Assessing in-session rumination and its effects on CBT for depression.

The study evaluated if rumination of patients during therapy (i.e., in-session rumination) relates to whether or not they do less well in CBT treatment. We developed a reliably assessed in-session rumination observational measure and evaluated its relationship to depression over the course of CBT. Rated sessions came from 63 treatment-naïve patients with major depressive disorder who participated in CBT in the PReDICT study (Dunlop et al., 2017). In-session rumination was operationalized as repetitive, negative, and passive talking about depressive topics. Trained undergraduates rated the intensity and duration of in-session rumination occurring during 57 initial therapy sessions (i.e., session one) and 45 sessions in the middle of treatment (i.e., session eight). The observational ratings were sufficiently reliable (all ICCs > 0.69). Mixed model results indicated that greater intensity of in-session rumination during the initial treatment session predicted higher levels of subsequent clinician-rated depressive symptoms (p < .023). Regression results indicated that greater intensity and duration of in-session rumination at session 8 significantly predicted higher clinician-rated symptoms at end of treatment (p's < 0.02). In-session rumination intensity and duration were not, however, related to subsequent self-reported depressive symptoms. The results support efforts to identify which patients might benefit from rumination-specific interventions.

Teasing and social rejection among obese children enrolling in family-based behavioural treatment: effects on psychological adjustment and academic competencies.

OBJECTIVES: The first objective was to determine the prevalence of psychological maladjustment (emotional and behavioural problems), low academic competencies and teasing/social rejection among obese Icelandic children enrolling in a family-based behavioural treatment. A second objective was to explore the degree to which teasing/social rejection specifically contributes to children's psychological adjustment and academic competencies when controlling for other variables, including demographics, children's physical activity, parental depression and life-stress. METHODS: Participants were 84 obese children (mean body mass index-standard deviation score=3.11, age range=7.52-13.61 years). Height and weight, demographics and measures of children's psychological adjustment, academic competencies, teasing/social rejection and physical activity were collected from children, parents and teachers. Parental depression and life-stress was self-reported. RESULTS: Over half the children exceeded cutoffs indicating concern on at least one measure of behavioural or emotional difficulties. Children endorsed significant levels of teasing/social rejection, with almost half acknowledging they were not popular with same-gender peers. Parent reports of peer problems were even higher, with over 90% of both boys and girls being rated by their parents as having significant peer difficulties. However, rates of low academic competencies as reported by teachers were not different from those of the general population. In regression analyses controlling for other variables, self-reported teasing/social rejection emerged as a significant contributor to explaining both child psychological adjustment and academic competencies. CONCLUSIONS: The results indicate that among obese children enrolled in family-based treatment, self-reported teasing/social rejection is quite high and it is associated with poorer psychological adjustment as well as lower academic competencies. Parent reports corroborate the presence of substantial peer difficulties, supporting the need to address peer relations with overweight children both in clinical practice and in public health interventions.

Predicting recurrence of major depressive disorder in young adults: a prospective study.

Sixty-five young adults with remitted major depressive disorder (MDD) were followed for 18 months. Recurrence of MDD was reported by 41.5% of the initial sample and 49.1% of those who completed the study (n = 53). Survival analyses were used to identify predictors of recurrence so that individuals at greatest risk could be targeted for intervention. Potential predictors included measures of comorbid psychopathology (Axis II pathology, and current and lifetime nonmood Axis I diagnoses), depression-specific clinical features (number of episodes, past treatment, and suicidality), and self-reported cognitive and interpersonal constructs (hope, dysfunctional attitudes, and interpersonal problems). Only personality pathology (specifically, the total dimensional and Cluster B dimensional scores on the International Personality Disorder Examination) significantly predicted hazard of recurrence.

The role of psychotherapy in treating psychiatric disorders.

Psychotherapy has shifted from long-term to short-term approaches, which have been found to be effective for the treatment of specific psychiatric disorders. These psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been found useful in presenting an educational framework for disorders and the treatment rationale for intervention programs. Short-term and maintenance empirical data support the effectiveness of using behavior therapy and CBT as adjunctive interventions with medications for bipolar I disorder and schizophrenia. In major randomized clinical trials, psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been shown to be effective as primary treatments (treatments of choice) for the major psychiatric problems of obsessive-compulsive disorder, panic disorder, and major depression as well as several other psychiatric disorders. The combination of psychotherapy and psychotropic medications is not always additive for acute treatment effects or especially for the maintenance of treatment effects so that the combination of psychotherapy and medications is not the most effective treatment for all psychiatric disorders. Badly needed, additional randomized controlled trials of psychotherapy, medications, and their combinations are under way in large, NIMH-supported studies of the treatment of several psychiatric disorders.

Exercise and weight loss reduce blood pressure in men and women with mild hypertension: effects on cardiovascular, metabolic, and hemodynamic functioning.

