Mediators and moderators of change in cognitive therapy of depression.

This article reviews the theoretical and empirical literature associated with the mediators and moderators of change in cognitive therapy (CT) of depression. Covariation between change in cognition and change in depression, specific effects for cognitive versus behavioral components of CT, specific effects for CT versus other treatments, moderating influence of nonspecific and technical aspects of the therapeutic environment, and moderating influence of client characteristics are reviewed. The clinical implications of prior research and suggestions for future research on identifying the critical ingredients of change in CT of depression are discussed.

Negative affect and cognitive biases in suicidal and nonsuicidal hospitalized adolescents.

OBJECTIVE: To examine the main and interactive effects of suicidal behavior and gender on negative affect and cognitive biases in hospitalized adolescents (N = 228) aged 13 to 18 years, identified as suicide ideators (n = 68), attempters (n = 90), and nonsuicidal (n = 70). METHOD: Standardized measures of negative affect (depression, anxiety, anger) and cognitive biases (hopelessness, self-concept) were administered upon admission. RESULTS: Suicide ideators reported significantly greater hopelessness and poorer self-concept than did nonsuicidal controls; suicide attempters did not differ from either group. Regression analysis indicated that negative affect and cognitive bias variables accounted for 48% of the variability in suicidal ideation; however, only anxiety and depression were uniquely related to suicidal ideation. Females reported greater depression severity and anxiety than did males; no interaction effects were evident. CONCLUSIONS: Suicide ideators and attempters may have different psychological profiles, with the former reporting greater cognitive biases than nonsuicidal adolescents. The findings regarding suicidal ideation support a mediational model in which negative views of the self and the future contribute to negative affect, and ultimately, suicidal ideation. An integrated assessment of suicidal ideation and affective and cognitive variables is recommended for early risk detection and treatment.

Studying intergenerational transmission of eating attitudes and behaviors: methodological and conceptual questions.

Associations between parent and child attitudes and behaviors related to eating and weight were examined among college-age men and women and their mothers and fathers (ns = 44, 47, 87, and 66, respectively). Parent attitudes and behaviors were assessed from the perspective of the parent and the student, and 2 pathways of influence were examined: modeling and direct criticism. In general, students' attitudes and behaviors were more strongly related to perceptions of their parents rather than to parents' own self-reports. There was more support for perceived direct criticism as a pathway of influence, particularly for daughters. Perceived criticism about eating and appearance had large associations with student attitudes and behaviors. Weight loss behavior was related to perceived criticism among daughters and to perceived paternal eating attitudes among sons. Results highlight important methodological and conceptual questions for intergenerational research.

Marital adjustment and outcome following treatments for depression.

Marital adjustment and treatment outcome were evaluated in the Treatment of Depression Collaborative Research Program, a multicenter clinical trial evaluating interpersonal psychotherapy, cognitive therapy, imipramine, and placebo. Marital adjustment and depression were assessed pre- and posttreatment, and depression was assessed at 6, 12, and 18 months after treatment. Results indicate that (a) there was a significant improvement in marital adjustment after treatment, (b) this effect was not moderated by treatment type, and (c) this effect was mediated by change in depression. Poor pretreatment marital adjustment was modestly associated with negative outcome, whereas poor posttreatment marital adjustment was strongly associated with negative outcome during follow-up. The findings suggest that poor marital adjustment at the end of active treatment is a risk factor for increases in depression severity during follow-up.

Relationship between behavioral marital therapy outcome and process variables.

This study was conducted to identify therapist and client behaviors associated with a positive response to social learning-based behavioral marital therapy. A sample of 32 couples receiving treatment was examined. Immediately after each therapy session, the therapist, husband, and wife independently completed process rating forms that measured therapist and client behaviors during the session. Composite scales, derived from these ratings, were entered into multiple regression equations to examine their relationship with posttherapy marital satisfaction. After controlling for pretherapy marital satisfaction and the other predictor variables, therapists', husbands', and wives' ratings of positive client behavior (i.e., collaboration, active participation, and homework compliance) were positively associated with therapy outcome. Implications for marital therapy and suggestions for future research are discussed.

