Childhood Trauma Questionnaire-based child maltreatment profiles to predict efficacy of the Cognitive Behavioral Analysis System of Psychotherapy versus non-specific psychotherapy in adults with early-onset chronic depression: cluster analysis of data from a randomised controlled trial.

BACKGROUND: Child maltreatment is a broadly confirmed risk factor for mental and physical illness. Some psychological treatments specifically target mental health conditions associated with child maltreatment. For example, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) focuses on maladaptive interpersonal behaviours in chronic depression. However, how the assessment of child maltreatment could inform personalised treatment is unclear. We used data from a previously published clinical trial to investigate whether a pre-established child maltreatment clustering approach predicts differential outcomes after CBASP versus non-specific supportive psychotherapy in patients with early-onset chronic depression. METHODS: We did a cluster analysis of data from a previous randomised controlled trial of unmedicated adult outpatients with early-onset chronic depression who were treated at eight university clinics and psychological institutes in Germany with 32 sessions of CBASP or non-specific supportive psychotherapy. Participants were eligible for the original trial if they were aged 18-65 years; had major depressive disorder (MDD) with an early onset and duration of at least 2 years, current MDD superimposed on a pre-existing dysthymic disorder, or recurrent MDD with incomplete remission between episodes as defined by DSM-IV; and had a score of at least 20 points on the 24-item Hamilton Rating Scale for Depression (HRSD-24). Participants were included in the current study if they had completed the short form of the Childhood Trauma Questionnaire (CTQ) at trial baseline. We used an agglomerative hierarchical clustering approach to derive child maltreatment clusters from individual patterns across the five domains of the CTQ. We used linear mixed models to investigate whether clustering could predict differential clinical outcomes (change in symptom severity on the HRSD-24) up to 2 years after treatment onset. People with lived experience were involved in the current study. FINDINGS: 253 patients (129 [51%] treated with CBASP and 124 [49%] with supportive psychotherapy) had complete CTQ records and were included in the analysis. 169 (67%) participants were women, 84 (33%) were men, and the mean age was 45·9 years (SD 11·7). We identified seven child maltreatment clusters and found significant differences in treatment effects of CBASP and supportive psychotherapy between the clusters (F(6,948·76)=2·47; p=0·023); differences were maintained over the 2-year follow-up. CBASP was superior in distinct clusters of co-occurring child maltreatment: predominant emotional neglect (change in ß -6·02 [95% CI -11·9 to -0·13]; Cohen's d=-0·98 [95% CI -1·94 to -0·02]; p=0·045), predominant emotional neglect and abuse (-6·39 [-10·22 to -2·56]; -1·04 [-1·67 to -0·42]; p=0·0011), and emotional neglect and emotional and physical abuse (-9·41 [-15·91 to -2·91]; -1·54 [-2·6 to -0·47]; p=0·0046). INTERPRETATION: CTQ-based cluster analysis can facilitate identification of patients with early-onset chronic depression who would specifically benefit from CBASP. Child maltreatment clusters could be implemented in clinical assessments and serve to develop and personalise trauma-informed care in mental health. FUNDING: The German Research Foundation and the German Federal Ministry of Education and Research.

Do interpersonal fears mediate the association between childhood maltreatment and interpersonal skills deficits? A matched cross-sectional analysis.

Objective: Childhood maltreatment, interpersonal fear and a specific kind of interpersonal skills deficit (preoperational thinking) have all been associated with persistent depressive disorder (PDD). We hypothesize that interpersonal fears mediate the association between childhood maltreatment and preoperational thinking.Method: A total of 108 matched participants have been examined cross-sectionally (31 healthy controls, 30 patients with episodic depression and 47 patients with PDD) with the following instruments: the Childhood Trauma Questionnaire (CTQ-SF), a measure of interpersonal fear (CBASP Interpersonal Questionnaire) and the Lübeck Questionnaire of Preoperational Thinking.Results: Patients with PDD reported significantly more childhood maltreatment than patients with episodic depression (d = 0.65) and healthy controls (d = 1.29). They also had more interpersonal fears (d = 0.71 and d = 2.11 respectively) and higher levels of preoperational thinking (d = 0.90 and d = 2.78 respectively). The association between childhood maltreatment and preoperational thinking was mediated through interpersonal fears.Conclusions: Our findings might have important implications for psychotherapy of PDD because they demonstrate how specific problems in social interactions can be associated with interpersonal fears that arise secondary to childhood maltreatment.

Characteristics of the Optimal Cognitive Behavioral Analysis System of Psychotherapy (CBASP) Therapist Role.

