Does early intervention increase latency to relapse in major depressive disorder? Re-evaluation with cognitive behavior therapy.

BACKGROUND: Major depressive disorder (MDD) has been studied in relation to its propensity for remission and likelihood of relapse. While the general clinical lore suggests that early intervention benefits treatment outcome, the empirical validation of this assumption is inconclusive. Specifically, no studies have been conducted concerning Time to Treatment Entry and long-term clinical course for MDD. METHODS: For the current study, 53 participants received 16-weeks of cognitive behavioral therapy (CBT). Participants who remitted (n=41) from their depression were then inducted into a longitudinal follow-up protocol. RESULTS: Longer Time to Treatment Entry was predictive of longer time to relapse. A greater number of previous depressive episodes was associated with decreased Time to Treatment Entry. LIMITATIONS: A more elaborate protocol could be designed in order to explore the nature of treatment effects and Time to Treatment Entry within one study. CONCLUSIONS: CBT may be the most effective for patients who have delayed seeking treatment. Although the present study adds to the developmental neurobiological assumptions of Post [Severe depressive disorders (1994) 23-65] concerning affective 'kindling,' it also challenges the kindling theory's assumptions concerning early intervention.

The roles of ethnicity and culture in the development of eating disturbance and body dissatisfaction: a meta-analytic review.

This meta-analysis involved 35 studies examining eating disturbance and body dissatisfaction in white and non-white populations and the role of acculturation in the development of eating-related psychopathology. While the role of acculturation in predisposing non-whites to eating disorders remains to be determined, mean effect sizes indicate that whites report more eating disturbance than non-whites. Differences are greatest when studies compare black and white college samples on measures of subclinical eating pathology, like dietary restraint, ideal body shape, and body dissatisfaction. They are weakest when non-clinic populations and clinical forms of eating disturbance, like bulimia nervosa, are examined. These findings suggest that the current literature may be incorrect in its view that subclinical and clinical forms of eating disturbance represent the poles of a single continuum. In addition, they call into question the belief that SES influences the development of eating pathology.

Life stress and the symptoms of major depression.

Life stress has been found to be associated with onset of depression and with greater severity of depressive symptoms. It is unclear, though, if life stress is related to particular classes or specific symptoms in depression. The association between severe life events and depressive symptoms was tested in 59 individuals diagnosed by Research Diagnostic Criteria with endogenous primary nonpsychotic major depression. As predicted, life stress was associated principally with cognitive-affective symptoms, not somatic symptoms. There also was a consistent association across different assessment methods between severe events and suicidal ideation. Finally, associations held specifically for severe events occurring before onset, not for severe events occurring after onset. Symptom variation in major depression is related specifically to severe stressors before onset and includes primarily cognitive-affective types of symptoms. There is an especially pronounced association of prior severe stress with suicidal ideation. The implications of stress-symptom associations are addressed for enlarging understanding of symptom heterogeneity and subtype distinctions in major depression.

Is cognitive behavior therapy just a 'nonspecific' intervention for depression? A retrospective comparison of consecutive cohorts treated with cognitive behavior therapy or supportive counseling and pill placebo.

BACKGROUND: There is a dearth of placebo-controlled studies of cognitive behavior therapy (CBT) of depression and the largest such study, by Elkin et al. (Arch. Gen. Psychiatry 46 (1989) 971-982), failed to find a significant difference between CBT and a clinical management plus placebo condition. METHODS: The outcomes of two consecutive cohorts of out-patients with major depressive disorder, treated with either CBT (n=90) or a nonspecific control condition (support-counseling-placebo; SCP: n=100), were compared. Although the principal comparisons between the CBT and SCP conditions were delimited to the first 4 weeks of treatment, a secondary set of analyses addressed the subset of 16 patients who received 12 additional weeks of supportive therapy. RESULTS: A consistent pattern of statistically and clinically significant differences favoring CBT over SCP was found in both weeks 4 and 16. LIMITATIONS: Interpretation of these findings are subject to several potential confounds, including the non-randomized nature of the groups and the greater amount of therapeutic contact during the first 4 weeks of CBT. CONCLUSIONS: While these results do not lessen the need for additional prospective studies, our findings do suggest that CBT has therapeutic effects beyond those attributable to placebo-expectancy and other nonspecific factors.

Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons.

OBJECTIVE: The purpose of this study was to compare the acute outcomes of antidepressant medication and cognitive behavior therapy in the severely depressed outpatient subgroups of four major randomized trials. A secondary objective was to compare the results obtained in the National Institute of Mental Health Treatment of Depression Collaborative Research Program, upon which treatment guidelines have been based, with those obtained in the other three studies. METHOD: Outcomes of antidepressant medication and cognitive behavior therapy were compared within each of the four studies separately and for patients aggregated across the four studies. In addition, the outcomes in the antidepressant medication and cognitive behavior therapy conditions of the Treatment of Depression Collaborative Research Program were compared with those obtained in the other three studies. RESULTS: The overall effect sizes comparing antidepressant medication to cognitive behavior therapy favored cognitive behavior therapy, but tests comparing the two modalities did not reveal a significant advantage for either modality overall. CONCLUSIONS: Cognitive behavior therapy has fared as well as antidepressant medication with severely depressed outpatients in four major comparisons. Until findings emerge from current or future comparative trials, antidepressant medication should not be considered, on the basis of empirical evidence, to be superior to cognitive behavior therapy for the acute treatment of severely depressed outpatients.

The generation of life events in recurrent and non-recurrent depression.

BACKGROUND: The stress generation hypothesis proposed by Hammen (1991) holds that depressed individuals generate stressful conditions for themselves, which lead to recurrence. The original test of this hypothesis compared dependent life events in women with recurrent depression to medical and normal controls. Two further research questions emerged from this work: (a) do individuals with a history of many depressive episodes generate more dependent life events than depressives with fewer episodes?; and (b) what is the aetiological relevance of any stress that may be generated? METHODS: The present research tested differences in dependent and independent events between depressed individuals who had experienced: (a) no previous major depressive episodes; (b) one previous episode; and (c) two or more previous episodes. We predicted that, based on the stress generation hypothesis, recurrent depressives would show more dependent events than people without a depression history, and that these generated stressors would be of aetiological importance for precipitating recurrence (i.e. severe events in the 3 months preceding recurrence). RESULTS: Recurrent depressives experienced significantly more total dependent events than first-onset depressives in the 12 months, but not the 3 months, preceding their episode. CONCLUSIONS: Although the findings supported the general premise of stress generation, the aetiological relevance of the generated stress for recurrence requires further study.

Electroencephalographic sleep profiles before and after cognitive behavior therapy of depression.

BACKGROUND: Previous studies have not fully resolved the state-dependent vs traitlike behavior of the electroencephalographic sleep abnormalities associated with depression. We therefore examined the sleep profiles of depressed patients before and after 16 weeks of treatment with cognitive behavior therapy to determine the stability or reversibility of selected abnormalities. METHODS: Seventy-eight unmedicated patients with major depressive disorder were stratified into abnormal and normal subgroups on the basis of pretreatment sleep study results. Two prospectively defined types of sleep variables were studied: those expected to be traitlike or state independent (type 1) and those predicted to be reversible or state dependent (type 2). RESULTS: The type 1 sleep disturbances (reduced rapid eye movement latency, decreased delta sleep ratio, and decreased slow wave sleep [in percentage]) were stable, as predicted, across time. A composite measure of type 2 disturbances (based on rapid eye movement latency, sleep efficiency, and rapid eye movement density) improved significantly, although a minority of patients in remission had persistent abnormalities. CONCLUSIONS: The electroencephalographic sleep correlates of depression can be disaggregated into state-independent and partially reversible subgroups. Persistent sleep disturbances in remitted patients may have ominous prognostic implications.

Comparison of cognitive models of depression: relationships between cognitive constructs and cognitive diathesis-stress match.

