depression in patients with the primary IR disorder polycystic ovary syndrome (PCOS), and we believe these populations have significantly increased risk of cognitive decline. Herein, we review the IR link in depressive disorders and AD and describe the results of our studies and others in support of this hypothesis.     

Mothers' depressive symptoms and children's facial emotions: examining the depression-inhibition hypothesis

Vibrant expression of emotion is the principal means infants and young children use to elicit appropriate and timely caregiving, stimulation, and support. This study examined the depression-inhibition hypothesis: that declines in mothers' support as their depressive symptoms increase inhibit children's emotional communication. Ninety-four mothers and their 14- to 27-month-olds interacted in a university playroom. Based on microanalytic coding of discrete facial displays, results supported three components of the hypothesis. (a) As mothers' depressive symptoms increased, children displayed less facial emotion (more flat affect, less joy, less sadness, less negative). (b) Mothers' low emotional and behavioral support predicted children's low facial communication and mediated relations between mothers' depressive symptoms and children's infrequent emotion. (c) Children who were passive with mothers behaviorally expressed emotion infrequently. Children's passivity mediated relations between mothers' depressive symptoms and children's infrequent emotion displays. Contrary to modeling and contagion theories, mothers' facial displays did not mediate relations between their depressive symptoms and children's facial displays. Nor were the outcomes children experienced regulating their facial displays. Rather, findings suggest that, even when depressive symptoms are modest, young children inhibit emotion as mothers' depressive symptoms increase to withdraw from unresponsive mothers, which may adversely affect children's subsequent relationships and competencies.     

Depressive disorders and the menopause transition

Aim

Depressive disorders and symptoms are common among middle-aged women. The effects of hormones on depression remain unclear. This review aims to clarify the nature of depressive disorders during the menopause transition as well as their links with climacteric syndrome, sexuality, cardiovascular risk and cognitive function.

Material and methods

The recent literature on depressive disorders and menopause is reviewed.

Results and conclusions

Women are more vulnerable than men to depressive disorders. Endocrine influences have been postulated but differences in, for example, coping style and response to stress may also contribute to the gender difference in the prevalence of depressive disorders. Gender differences in socialization may lead to higher rates of depression in women. There are data top suggest that menopause and depression are associated, although there is not a common clear causative factor. Women with climacteric symptoms (hot flushes, night sweats, vaginal dryness and dyspareunia) are more likely to report anxiety and/or depressive symptoms. Bothersome vasomotor symptoms could be associated with sleep disturbances, which in turn can increase reports of anxiety and depressive symptoms. Biopsychosocial and partner factors have a significant influence on middle-aged women's sexuality and depressive disorders, and most antidepressants can have a negative effect on sexual response. Lastly, studies have consistently shown that women with high levels of depressive symptoms are at greater cardiovascular risk and have poorer cognitive function than non-depressed women. At present, a direct relationship between psychiatric symptoms and hormonal changes such as estrogen decrease has not been clearly found. Stress, educational level, ethnicity, socioeconomic factors and partner status may influence the prevalence and clinical course of both menopause symptoms and depressive disorders. Since in many cases depression is a lifelong condition, and is associated with severe comorbid conditions, further studies are needed to improve the early diagnosis of depression; it may be advisable to monitor a woman's mental health during the menopause transition to prevent a depressive disorder having long-term negative consequences.     

Symptoms of Depression and Anxiety in Children: Specificity of the Hopelessness Theory

The common etiology hypothesis proposes that depression and anxiety commonly co-occur because they share etiological factors. This study examined the specificity of the hopelessness theory in the development of depressive and anxious symptoms in children. Students in Grades 3 through 6 (N = 418, 47% boys) completed measures assessing inferential styles about causes, consequences, and the self, depressive symptoms, and anxious symptoms. Six weeks later, children completed measures of depressive symptoms, anxious symptoms, and hassles. All 3 inferential styles interacted with hassles to predict increases in depressive symptoms, although this relation only held for children with low levels of initial symptoms. Inferential styles about consequences and the self also predicted increases in anxious symptoms. Consistent with the common etiology hypothesis, after controlling for the association between depressive and anxious symptoms, the effects of inferential styles about consequences and the self persisted.     

