Improved cognitive content endures for 2 years among unstable responders to acute-phase cognitive therapy for recurrent major depressive disorder.

BACKGROUND: The cognitive model of depression suggests that cognitive therapy (CT) improves major depressive disorder (MDD) in part by changing depressive cognitive content (e.g. dysfunctional attitudes, hopelessness). The current analyses clarified: (1) the durability of improvements in cognitive content made by acute-phase CT responders; (2) whether continuation-phase CT (C-CT) or fluoxetine (FLX) further improves cognitive content; and (3) the extent to which cognitive content mediates continuation treatments' effects on depressive symptoms and major depressive relapse/recurrence. METHOD: Out-patients with recurrent MDD who responded to acute-phase CT (n = 241) were randomized to 8 months of C-CT, FLX or pill placebo (PBO) and followed for an 24 additional months. Cognitive content was assessed approximately every 4 months using five standard patient-report measures. RESULTS: Large improvements in cognitive content made during acute-phase CT were maintained for 32 months, with 78-90% of patients scoring in normal ranges, on average. Cognitive content varied little between C-CT, FLX and PBO arms, overall. Small, transient improvements in cognitive content in C-CT or FLX compared with PBO patients did not clearly mediate the treatments' effects on depressive symptoms or on major depressive relapse/recurrence. CONCLUSIONS: Outpatients with recurrent MDD who respond to acute-phase CT show durable improvements in cognitive content. C-CT or FLX may not continue to improve patient-reported cognitive content substantively, and thus may treat recurrent MDD by other paths.

Change in psychosocial functioning and depressive symptoms during acute-phase cognitive therapy for depression.

BACKGROUND: Major depressive disorder (MDD) is highly prevalent, is recurrent, and impairs people's work, relationships and leisure. Acute-phase treatments improve psychosocial impairment associated with MDD, but how these improvements occur is unclear. In this study, we tested the hypotheses that reductions in depressive symptoms exceed, precede and predict improvements in psychosocial functioning. METHOD: Patients with recurrent MDD (n=523; 68% women, 81% Caucasian, mean age 42 years) received acute-phase cognitive therapy (CT). We measured functioning and symptom severity with the Social Adjustment Scale - Self-Report (SAS-SR), Range of Impaired Functioning Tool (RIFT), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HAMD) and Inventory for Depressive Symptomatology - Self-Report (IDS-SR). We tested cross-lagged correlations between functioning and symptoms measured at baseline and the beginning, middle and end of acute-phase CT. RESULTS: Pre- to post-treatment improvement in psychosocial functioning and depressive symptoms was large and intercorrelated. Depressive symptoms improved more and sooner than did psychosocial functioning. However, among four assessments across the course of treatment, improvements in functioning more strongly predicted later improvement in symptoms than vice versa. CONCLUSIONS: Improvements in psychosocial functioning and depressive symptoms correlate substantially during acute-phase CT, and improvements in functioning may play a role in subsequent symptom reduction during acute-phase CT.

Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial.

BACKGROUND: Cognitive therapy (CT) may reduce depressive relapse and recurrence when patients learn and use the associated skills. Reported relapse and recurrence rates after CT discontinuation vary widely. The factors that determine when CT is preventive remain unidentified. We developed continuation-phase CT (C-CT) to teach responders skills to prevent relapse. This is the first randomized trial comparing CT with and without a continuation phase in responders to CT who were vulnerable, given their history of recurrent unipolar depression. METHODS: Patients aged 18 to 65 years (n = 156) with recurrent DSM-IV major depressive disorder (MDD) entered 20 sessions of acute-phase CT (A-CT). Unmedicated responders (ie, no MDD and 17-item Hamilton Rating Scale for Depression score < or =9; n = 84) were randomized to either 8 months (10 sessions) of C-CT or control (evaluation without CT). Follow-up lasted an additional 16 months. A clinician blind to assignment evaluated relapse and recurrence (ie, DSM-IV MDD). RESULTS: Over an 8-month period, C-CT significantly reduced relapse estimates more than control (10% vs 31%). Over 24 months, including the CT-free follow-up, age of onset and quality of remission during the late phase of A-CT each interacted with condition assignment to influence durability of effects. In patients with early-onset MDD, C-CT significantly reduced relapse and recurrence estimates (16% vs 67% in control). When patients had unstable remission during late A-CT, C-CT significantly reduced relapse and recurrence estimates to 37% (vs 62% in control). CONCLUSIONS: Findings suggest that 8 months of C-CT significantly reduces relapse and recurrence in the highest-risk patients with recurrent MDD. Risk factors influenced the necessity for C-CT.