The characteristics of the optimal CBASP therapist role for the treatment of the Persistent Depressive Disorder patient (chronic depression) is delineated in this paper. This paper contains the opinions and experiences of the creator of CBASP who has developed and revised the model over more than 4 decades. The paper is not a rigorous study nor a review of rigorous studies. The difficulties of the patient are briefly discussed and then the characteristics of the optimal clinical role are presented. The clinical role of CBASP, the only model to have been developed specifically to treat the chronically depressive patient, is unique in the field of psychotherapy. Four role categories describing the behavior of the best therapists are presented and discussed: (1) the therapist is able to enact a Disciplined Personal Involvement clinical role with the patient; (2) the therapist is able to implement an acquisition-learning approach to therapeutic administration; (3) the practitioner is able to adhere to the standards of CBASP technique administration; and finally, (4) the clinician is able to implement several facilitative interpersonal skills.

The Statistical Curriculum Within Randomized Controlled Trials in Critical Illness.

OBJECTIVES: Incomplete biostatistical knowledge among clinicians is widely described. This study aimed to categorize and summarize the statistical methodology within recent critical care randomized controlled trials. DESIGN: Descriptive analysis, with comparison of findings to previous work. SETTING: Ten high-impact clinical journals publishing trials in critical illness. SUBJECTS: Randomized controlled trials published between 2011 and 2015 inclusive. INTERVENTIONS: Data extraction from published reports. MEASUREMENTS AND MAIN RESULTS: The frequency and overall proportion of each statistical method encountered, grouped according to those used to generate each trial's primary outcome and separately according to underlying statistical methodology. Subsequent analysis compared these proportions with previously published reports. A total of 580 statistical tests or methods were identified within 116 original randomized controlled trials published between 2011 and 2015. Overall, the chi-square test was the most commonly encountered (70/116; 60%), followed by the Cox proportional hazards model (63/116; 54%) and logistic regression (53/116; 46%). When classified according to underlying statistical assumptions, the most common types of analyses were tests of 2 × 2 contingency tables and nonparametric tests of rank order. A greater proportion of more complex methodology was observed compared with trial reports from previous work. CONCLUSIONS: Physicians assessing recent randomized controlled trials in critical illness encounter results derived from a substantial and potentially expanding range of biostatistical methods. In-depth training in the assumptions and limitations of these current and emerging biostatistical methods may not be practically achievable for most clinicians, making accessible specialist biostatistical support an asset to evidence-based clinical practice.

A Procedure to Graph the Quality of Psychosocial Functioning Affected by Symptom Severity.

Assessment of the variations of clinical course to aid in diagnosis, assessment of patients' functioning and to guide treatment planning has gained momentum in recent years. A specific scale is introduced to plot the temporal course to assist empirically-minded psychotherapists and researchers who treat the DSM-5 Disorders and who want to monitor the quality of the course of psychosocial functioning over time. A Timeline Course Graphing Scale to Chart the Quality of Psychosocial Functioning Affected by Symptom Severity (PFS) is described and accompanied by administration guidelines.

Introducing a Clinical Course-Graphing Scale for DSM-5 Mood Disorders.

Assessment of clinical course to aid in the diagnosis of patients and to guide treatment planning has gained momentum in recent years. A course-graphing scale for the DSM-5 Mood Disorders is presented to facilitate clinical history-taking and diagnosis of the mood disorders during the screening interview. The scale can be administered in the more traditional historytaking portion of the screening interview. The only difference is that it is a more systematic approach especially when the clinician suspects the presence of a mood disorder. The Timeline Course Graphing Scale for the DSM-5 Mood Disorders (TCGS) is described and accompanied with guidelines for administration.

The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial.

BACKGROUND: It is widely agreed that chronic depression is difficult to treat, knowledge about optimal treatment approaches is emerging. METHOD: A multisite randomized controlled trial was conducted comparing the cognitive behavioral analysis system of psychotherapy (CBASP), a psychotherapy model developed specifically to treat chronic depression (n = 67) with care as usual (CAU; evidence-based treatments, n = 72) over a period of 52 weeks, with 23 sessions on average, in 3 outpatient clinics in the Netherlands. In both arms algorithm-based pharmacotherapy was provided. Patients (aged 18-65) met criteria for a DSM-IV diagnosis of major depressive disorder with diagnostic specifiers (chronic, without interepisode recovery) or with co-occurring dysthymic disorder indicating a chronic course. The Inventory for Depressive Symptomatology (IDS) Self-Report was used as the primary outcome measure. Mixed-effects linear regression analysis was used to compare the changes on the IDS scores between CBASP and CAU. The IDS was administered before treatment, and after 8, 16, 32 and 52 weeks. RESULTS: At week 52, patients assigned to CBASP had a greater reduction of depressive symptoms compared to patients assigned to CAU (t = -2.00, p = 0.05). However, CBASP and CAU did not differ from each other on the IDS after 8 weeks (t = 0.49, p = 0.63), 16 weeks (t = -0.03, p = 0.98) and 32 weeks (t = -0.17, p = 0.86) of treatment. CONCLUSIONS: This trial shows that CBASP is at least as effective as standard evidence-based treatments for chronic depression. In the long run, CBASP appears to have an added effect.