Cognitive therapy with depressed inpatients: specific effects on dysfunctional cognitions.

Specificity of cognitive change following cognitive therapy for depression was assessed in 39 depressed inpatients who completed either a standard inpatient treatment (pharmacotherapy and milieu management) or the standard treatment plus cognitive therapy. Following treatment, patients in both groups endorsed fewer dysfunctional cognitions on 2 of 4 measures of cognitive distortion. Compared with patients receiving only the standard treatment, patients also receiving cognitive therapy reported less hopelessness and fewer cognitive biases at posttreatment and 6- and 12-month follow-up assessments and fewer dysfunctional attitudes at the 6-month follow-up. Treatment effects for dysfunctional cognitions were found even though the treatment groups did not differ in depression severity, suggesting that results did not reflect state-dependent differences between treatments secondary to difference in depression.

Marital dissatisfaction and psychiatric disorders: results from the National Comorbidity Survey.

The association between marital dissatisfaction and 12-month prevalence rates of Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., 1987) Axis I psychiatric disorders was examined in married respondents from the National Comorbidity Survey (N = 2,538). Results indicate that marital dissatisfaction was associated with the presence of any disorder, any mood disorder, any anxiety disorder, and any substance-use disorder; dissatisfaction was also associated with 7 of 12 specific disorders for women and 3 of 13 specific disorders for men. To evaluate the unique association between marital dissatisfaction and psychiatric disorders, analyses were conducted controlling for comorbid disorders. Covariance analyses generally attenuated the bivariate associations between marital dissatisfaction and specific disorders and groupings of disorders. Results indicate that marital dissatisfaction was uniquely related to major depression and posttraumatic stress disorder for women and dysthymia for men.

Marital dissatisfaction and incidence of major depressive episode in a community sample.

The association between marital dissatisfaction at baseline and 12-month incidence of major depressive episode (MDE) was examined in a community sample of married individuals from the New Haven Epidemiologic Catchment Area program (N = 904) who did not meet criteria for MDE at baseline. Results indicate that marital dissatisfaction was associated with increased incidence of MDE, with a significant risk ratio of 2.7 and an attributable risk of 29.5%. Thus, dissatisfied spouses were nearly 3 times more likely than nondissatisfied spouses to develop an MDE during the year, and nearly 30% of the new occurrences of MDE were associated with marital dissatisfaction. The association between marital dissatisfaction and risk of MDE (a) remained significant when controlling for demographics and depression history and (b) was not moderated by sex or by depression history. Findings suggest that marital dissatisfaction may be etiologically related to major depression.

Psychiatric disorders and dissatisfaction with social relationships: does type of relationship matter?

The specificity of the association between 9 Axis I psychiatric disorders and quality of the relationship with spouse, relatives, and friends was evaluated for married participants who completed the Ontario Health Survey Mental Health Supplement (N = 4,933). When the authors controlled for the quality of other social relationships, not getting along with one's spouse was related to 6 disorders, with the strongest associations found for generalized anxiety disorder, major depression, panic, and alcohol problems; 4 associations remained significant when they controlled for comorbid disorders. Not getting along with relatives and friends was generally unrelated to psychiatric disorders when they controlled for the other social relationships. Results indicate that the association between marital quality and psychiatric disorders is not an artifact of general social dissatisfaction and that this association is significant for several disorders.

Depressed patients with dysfunctional families: description and course of illness.

Sixty-eight depressed patients were subdivided according to their family's level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels of neuroticism. A 12-month follow-up of these patients indicated that depressed patients with dysfunctional families had a significantly poorer course of illness, as manifested by higher levels of depression, lower levels of overall adjustment, and a lower proportion of recovered patients. Thus, impaired family functioning appears to be an important prognostic factor in major depression.

Life stress and dysphoria: the role of self-esteem and hopelessness.