Treatment of atypical depression with cognitive therapy or phenelzine: a double-blind, placebo-controlled trial.

BACKGROUND: Patients with atypical depression are more likely to respond to monoamine oxidase inhibitors than to tricyclic antidepressants. They are frequently offered psychotherapy in the absence of controlled tests. There are no prospective, randomized, controlled trials, to our knowledge, of psychotherapy for atypical depression or of cognitive therapy compared with a monoamine oxidase inhibitor. Since there is only 1 placebo-controlled trial of cognitive therapy, this trial fills a gap in the literature on psychotherapy for depression. METHODS: Outpatients with DSM-III-R major depressive disorder and atypical features (N = 108) were treated in a 10-week, double-blind, randomized, controlled trial comparing acute-phase cognitive therapy or clinical management plus either phenelzine sulfate or placebo. Atypical features were defined as reactive mood plus at least 2 additional symptoms: hypersomnia, hyperphagia, leaden paralysis, or lifetime sensitivity to rejection. RESULTS: With the use of an intention-to-treat strategy, the response rates (21-item Hamilton Rating Scale for Depression score, < or =9) were significantly greater after cognitive therapy (58%) and phenelzine (58%) than after pill placebo (28%). Phenelzine and cognitive therapy also reduced symptoms significantly more than placebo according to contrasts after a repeated-measures analysis of covariance and random regression with the use of the blind evaluator's final Hamilton Rating Scale for Depression score. The scores between cognitive therapy and phenelzine did not differ significantly. Supplemental analyses of other symptom severity measures confirm the finding. CONCLUSIONS: Cognitive therapy may offer an effective alternative to standard acute-phase treatment with a monoamine oxidase inhibitor for outpatients with major depressive disorder and atypical features.

Conceptualization and rationale for consensus definitions of terms in major depressive disorder. Remission, recovery, relapse, and recurrence.

In 1988, the MacArthur Foundation Research Network on the Psychobiology of Depression convened a task force to examine the ways in which change points in the course of depressive illness had been described and the extent to which inconsistency in these descriptions might be impeding research on this disorder. We found considerable inconsistency across and even within research reports and concluded that research on depressive illness would be well served by greater consistency in the definition change points in the course of illness. We propose an internally consistent, empirically defined conceptual scheme for the terms remission, recovery, relapse, and recurrence. In addition, we propose tentative operational criteria for each term. Finally, we discuss ways to assess the usefulness of such operational criteria through reanalysis of existing data and the design and conduct of new experiments.

Reduced REM latency predicts response to tricyclic medication in depressed outpatients.

Forty-two outpatients with major depressive disorder entered a double-blind, randomized trial of either desipramine or amitriptyline for a minimum of 6 weeks. Pretreatment polysomnographic and clinical measures were used to predict response. Response was defined as a 17-item Hamilton Rating Scale for Depression score less than or equal to 9 at the end of treatment. There was a 61.1% response rate for patients treated with amitriptyline and a 66.7% response rate for patients treated with desipramine. Reduced REM latency (2-night mean less than or equal to 65.0 min) predicted a positive response to these tricyclic antidepressants. REM latency did not differentiate between desipramine or amitriptyline responders. More patients with reduced REM latency (80%) responded to treatment compared with patients with nonreduced REM latency (50%). The 80% response rate in reduced REM latency depressed patients confirms our previous findings in a mixed inpatient and outpatient sample. Contrary to our hypothesis, in this sample, endogenous depression was not associated with a good response to tricyclic medication.

Clinical predictors of recurrence in depression.