Symptoms of depression and anxiety in children: specificity of the hopelessness theory.

The common etiology hypothesis proposes that depression and anxiety commonly co-occur because they share etiological factors. This study examined the specificity of the hopelessness theory in the development of depressive and anxious symptoms in children. Students in Grades 3 through 6 (N = 418, 47% boys) completed measures assessing inferential styles about causes, consequences, and the self, depressive symptoms, and anxious symptoms. Six weeks later, children completed measures of depressive symptoms, anxious symptoms, and hassles. All 3 inferential styles interacted with hassles to predict increases in depressive symptoms, although this relation only held for children with low levels of initial symptoms. Inferential styles about consequences and the self also predicted increases in anxious symptoms. Consistent with the common etiology hypothesis, after controlling for the association between depressive and anxious symptoms, the effects of inferential styles about consequences and the self persisted.     

Differential changes in areas of social adjustment from depressive episodes through recovery

The findings of the present short-term prospective study of 99 depressed outpatients further support previous cross-sectional observations to the effect that the course of depressive illness is often complicated by fluctuating social disturbances manifested by uneasiness in the work area, by disagreements with colleagues, and by difficulty in maintaining conflict-free relationships with significant others. By contrast, the incapacity to enjoy and use leisure time appeared less related to the symptomatologic variation in depression. Although we favor the hypothesis that impairment in leisure activity may represent a trait marker of depression, the hypothesis of it being a residual complication of repeated depressive episodes cannot be ruled out in view of short follow-up.     

Social Control in Older Adults’ Diabetes Self Management and Well-Being

The “dual effects” hypothesis argues that social control can be effective in promoting positive health-related behavior change, but it can also jeopardize the targeted individual's well-being. This hypothesis is tested using hemoglobin A1C as an objective indicator of behavioral compliance with diabetes self-management behavior and depressive symptoms. Differences in the effects of social control on A1C and depressive symptoms by sex and ethnicity are tested.

Cross-sectional data were obtained from a multi-ethnic sample of older adults with diabetes (N = 593). Greater social control was associated with poorer rather than better odds of achieving glucose control, and with greater depressive symptoms. There was no evidence that social control has differential effects on either glucose control or depressive symptoms by sex or ethnicity. Active use of social control attempts by family members and friends, especially if they are coercive or punitive in nature, are likely counterproductive for maintaining the physical and mental health of older adults with diabetes.     

The nature of the depressive symptomatology preceding myocardial infarction

Little is known about the nature of the depressive symptomatology preceding myocardial infarction (MI). Specification of the depressive symptomatology is important for the development of hypotheses about the biological mechanisms relating depressive symptoms to MI. To test the hypothesis that feelings of fatigue and loss of energy have the strongest predictive power of all depressive symptoms, the authors reanalyzed data from a prospective study of 3877 healthy men aged 40 to 65 years. The men's mental state was assessed using the Maastricht Questionnaire, a scale that measures vital exhaustion, which is characterized by unusual fatigue and lack of energy, increased irritability, and depressive symptoms, including demoralization. Oblique factor analysis was used to validate these dimensions. Results of Cox's regression analyses showed that the fatigue subscale has the strongest predictive power for incident MI and that depression and irritability subscales lose their predictive power when controlled for fatigue.     