BACKGROUND: Lifestyle modifications have been recommended as the initial treatment strategy for lowering high blood pressure (BP). However, evidence for the efficacy of exercise and weight loss in the management of high BP remains controversial. METHODS: One hundred thirty-three sedentary, overweight men and women with unmedicated high normal BP or stage 1 to 2 hypertension were randomly assigned to aerobic exercise only; a behavioral weight management program, including exercise; or a waiting list control group. Before and following treatment, systolic and diastolic BPs were measured in the clinic, during daily life, and during exercise and mental stress testing. Hemodynamic measures and metabolic functioning also were assessed. RESULTS: Although participants in both active treatment groups exhibited significant reductions in BP relative to controls, those in the weight management group generally had larger reductions. Weight management was associated with a 7-mm Hg systolic and a 5-mm Hg diastolic clinic BP reduction, compared with a 4-mm Hg systolic and diastolic BP reduction associated with aerobic exercise; the BP for controls did not change. Participants in both treatment groups also displayed reduced peripheral resistance and increased cardiac output compared with controls, with the greatest reductions in peripheral resistance in those in the weight management group. Weight management participants also exhibited significantly lower fasting and postprandial glucose and insulin levels than participants in the other groups. CONCLUSIONS: Although exercise alone was effective in reducing BP, the addition of a behavioral weight loss program enhanced this effect. Aerobic exercise combined with weight loss is recommended for the management of elevated BP in sedentary, overweight individuals.

Modification of the cognitive model for bulimia via path analysis on a Brazilian adolescent sample.

Eating disturbances in middle-class Brazilian adolescents attending three high schools (one Military, two Private schools) were investigated. Participants from both Private schools were similar to U.S. samples on the EAT-26. Path analysis on the Private schools revealed the following. Higher body weight leads to weight concerns most strongly through greater discrepancy from the ideal, but it also leads directly to weight concern. Thus, both the reality of being heavier and the perception that one is larger than ideal (which could be due to being heavier and/or having a thin ideal) contribute to weight concern. Greater weight concern is associated most directly with lower self-esteem, which in turn is associated with endorsing greater importance of weight and shape. Importance of weight and shape contributes most powerfully to eating pathology through dieting, but this variable has a modest direct effect as well. These paths were not significant for the Military school sample in which participants reported lower levels of weight concern, dieting, body dissatisfaction, and a larger ideal figure. However, the Military sample rated importance of weight and shape as high as did Private-school participants. The results provide support for variables identified as important in the cognitive model of bulimia and suggest the model may be enhanced by including body weight and one's perceived ideal body shape as additional variables.

Relationship between self-efficacy perceptions and in-treatment drug use among regular cocaine users.

The perceived ability to engage in situation-specific behaviors (self-efficacy) to overcome nicotine dependence and alcohol abuse has been shown to correlate significantly with and be predictive of the actual ability to engage in such behaviors. Self-efficacy is also related to subsequent behavior change during treatment and maintenance of this change after treatment termination. In this study, part of national outcome study, the relationship between self-efficacy and drug use was investigated in a subsample of regular cocaine users (n = 294) who completed at least three months of treatment in community-based outpatient treatment programs. Frequency of cocaine and other drug use was reported for the period of 1 year before treatment and a 1 month and 3 months in treatment. Self-efficacy regarding resisting drug use was measured at 1 and 3 months in treatment. Self-efficacy at 1 month was correlated with cocaine use at 1 month and self-efficacy contributed to the prediction of self-reported drug use at 1 month over and above pretreatment and demographic variables. Similarly, self-efficacy at 3 months was correlated with cocaine use at 3 months and contributed to the prediction of self-reported drug use at 3 months. These outcomes were obtained even though over 75% of subjects reported no drug use during treatment. The results supported previous findings suggesting that increased self-efficacy regarding resisting drug use is associated with lower rates of drug use during treatment, and that self-efficacy enhancement may be an important intervention in the treatment of cocaine use.

Mechanisms of action in cognitive-behavioral and pharmacological interventions for obesity and bulimia nervosa.

In the treatment of obesity, anorexiant medication appears to enhance restraint, presumably through altering internal cues, and facilitates weight loss with behavioral treatment. However, relapse occurs once medication is withdrawn. Antidepressants appear to work similarly, and initial evidence suggests the same limitations. Long-term combined pharmacologic and behavioral treatment, however, may be useful for some individuals not responding positively to behavioral treatment alone. In the treatment of bulimia nervosa, antidepressants appear to enhance restraint, whereas cognitive behavioral treatment decreases restraint. Thus, these modalities appear to be incompatible, and highly restrictive eating is not desirable for those of normal weight. However, for individuals not responding to cognitive-behavioral treatment, long-term pharmacologic treatment may be an alternative, perhaps combined with a more compatible psychological treatment.

Relationship between depressed mood and sex-typed personality characteristics in adolescents.