The authors examined the relationship between the cognitive components of the Beckian and Hopelessness models of depression by administering measures of dysfunctional attitudes, attributional style, and life stress to a sample of 59 depressed adults. Confirmatory factor analyses indicated that dysfunctional attitudes and attributional style load on separate factors as opposed to a single factor. Additional analyses revealed that depressed persons conforming to diathesis-stress criteria according to each model were largely independent of one another. Results supported the conclusion that the Beckian and Hopelessness models of depression describe distinct cognitive constructs and refer to distinct subsets of depressed persons.

Response to cognitive-behavioral therapy in depression: effects of pretreatment cognitive dysfunction and life stress.

Response to cognitive-behavioral therapy (CBT) for depression is variable and the factors that account for differences in response are not yet well established. Level of cognitive dysfunction and the occurrence of negative life stress have been theorized as patient variables, which may account for differences in response to CBT. The relationship between response to CBT and the interaction of cognitive dysfunction with negative life events was examined in a sample of 53 depressed outpatients. Overall, there was little support for the prediction of a difference in acute outcome between patients with or without pretreatment cognitive dysfunction and negative stressors.

Identifying an abnormal electroencephalographic sleep profile to characterize major depressive disorder.

There is little agreement as to the best definition of a categorically abnormal electroencephalographic (EEG) sleep profile to characterize major depressive disorder. Therefore, a series of classification, replication, and validation analyses were conducted to identify such a profile. The EEG sleep studies of healthy controls (n = 44), depressed inpatients (n = 44), and depressed outpatients (n = 181) were utilized, including subgroups of patients studied both before and after nonpharmacologic treatment with either cognitive behavior therapy (CBT) or interpersonal psychotherapy (IPT). A discriminant index score (based on reduced REM latency, increased REM density, and decreased sleep efficiency) was found to: 1) reliably discriminate between depressed inpatients, depressed outpatients, and controls; 2) show good test-retest reliability; and 3) identify a subset of depressed outpatients who were older, manifested a broader array of EEG sleep disturbances, and were less responsive to CBT or IPT. Posttreatment studies of patients indicated that normal sleep profiles were relatively stable, whereas abnormal profiles tended to normalize. These findings provide an empirically validated method that may improve the applicability, efficiency, and prognostic utility of EEG sleep studies of depressed patients.

A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy.

The definitions that are commonly employed to describe the outcome of the depressive disorders are often used in inconsistent ways and remain largely untested. The lack of a standard and valid set of outcome definitions hinders the study of the naturalistic course and treatment of depressive disorders. In the present study, we operationalized definitions for response, remission, relapse, recovery, and recurrence and examined their validity in a sample of depressed patients treated with cognitive behavior therapy. Validity was evaluated by the ability of the definitions to predict subsequent outcome in acute treatment and during a 3 year follow-up period. All five definitions demonstrated moderate to excellent validity. Moreover, we were able to empirically distinguish response from remission, and relapse from recurrence, despite the frequent confusion of these terms in the literature. Several of the findings suggest that continued refinement of the outcome definitions may enhance validity even further.

Gender differences in cognitive diathesis-stress domain match: implications for differential pathways to depression.

The frequency of cognitive diathesis-stress match was compared in a sample of depressed women and men to investigate hypotheses positing gender differences in the relation of cognitive diathesis-stress factors to depression. Depressed women were more likely to have experienced a match between a cognitive diathesis and a preonset negative stressor compared with depressed men. Comparisons of women and men on the cognitive and stress variables singly yielded differences in stress variables but not in cognitive variables. Depressed women were more likely to have experienced a negative severe event before the onset of depression and had a greater frequency of negative interpersonal events. Results supported the hypothesis of gender differences in pathways to depression.

Abnormal electroencephalographic sleep profiles in major depression: association with response to cognitive behavior therapy.