Omega-3 fatty acid deficiency in major depressive disorder is caused by the interaction between diet and a genetically determined abnormality in phospholipid metabolism

Omega-3 fatty acids are a type of polyunsaturated fatty acid (PUFA). A growing body of evidence suggests that this form PUFA is a useful and well tolerated treatment for major depressive disorder, a common and serious mental illness. The efficacy of omega-3 PUFA is routinely explained as being due to a deficiency caused by inadequate dietary intake of this class of fatty acid. The hypothesis considered states that low omega-3 PUFA abundance in patients with major depressive and related disorders is due to an underlying genetically determined abnormality. The hypothesis can explain why although a specific and consistent deficit in omega-3, but not omega-6, PUFA occurs in major depressive and related disorders, the literature does not consistently support the notion that this is due to deficient dietary intake. Specifically it is hypothesized that having genetically determined low activity of fatty acid CoA ligase 4 and/or Type IV phospholipase A(2) combined with the low dietary availability of omega-3 PUFA results in reduced cellular uptake of omega-3 PUFA and constitutes a risk factor for depression. The hypothesis also has important consequences for the pharmacological treatment of depression in that it predicts that administering agents which enhance phospholipid synthesis, particularly those containing ethanolamine such as CDP-ethanolamine, should be effective antidepressants especially when co-administered with omega-3 PUFA.     

Revisiting the Accuracy Hypothesis in Families of Young Children With Conduct Problems

Revisited the accuracy hypothesis in an examination of the relation between maternal depressive symptomatology and child conduct problems. All data were gathered as part of the pretreatment assessment in an outcome study of families with clinic-referred children with conduct problems (age 3 to 6). The mothers varied in their depressive symptomatology, from not at all symptomatic to severely symptomatic. Correlations indicated that with increasing depressive symptomatology, mothers (N = 97) displayed a higher rate of physical negative behaviors towards their child and reported more child conduct problems. Regression analyses revealed that at the lowest levels of maternal depressive symptomatology there was a discrepancy between mothers' reports of child behavior problems and child deviant behaviors observed during mother-child interaction. In contrast, at higher levels of depression, mothers' reports of child behavior were consistent with laboratory observations of their child's behavior. These findings provide evidence to support the accuracy hypothesis in reference to mothers who display a high degree of depressive symptomatology, but the results also call into question the validity of maternal report in families with children with conduct problems.     

The Nature of the Depressive Symptomatology Preceding Myocardial Infarction

Abstract

Little is known about the nature of the depressive symptomatology preceding myocardial infarction (MI). Specification of the depressive symptomatology is important for the development of hypotheses about the biological mechanisms relating depressive symptoms to MI. To test the hypothesis that feelings of fatigue and loss of energy have the strongest predictive power of all depressive symptoms, the authors reanalyzed data from a prospective study of 3877 healthy men aged 40 to 65 years. The men's mental state was assessed using the Maastricht Questionnaire, a scale that measures vital exhaustion, which is characterized by unusual fatigue and lack of energy, increased irritability, and depressive symptoms, including demoralization. Oblique factor analysis was used to validate these dimensions. Results of Cox's regression analyses showed that the fatigue subscale has the strongest predictive power for incident MI and that depression and irritability subscales lose their predictive power when controlled for fatigue.     

Major depressive disorder viewed as a dysfunction in astroglial bioenergetics

For many years scientists and physicians have pondered upon the apparent connection between depressive disorder and diabetes mellitus. Several epidemiologic studies confirm that diabetics have increased incidence of depression, and vice versa. In addition: depressive, non-diabetic patients have several insulin- and glucose-metabolism disturbances, probably exerting a compensatory reaction to the malfunction in the depressed brain as these disturbances are normalised in remission. After the discovery of PET-scanning, such studies have shown that patients with depressive disorder have reduced glucose metabolism in frontal parts of the brain. The present hypothesis regards the PET findings as observations of the primary pathophysiology of depression. Furthermore: two studies of post mortem samples from depressed patients show reduced numbers of astroglia. This is in accordance to the mentioned insulin disturbances, as only astroglia, not neurons, have insulin-sensitive glucose metabolism. Hence: the astroglia, not necessarily the neurons, are proposed to be the type of cells in which the disease resides. Most probably depressive disorder is a multitude of diseases, explaining the apparent multitude of symptoms, and the fact that different patients do respond to different drugs. Therefore: one can only formulate the hypothesis by mentioning a common denominator to these specific malfunctions, namely: disturbed glucose metabolism in the depressed brain. The present paper reviews several findings and proposes that attenuated cerebral glucose metabolism in frontal parts of the brain, in the astroglia, is the cause of depressive disorder.     