Cognitive Behavioural Analysis System of Psychotherapy (CBASP) for chronic depression: clinical characteristics and six month clinical outcomes in an open case series.

BACKGROUND: Evidence-based guidance on how best to treat chronic depression is limited. Cognitive Behavioural Analysis System of Psychotherapy (CBASP) has shown some promise with this 'difficult-to-treat' clinical group. This case series was designed to assess the acceptability and utility of this novel treatment in routine clinical practice within the U.K. National Health Service. METHODS: We offered an open trial of CBASP to a cohort of 115 referred patients within primary and secondary care. Diagnostic interview and standardised outcome measures were administered before and after 6 months of CBASP with a trained, accredited therapist. RESULTS: Seventy-four patients entered therapy, with 46 completing. 30% met criteria for remission (≤ 8 HRSD-24 score) and a further 30% met criteria for clinically significant change (> 8 and ≤15 HRSD-24 plus 50% reduction in baseline score). Thirty-nine per cent made "No change". Group measures of quality of life, social functioning and interpersonal functioning also improved. LIMITATIONS: This was an open study design with a moderate sample size and no control group. Ratings were not completed using a blinded procedure. CONCLUSIONS: CBASP is an acceptable therapy for a large proportion of patients with chronic depression and was associated with clinically significant change in 60% of completers.

Relationship of childhood trauma to depression and smoking outcomes in pregnant smokers.

OBJECTIVE: We evaluated whether childhood trauma moderated the treatment effect on depression and smoking outcomes in pregnant smokers. METHOD: The sample included pregnant smokers participating in a randomized trial evaluating the efficacy of a 10-session interpersonally focused therapy-cognitive behavioral analysis system of psychotherapy (CBASP)-versus a time-matched health and wellness control (HW) for smoking cessation and depression reduction. Women (N = 248) who completed the Childhood Trauma Questionnaire (CTQ) were included. On average, women were 25 years old (SD = 5.91) and smoked 10 (SD = 6.9) cigarettes per day. Depressive symptoms were assessed with the Center for Epidemiological Studies Depression Scale (CES-D), and women had an average score of 21 (SD = 11.03). Seventy-six percent of women had experienced some form of moderate to severe childhood trauma as assessed by the CTQ. RESULTS: In women with a history of moderate to severe childhood trauma, there was a dose-response association of treatment on depression outcome through 6 months postpartum; those with increasing amounts of childhood trauma benefitted more from CBASP, whereas those in the HW condition did not. Childhood trauma did not moderate the treatment effect on abstinence, although increasing amounts of trauma were associated with reduced likelihood of abstinence at 6 months posttreatment. CONCLUSIONS: An interpersonally focused therapy may be beneficial for the treatment of depression during the prenatal period in pregnant smokers with childhood trauma histories, and such treatment becomes increasingly more important with cumulative trauma experience. Childhood trauma increases risk for cessation failure in pregnant smokers. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

An investigation of the relationship between hemodynamics and thrombus deposition within patient-specific models of abdominal aortic aneurysm.

The relationship between hemodynamics and thrombus deposition in abdominal aortic aneurysm is investigated for three patients (A, B and C), each with mature fusiform aneurysms. Our methodology utilises initial and follow-up computerised tomography scans for each patient to identify regions of mural thrombus growth and to provide patient-specific models for hemodynamic analysis using computational fluid dynamics. The intervals between scans for patients A, B and C were 17, 15 and 3 months, respectively. The simulations were performed using physiologically realistic boundary conditions. The hemodynamic features of the flow considered include the velocity field, the shear strain rate field, the time averaged wall shear stress and the oscillatory shear index. The parameter that showed best correlation with the location of thrombus growth was the oscillatory shear index. In particular, in the case of patient C where the interval between scans was the shortest, thrombus growth was observed at regions of low oscillatory shear index (OSI < 0.1).

The significant other history: an interpersonal-emotional history procedure used with the early-onset chronically depressed patient.