BACKGROUND: To test the hypothesis that depressed patients with selected neurobiologic disturbances are less responsive to psychotherapy, we examined responses to cognitive behavior therapy in relation to electroencephalographic sleep profiles. METHODS: Under a prospective, case-control design, 90 outpatients with probable or definite endogenous major depression (Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria) were stratified into abnormal and normal sleep subgroups (on the basis of an empirically validated electroencephalographic sleep profile) and more severe and less severe depression subgroups (on the basis of pretreatment Hamilton scores). Response to 16 weeks of treatment was analyzed for both intention-to-treat and completers (n = 82) samples. Outcomes during a 36-month prospective follow-up were assessed with survival analyses. RESULTS: Abnormal sleep profiles and higher pretreatment depression severity were independently associated with poorer outcomes on several analyses. The association between sleep abnormality and cognitive behavior therapy response was not significant in the completers analyses, however, largely because of differential attrition. During follow-up, pretreatment depression severity was predictive of relapse and a lower recovery rate, whereas sleep abnormality was predictive of a lower recovery rate and a higher risk of recurrence. CONCLUSIONS: Depressed patients characterized by higher severity and/or an abnormal electroencephalographic sleep profile were relatively less responsive to cognitive behavior therapy. These associations are hypothesized to result from a constellation of neurophysiologic disturbances that interfere with the acquisition, application, and implementation of the skills emphasized in cognitive behavior therapy.

Electroencephalographic sleep profiles in single-episode and recurrent unipolar forms of major depression: I. Comparison during acute depressive states.

The current study was conducted to examine if recurrent depression is associated with more severe disturbances of all-night EEG sleep profiles than single-episode depressions. Unmedicated sex- and age-matched groups of 22 single-episode (SE) and 44 recurrent unipolar (RU) outpatients with DSM-III-R/SADS/RDC major depression underwent 2 consecutive nights of EEG sleep recording. Multivariate analyses of covariance (MANCOVAs) and/or analyses of covariance (ANCOVAs) were performed on six sets of sleep measures. Recurrent unipolar depression was associated with significantly increased phasic REM sleep, as well as increased REM counts on the second night of study. Recurrent depression also was associated with significantly poorer sleep efficiency, although the groups did not show consistent differences in sleep architecture or slow-wave sleep. Our findings generally support the hypothesis that recurrent depression is associated with a more severe neurophysiologic substrate than phenotypically similar SE cases. Results are, for the most part, compatible with Post's (1992) model of illness progression, particularly with respect to greater disturbances of state-dependent sleep abnormalities in the RU cases. Longitudinal studies are needed to confirm the evolution of such changes prospectively.

Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy.

The present study attempted to integrate key variables from 3 major domains of theory in depression (cognition, stress, and psychobiology) that are typically studied separately in analyses of course and response to cognitive therapy. Dysfunctional attitudes, negative life events, or sleep electroencephalogram were assessed in 53 outpatients before treatment with cognitive therapy. High levels of dysfunctional attitudes were found to be associated with poorer response to treatment but not for those patients who had experienced a severe negative life event. Examination of the length of time required to achieve remission revealed an effect for rapid eye movement (REM) latency as well as the interaction between REM latency and life events. These results are discussed in terms of the promise of integrative research in the study of depression and its treatment.

Do depressed men and women respond similarly to cognitive behavior therapy?

OBJECTIVE: A great majority of the evidence pertaining to the effectiveness of the time-limited psychotherapies as treatments of major depression are derived from studies of either predominantly or entirely female subject groups. Depressed men and women differ in a number of important respects that may alter the course of affective disorder, and as a result, they may also differ in their responses to psychotherapy. In this study the outcomes of 40 men and 44 women treated with cognitive behavior therapy were compared. METHOD: The patients were interviewed with the Schedule for Affective Disorders and Schizophrenia and diagnosed according to the Research Diagnostic Criteria and DSM-III-R criteria. Subsequently, they were assessed every other week (with the Hamilton Depression Rating Scale, Beck Depression Inventory, and Global Assessment Scale) during a standardized, time-limited cognitive behavior therapy protocol. The outcomes of the men and women were compared by means of a series of analyses of variance and covariance and survival analyses. RESULTS: There were several significant pretreatment differences, and the men attended significantly fewer therapy sessions than the women. Although the men and women generally had comparable responses, patients with higher pretreatment levels of depressive symptoms, particularly women, had poorer outcomes. CONCLUSIONS: This study provides further evidence of gender-specific differences in depressed patients' symptoms and treatment utilization. Cognitive behavior therapy appears to be a comparably useful outpatient treatment for men and women. However, either more intensive cognitive behavior therapy or alternative methods of treatment may be warranted for patients with more severe syndromes.