In a longitudinal study of 30 successfully treated unipolar depressed patients, the authors evaluated number of depressive episodes, early onset of depression, and lifetime prevalence of affective disorders other than major depression as risk factors for recurrence. Early onset of depression (before age 20) and a history of affective disorders other than major depression were each significantly associated with recurrence. Number of episodes was not as powerful in predicting recurrence as either early onset or lifetime prevalence of other affective disorders.

Reduced rapid eye movement latency. A predictor of recurrence in depression.

In this longitudinal study of 25 successfully treated depressed patients, rapid eye movement (REM) latency during an episode of depression was evaluated as a predictor of recurrence. Patients with reduced REM latency prior to treatment were more likely to develop another episode of depression during the follow-up period.

Psychosocial aspects of depression and the role of psychotherapy.

The psychosocial aspects of depression are considered with respect to psychological factors (i.e., thinking, personality, coping style) and social factors (i.e., family, relationships, employment, life events). Etiologic/mechanistic controversies are only acknowledged, as the purpose of this review is to underscore the wide variety of psychosocial complications that can occur during a depressive episode. The potential roles of psychotherapy in the treatment of mood disorders are considered. Results regarding the efficacy of behavioral therapy, cognitive therapy, and interpersonal psychotherapy in the treatment of unipolar, nonpsychotic, adult depressed outpatients are summarized.

Guilt in depressed outpatients.

This study was designed to determine whether normal control subjects (n = 17) and depressed outpatients (n = 72) differed with respect to the extent and conditions under which they reported dysfunctional guilt. Depressed outpatients reported significantly more guilt than normal control subjects in most types of situations. A family history of depression was related to a higher overall level of guilt in patients. Course and severity of depression and endogenous subtype did not relate to the amount of guilt reported by the patients. This study provides clinical norms on the Situational Guilt Scale (SGS) for a sample of unipolar, nonpsychotic outpatients with major depressive disorder.

Is there a role for continuation phase cognitive therapy for depressed outpatients?

Two pilot studies evaluated the rate of relapse or recurrence (i.e., major depressive disorder) after cognitive therapy (CT). Two sequential cohorts included outpatients who responded to acute phase CT (A-CT) and who agreed to monthly, treatment-free follow-up. In Study 1, the Kaplan-Meier technique estimated relapse and recurrence rates of 40% at 6 months, 45% at 8 months, 50% at 12 months, 67% at 18 months, and 74% at 24 months. In Study 2, responders to A-CT received 8 months (10 sessions) of continuation phase CT (C-CT). In Study 2, relapse or recurrence was 20% at 6 and 8 months, 27% at 12 months, and 36% at 18 and 24 months after A-CT. An exploratory log-rank test showed that relapse or recurrence-free survival was greater in Study 2 than in Study 1. If replicated, this result suggests that C-CT can reduce depressive relapse or recurrence. Alternative explanations are presented.

Does learned resourcefulness predict response to cognitive therapy in depressed outpatients?

Thirty-seven unipolar, nonpsychotic, outpatients with major depression were treated with cognitive therapy in an ongoing study designed to identify which depressions respond to cognitive therapy. Pretreatment levels of learned resourcefulness, assessed by Rosenbaum's (1980) Self Control Schedule (SCS), were used to predict response to cognitive therapy (according to the 17-item Hamilton Rating Scale for Depression and the 21-item Beck Depression Inventory). Pretreatment SCS scores did not predict response to cognitive therapy according to either measure.

Clinical characteristics of outpatients with chronic major depression.

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179). Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.

Does the pretreatment polysomnogram predict response to cognitive therapy in depressed outpatients? A preliminary report.

Although several studies reveal that cognitive therapy effectively remediates depressive symptoms in many unipolar nonpsychotic depressed outpatients, the question as to which depressions respond to cognitive therapy remains unanswered. We hypothesized that patients with reduced rapid eye movement (REM) latency (less than or equal to 65.0 min) before treatment would be less likely than those with nonreduced REM latency (greater than 65.0 min) to respond to cognitive therapy. The rationale for this prediction was that endogenous depressions are more likely to exhibit this abnormality and also tend to respond to tricyclic antidepressant medication. Thus, we queried whether these depressions might also respond less to a psychosocial intervention. To date, 39 outpatients with nonpsychotic, unipolar major depression (by the Schedule for Affective Disorders and Schizophrenia-Lifetime Version and Research Diagnostic Criteria) who score at least 14 on the 17-item Hamilton Rating Scale for Depression have completed this project, which is still in process. Preliminary findings do not suggest a systematic relationship between pretreatment REM latency and response to cognitive therapy. Further, these results suggest that at least some patients with biological dysregulation, as indicated by reduced REM latency, show a favorable response to an acute trial of cognitive therapy. Study limitations include a small sample of patients who exhibit extremely reduced REM latencies (less than or equal to 51.0 min) and a small number of endogenous depressions. Data collection continues.