The current study investigated the relationship between self-reports of depressed mood, self-esteem, and endorsement of sex-typed personality characteristics in a normal adolescent population. For positively valenced (socially desirable) sex-typed characteristics, masculinity was inversely related to depression while femininity was not significantly related. In contrast, for negatively valenced sex-typed characteristics the masculine and feminine scales showed similar effects: all were positively correlated with depression. Self-esteem was the best single predictor of depression and none of the sextyped characteristics contributed significantly beyond that accounted for by self-esteem. The results support previous findings with younger children and high school students by demonstrating that sex-typed characteristics in adolescents are significantly associated with depression, although this relationship is accounted for by the variance shared with self-esteem, a more general measure of mental health. However, the presence of negative feminine-typed characteristics was as highly correlated with depression as the absence of positive masculine characteristics and both relationships were stronger for females than males. Thus the linkages between sex-role socialization, sex-typed characteristics, self-esteem, depressed mood, and clinical depression bear further investigation, and may prove useful in understanding the development of depression in males and females.

Normative and reliability data for the Children's Depression Inventory.

The present study was undertaken to examine some of the psychometric properties of the Children's Depression Inventory (CDI), a self-report inventory devised by Kovacs and Beck (1977) to measure depression in children and adolescents. Normative and reliability data were obtained from three independent samples taken from eight public schools in central Pennsylvania. Age- and gender-related differences in reported characteristics of depression were also investigated. The subjects were 594 males and 658 females whose ages ranged from 8 to 16 years and whose combined mean age was 11.67 years (SD = 1.91). The CDI was group-administered to all 1,252 subjects; 155 fifth-grade subjects (77 males and 78 females) were retested after 3 weeks, and 107 seventh- and eight-grade subjects (45 males and 62 females) were retested after 1 year. The distribution statistics for the combined samples yielded an overall CDI mean of 9.09, a standard deviation of 7.04, and a cutoff score of 19 for the upper 10% of the distribution. Reliability assessed through coefficient alpha, item-total score product-moment correlations, and test-retest coefficients proved acceptable. Gender differences were obtained for several item-total score correlations and for test-retest reliability of CDI scores.

A conceptual model for cognitive-behavior therapy with children.

This paper briefly reviews the historical and conceptual developments that produced the cognitive-behavioral model for clinical interventions with children. It is suggested that this model should be expanded by including the person variables of emotion and developmental level and by broadening the scope of environmental variables to include the family, school, and other social/community contexts. The implications of this expansion of the cognitive-behavioral model for psychopathology, assessment, and intervention are discussed.

The Master Questionnaire: preliminary report on an obesity assessment device.

Behavioral obesity researchers are increasingly concerned with thorough assessment of obesity. The present report describes the preliminary testing and refinement of the Master Questionnaire (MQ), a true-false scale developed expressly for use in obesity research. It was initially divided into four subscales: Spouse Support, Energy Balance Habits, Cognitive Factors, and Energy Balance Knowledge, and was intended for use as an outcome measure and as a predictor of change in obesity status. Its stability, internal consistency, sensitivity to treatment-related change, and predictive validity were examined. Test-retest reliability and sensitivity to treatment-related change were each found to be acceptable for three out of four subscales. Two subscales, Energy Balance Knowledge and Cognitive Factors, predicted outcome. The major weakness of the subscales was a lack of unidimensionality which would limit their utility. Cluster and factor analyses were used to develop five new subscales with acceptable levels of internal consistency. While some additional development and validation is still needed, the available evidence suggests that we have the nucleus of a strong assessment tool for obesity research.

Behavior therapy and pharmacotherapy for obesity.

The effects of behavior therapy, pharmacotherapy, and their combination were compared in 120 women during six months of treatment of obesity and one year after treatment. Patients who received fenfluramine hydrochloride alone lost 14.5 kg, ad those who had combined pharmacotherapy and behavior therapy lost 15.3 kg; both losses were significantly greater than that of those who had behavior therapy alone (10.9 kg). A waiting-list control group gained 1.3 kg. One-year follow-up of all living patients who completed treatment showed a striking reversal in the relative efficacy of the treatments. Behavior-therapy patients regained significantly less than pharmacotherapy and combined-treatment patients. Accordingly, at follow-up, these groups did not differ significantly in weight loss. Thus, pharmacotherapy produced more rapid regaining of weight after treatment. Furthermore, adding pharmacotherapy to behavior therapy apparently compromised the long-term effects of the latter treatment.

Controlled trial of behaviour therapy, pharmacotherapy, and their combination in the treatment of obesity.

Behaviour therapy, pharmacotherapy, and a combination of the two were compared in 120 obese women and 14 obese men during six months of treatment for obesity and at one-year follow-up. Patients who received the appetite suppressant fenfluramine lost 14.5 kg and those who received the combined treatment lost 15.3 kg, both significantly more than those who received only behaviour therapy (10.9 kg). One-year follow-up of all living patients who completed treatment showed a striking reversal of these effects: behaviour-therapy patients regained only 1.9 kg, significantly less than pharmacotherapy patients (8.2 kg) and combined-therapy patients (10.7 kg). Weight changes of the 14 men did not differ from those of the women. Although pharmacotherapy produced more rapid initial weight loss than behaviour therapy, it was followed by more rapid weight gain after treatment. Addition of pharmacotherapy apparently compromised the long-term effects of behaviour therapy. Better maintenance of weight loss and lower costs favour behaviour therapy over pharmacotherapy for the treatment of obesity.