Cognition and life stress in depression: cognitive factors and the definition, rating, and generation of negative life events.

The relationship between cognitive factors and different conceptualizations and measures of life stress poses important questions for contemporary theories of depression. We examined whether cognitive factors (dysfunctional attitudes and attributional style) are related to the definition, rating, and generation of negative life events. Life events were assessed with both subjective self-report and more objective interview-based methods in endogenously depressed outpatients. The results partially support the hypothesis that cognitive factors are related to definition and severity ratings of self-report measures of particular types of life events. These relationships held primarily for achievement, as compared with interpersonal, events. The results also support the hypothesis that elevated scores on measures of cognition are associated with the number of objectively defined events occurring prior to the onset of depression, suggesting that some patients may generate the life events that in turn may initiate a depressive episode.

Evaluating the hopelessness model of depression: diathesis-stress and symptom components.

The hopelessness model of depression posits that latent attributional diatheses combine with stressors to produce a specific subtype of depression characterized by a specific set of symptoms. Associations between attributional diathesis, stress, and symptoms were examined to test the prediction that hopelessness depressions are characterized by a specific symptom profile. Fifty-seven depressed outpatients were categorized into subgroups on the basis of whether or not they met the criteria of L. Y. Abramson, L. B. Alloy, and G. I. Metalsky's (1988) hopelessness depression, defined as a match in content domain between attributional diathesis and negative stressor. Support for hopelessness depression was mixed. The hopelessness subtype differed from other major depressions with respect to symptom profile. However, the differences in symptomatology were not wholly consistent with the predictions of the hopelessness model.

Psychobiological correlates of poor response to cognitive behavior therapy: potential indications for antidepressant pharmacotherapy.

Correlates of outcome were studied in a sample of 142 unmedicated patients with major depressive disorder treated with cognitive behavior therapy (CBT) in outpatient (n = 110) or inpatient (n = 32) protocols. Outpatients received up to 20 sessions of therapy over 16 weeks; inpatients received up to 20 sessions over 4 weeks. Across all three protocols, nonresponse was associated with unemployment, higher levels of pretreatment severity, and an abnormal electroencephalographic (EEG) sleep profile. Chronicity was associated with poor outcomes in male outpatients, whereas high scores on a measure of dysfunctional attitudes were associated with a trend for poor outcome only in female patients. Among inpatients, male gender, diagnostic comorbidity, and elevated urinary free cortisol levels also were associated with poor outcome. Although a majority of the unmedicated patients experienced full or partial remissions, our findings suggest that assessments of both clinical (e.g., severity, chronicity, and comorbidity) and psychobiological (EEG sleep and adrenocortical function) factors may identify those depressed patients who are less likely to benefit from CBT alone. Such patients may be preferentially responsive to treatment with pharmacotherapy, either alone or, in more complicated cases, in combination with psychotherapy.

Social factors and the psychobiology of depression: relations between life stress and rapid eye movement sleep latency.

We examined psychosocial factors (i.e., life stress) and biological factors (i.e., REM sleep latency) that are hypothesized to be of complementary importance for defining depressive subtypes in a sample of 61 nonpsychotic, endogenous major depressives. Subjects were evaluated on several diagnostic scales for life stress, on electroencephalographic sleep data, and on 2 symptom measures for depression. As predicted, persons with severe stress that occurred shortly before depression onset had essentially normal REM latency values; patients without such stress had reduced REM latency values. Both stress and REM latency were also associated with greater severity of self-reported depressive symptoms. Alternative explanations of these findings are discussed, with particular emphasis on different roles of pre-onset and post-onset stressors.