An interpersonal-emotional history procedure, the Significant Other History, is administered to the early-onset chronically depressed patient during the second therapy session in the Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Patients are asked to name up to six significant others and answer two questions: (1) What was it like growing up with or being around this person? (2) What is the emotional "stamp" you take from this relationship that informs who you are today? An interpersonal-emotional theme reflecting the early learning history of the patient is derived from these "stamps" or causal theory conclusions. One transference hypothesis (TH) is derived from the Significant Other History (SOH) and is formulated in one sentence, such as "If I do this, then the therapist will likely do that" (e.g., "If I make a mistake around Dr. E, then Dr. E will label me 'stupid' or 'incompetent"). The transference hypothesis highlights the interpersonal content that most likely informs the patient's expectancy of the therapist's reactions toward him or her. Throughout the therapy process, the therapist will proactively employ the transference hypothesis in a technique known as the Interpersonal Discrimination Exercise to help patients cognitively and emotionally discriminate the practitioner from hurtful significant others. The goal here is to increase the patient's felt safety within the therapeutic dyad and eventually to generalize the felt safety to the patient's other relationships.

Effects of an intensive depression-focused intervention for smoking cessation in pregnancy.

OBJECTIVE: The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. METHOD: Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies-Depression Scale (Radloff, 1977). RESULTS: At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. CONCLUSIONS: The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.

A method for conducting intensive psychological studies with early-onset chronically depressed patients.

An intensive empirical methodology is introduced to evaluate the efficacy of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) treatment for outpatients with early onset chronic depression. The patient with chronic illness presents a unique measurement challenge to psychotherapists. One of the most prominent reasons is the refractory nature of the disorder. In order to measure the change process, the authors have found it helpful to use an acquisition-learning methodology to answer three questions: (1) What are we trying to teach the patient? (2) How much has the patient learned throughout the course of therapy? And, (3) how does the extent of patient learning impact the change indices at the end of treatment and during the follow-up period? Answering questions 2 and 3 allows us to superimpose the change process variables over the performance learning variables on a graph. These combined variables also allow us to test the hypothesis: By learning what psychotherapy teaches, the chronic psychological disorder may be resolved.

Treatment of chronically depressed patients: a multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depressions versus usual secondary care.

BACKGROUND: 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) is a form of psychotherapy specifically developed for patients with chronic depression. In a study in the U.S., remarkable favorable effects of CBASP have been demonstrated. However, no other studies have as yet replicated these findings and CBASP has not been tested outside the United States. This protocol describes a randomized controlled trial on the effectiveness of CBASP in the Netherlands. METHODS/DESIGN: The purpose of the present paper is to report the study protocol of a multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depression in the Netherlands. In this study, CBASP in combination with medication, will be tested versus usual secondary care in combination with medication. The aim is to recruit 160 patients from three mental health care organizations. Depressive symptoms will be assessed at baseline, after 8 weeks, 16 weeks, 32 weeks and 52 weeks, using the 28-item Inventory for Depressive Symptomatology (IDS). Effect modification by co morbid anxiety, alcohol consumption, general and social functioning and working alliance will be tested. GEE analyses of covariance, controlling for baseline value and center will be used to estimate the overall treatment effectiveness (difference in IDS score) at post-treatment and follow up. The primary analysis will be by 'intention to treat' using double sided tests. An economic analysis will compare the two groups in terms of mean costs and cost-effectiveness from a societal perspective. DISCUSSION: The study will provide an answer to the question whether the favorable effects of CBASP can be replicated outside the US. TRIAL REGISTRATION: The Dutch Cochrane Center, NTR1090.

Shifting Wallgraft position: case reports and review of the forces affecting Wallgraft positioning.

Extensive use of stent-grafts in the iliac arteries is an increasingly common endovascular alternative to an aortobifemoral bypass procedure. The treatment of diffuse bilateral disease is frequently performed by using the technique of paired stent-grafts in the proximal common iliac arteries to effectively re-create the aortic-bifurcation. We present three patients treated with this technique who returned with recurrent occlusive disease. During subsequent treatment, the stent-grafts were noted to be in different positions from where they were initially deployed. A discussion of the possible explanations for the shifting positions follows.

Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression.

Although the efficacy of maintenance pharmacotherapy for the prevention of recurrence in major depressive disorder (MDD) is well documented, few studies have tested the efficacy of psychotherapy as a maintenance treatment. The authors examined the efficacy of the cognitive-behavioral analysis system of psychotherapy (CBASP) as a maintenance treatment for chronic forms of MDD. Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assessment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time. These findings support the use of CBASP as a maintenance treatment for chronic forms of MDD.

Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2.

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.

Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics.

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.