Clinical, cognitive, and demographic predictors of response to cognitive therapy for depression: a preliminary report.

This preliminary study evaluated prognostic indicators or predictors of response to cognitive therapy. The sample included 37 unipolar outpatients with moderate to severe major nonpsychotic depressive disorder, according to Research Diagnostic Criteria. Demographic characteristics (sex, age, marital status, and education), pretreatment severity measures (Hamilton Rating Scale for Depression [HRSD] and Beck Depression Inventory [BDI]), pretreatment cognitive measures (Dysfunctional Attitudes Scale [DAS] and Attributional Style Questionnaire Failure Composite [ASQ-F]), and historical features (length of illness, length of current episode, number of episodes, and age of onset) were used in multiple regression models to predict response. In accord with previous findings, patients who had higher (rather than lower) pretreatment HRSD, BDI, or DAS scores and were single (rather than married) showed a poorer response to cognitive therapy, according to the HRSD. Furthermore, married outpatients with high DAS scores or single patients with low DAS scores showed an intermediate response to cognitive therapy, while single patients with high DAS scores responded the least. Generally, effects were stronger when response was assessed according to clinician-rated severity measures rather than patient self-reports.

Prospective assessment of electroencephalographic sleep in remitted major depression.

We studied 29 patients with major depression before treatment and then followed these patients prospectively with monthly electroencephalographic (EEG) sleep assessments after successful treatment. Most EEG sleep measures demonstrated no change from the episode throughout a prolonged period of clinical remission. When there was evidence of a change in EEG sleep measures, the effect was modest and due to only a small subset of patients. These findings contribute to the accumulating evidence that selected EEG sleep measures appear to be trait-like and may be useful in identifying individuals at risk for major depression.

Psychological treatments of dysmenorrhea: differential effectiveness for spasmodics and congestives.

Two studies are reported, examining the effectiveness of psychological treatments for dysmenorrhea. In Experiment 1, 33 women with spasmodic dysmenorrhea were treated with relaxation alone, or relaxation plus imagery, or assigned to a waiting-list control condition; and 29 women with congestive dysmenorrhea were treated with relaxation alone, or assigned to a waiting-list control condition. In Experiment 2, 18 additional congestives were treated with a coping skills package, or this package plus relaxation; these two groups were compared with the two congestive groups from Experiment 1. The dependent measures were reports of symptom severity, general discomfort, resting time, and medication use. Consistent with the literature, the main findings of the present studies are: (a) relaxation training (alone or with imagery) effectively reduces resting time for spasmodics; and (b) none of the treatments was shown to be effective for congestive sufferers.

Short-term psychotherapy of depressive disorders: current status and future directions.

Depressive disorders can affect all aspects of a person's functioning and are often associated with significant psychosocial impairment. Such psychosocial problems promote studies of the efficacy of short-term psychotherapy for depressive disorders. This report summarizes the literature on acute-phase, short-term psychotherapy for adult outpatients with major depressive disorder and is an updated component of a larger review commissioned by the United States Public Health Services Agency for Health Care Policy and Research (AHCPR review on "Short-term Psychotherapy for Depression," Jarrett and Maguire [1991]; Jarrett and Down [in press] during the preparation of the Clinical Practice Guidelines in primary care (Depression Guideline Panel 1993). The short-term psychotherapies reviewed here and studied most often include behavior therapy, cognitive therapy, interpersonal psychotherapy, and brief dynamic psychotherapy, which all aim to reduce depressive symptoms. We comment on the state of the literature and raise some of the questions which await data.