This study evaluated the hypotheses that the relation between life stress (life events and daily hassles) and longitudinal change in dysphoria would be (a) moderated by self-esteem and (b) mediated by longitudinal change in hopelessness. Eighty undergraduates were first assessed on self-esteem, hopelessness, and dysphoria and then reassessed 3 months later on life events, daily hassles, hopelessness, and dysphoria. Residual change in dysphoria was significantly associated with self-esteem, life stress, and a Self-Esteem X Life Stress interaction. However, inconsonant with predictions, the moderating impact of self-esteem was greatest under conditions of low (vs. high) life stress. Moreover, residual change in hopelessness mediated the relations between residual change in dysphoria and both self-esteem and life stress.

Depression, marital satisfaction, and marital and personality measures of sex roles*.

The present study examined the relationship between depression, marital satisfaction, and marital and personality measures of sex roles. Subjects included 50 couples in which the woman was clinically depressed (and of which 26 were maritally distressed), and 24 nondepressed, nondistressed control couples. Results indicated that compared to nondepressed couples, husbands and wives in relationships in which the wife was depressed showed greater inequality in decision making and dissatisfaction with the distribution of decision making and household tasks; wives additionally indicated greater dissatisfaction with distribution of childrearing responsibilities. The relationship between marital roles and depression was largely mediated by the impact of marital distress in the clinic couples. In addition, depressed wives were less masculine than nondepressed wives, and women with high levels of masculinity reported less depression than women with low levels.

Sociotropy, autonomy, and bulimic symptomatology.

OBJECTIVE: The cognitive-behavioral model of bulimia nervosa suggests that maladaptive cognitions are associated with the development and maintenance of bulimia nervosa. This study was conducted to evaluate (a) the relation between bulimic symptomatology and the cognitive-personality styles of sociotropy (reflecting themes of acceptance and approval) and autonomy (reflecting themes of independence and achievement), and (b) the specificity of the relation between these two cognitive-personality styles and bulimic versus depressive symptoms. METHOD: 105 undergraduate women were administered self-report measures of sociotropy and autonomy, as well as bulimic and depressive symptomatology. RESULTS: Whereas both sociotropy and autonomy were related to bulimic symptomatology, only sociotropy was uniquely associated with symptoms of bulimia when controlling for the effects of depressive symptoms. DISCUSSION: Themes of acceptance and approval may be important cognitive-personality features of bulimia nervosa.

Factor structure of the Beck Depression Inventory-Second Edition (BDI-II) in a student sample.

A confirmatory factor analysis was performed to evaluate the factorial validity of the Beck Depression Inventory-Second Edition (BDI-II) in a large sample of undergraduates (N = 576). Results suggest that the revised measure is internally consistent and consists of two underlying factors assessing cognitive-affective and somatic symptoms of depression. Results support the use of the BDI-II as a severity measure of symptoms of depression.

Reasons for living in a clinical sample of adolescents.

The psychometric properties and validity of the Reasons for Living (RFL) Inventory were examined in a sample of psychiatrically hospitalized adolescents (n = 253), aged 13 to 18 years, identified as suicide ideators, suicide attempters, and psychiatric controls. Confirmatory factor analysis suggested that the original RFL factors did not provide a good fit; exploratory factor analysis identified five factors, of which three were identical with the original RFL factors. Factor scores differentiated suicidal from non-suicidal adolescents and attempters from ideators. Correlational analyses indicated that RFL factors were associated with suicidal ideation, depression, and hopelessness, and predicted unique variance in suicidal ideation over that accounted for by depression and hopelessness. Our findings provide support for the RFL as a sound measure for clinical and research assessment in adolescents.

Marital status, marital satisfaction, and body image dissatisfaction.

OBJECTIVE: This study examined whether married individuals have comparable body image disturbance to nonmarried individuals and whether the quality of a marital relationship is significantly related to body image disturbance in a sample of dieters. METHOD: Measures of marital status, marital satisfaction, and body dissatisfaction were administered to a sample of 16,377 subjects who had tried to lose weight at least once within the previous 3 years. RESULTS: Marital status was not associated with increased body dissatisfaction. Marital satisfaction was significantly related to body dissatisfaction when controlling for age, body mass index, self-esteem, and gender. DISCUSSION: Body dissatisfaction occurs at comparable levels among married and single individuals and the study of marital functioning among eating-disordered individuals represents a large gap in the literature.