Metacognition and depressive realism: Evidence for the level-of-depression account

Introduction. The present study examined the relationship between metacognition (i.e., “thinking about thinking”) and depression. More specifically, the depressive realism hypothesis (Alloy & Abramson, 1979), which posits that depressed people have a more accurate view of reality than nondepressed people, was tested.

Methods. Nondepressed, mildly depressed, and moderately depressed individuals predicted their memory performance by making judgements of learning after each studied item. These predictions were then compared with actual performance on a free recall task to assess calibration, an index of metacognitive accuracy.

Results and conclusions. Consistent with the depressive realism hypothesis, mild depression was associated with better calibration than nondepression. However, this “sadder but wiser” phenomenon appears to only exist to point, as moderate depression and nondepression showed no calibration differences. Thus, the level-of-depression account of depressive realism is supported.     

Vascular disease risk factors as determinants of incident depressive symptoms: a prospective community-based study

BACKGROUND: The potential association between vascular disease and depression have been the focus for much clinical psychiatric research, although few epidemiological prospective studies have looked into this association. AIMS: This study explores the a priori hypothesis of a prospective association between cardiovascular disease or its risk factors and incident depressive symptoms. METHOD: A prospective primary care based study derived from a multi-centre randomized controlled trial of moderate hypertension. 2584 moderately-hypertensive volunteers were followed-up for 54 months when five assessments of depressive symptoms, vascular disease and its risk factors were made. RESULTS: We found an association between the dependent variable (incident depressive symptoms measured with the Self-CARE-D) and baseline smoker status, low serum cholesterol levels, poorer cognitive function (particularly executive dysfunction), female gender and increasing age. These associations were independent of all other cardiovascular risk factors (ECG evidence of ischaemia or arrhythmia, systolic or diastolic blood pressure, blood pressure decline along the trial and body mass index). CONCLUSIONS: Our results do not support the hypothesis of a specific association between vascular disease or its risk factors and incident depressive symptoms.     

Sensitization: The sine qua non of the depressive disorders?

Available definitions of depressive disorders do not adequately distinguish depressive disorders from non-pathological mood states. When depression occurs as a reaction to life events (e.g., bereavement) a diagnosis is not usually warranted since these reactions represent normal and presumably adaptive reactions to life circumstances. Various approaches in DSM-IV such as the bereavement exclusion criterion and clinical significance criteria (addressing levels of distress and dysfunction) have not provided a fully satisfactory solution. The distinction between pathological and non-pathological expressions of depression would be facilitated were there to be a clearer understanding of the adaptive purpose of depression in its normal manifestations. Such an understanding would provide a basis for distinguishing adaptive manifestations of depression from those that represent a disorder. This paper presents the hypothesis that sensitization to life events is the core feature of depressive disorders. Sensitization may be an adaptive mechanism because it can fine-tune responses in a changing environment. Sensitization, however, may fail as an adaptive mechanism if it leads to an over-sensitized state in which a person cannot function or is intensely distressed even in a normal environment. This hypothesis predicts that a pattern of increasing reactivity to life events will be a better predictor of the need for, and response to, psychiatric treatment than current definitions.     

A longitudinal study of the relationship of self-preoccupation with depression

Self-preoccupation, the tendency to focus more on the self and to maintain self-focused attention, is believed to be a vulnerability factor to depression. The present study investigated this hypothesis in a longitudinal design, using Japanese undergraduates. At Time 1, both self-preoccupation and depressive symptoms at that time, measured by the Zung Self-rating Depression Scale (SDS), were assessed. At Time 2, 3 months later, life events experienced from Time 1 to Time 2 and depressive symptoms at that time were assessed. Data from 169 undergraduates who scored less than 50 on the SDS in Time 1 were analyzed and the above hypothesis was suggested. When experiencing a greater number of negative events, those high in self-preoccupation became more depressed than those who were low in that tendency, though when there were a smaller number of negative events, this difference disappeared.