The Effects of a Digital Mental Health Intervention in Adults With Cardiovascular Disease Risk Factors: Analysis of Real-World User Data.

BACKGROUND: The American Heart Association has identified poor mental health as a key barrier to healthy behavior change for those with cardiovascular disease (CVD) risk factors such as high blood pressure, high cholesterol, and diabetes. Digital mental health interventions, like those delivered via the internet to computers or smartphones, may provide a scalable solution to improving the mental and physical health of this population. Happify is one such intervention and has demonstrated evidence of efficacy for improving aspects of mental health in both the general population and in users with chronic conditions. OBJECTIVE: The objectives of this analysis of real-world data from Happify users with self-reported CVD risk factors, including high blood pressure and cholesterol, diabetes, and heart disease, were to examine whether these users would report improvements in subjective well-being and anxiety over time (H1) and use of Happify as recommended would be associated with significantly greater improvement in subjective well-being and anxiety over time compared to less-than-recommended usage (H2). METHODS: Data were obtained from existing Happify users who reported the aforementioned CVD risk factors. The sample included 1803 users receiving at least 6 weeks' exposure to Happify (ranging from 42 days to 182 days) who completed at least one activity and two assessments within the app during that time. Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction, and anxiety was assessed with the Generalized Anxiety Disorder 2 (GAD-2). To evaluate H1, changes over time in both outcomes were assessed using mixed effects linear regression models, controlling for demographics and usage. For H2, an interaction term was added to the models to assess whether usage as recommended was associated with greater improvement over time. RESULTS: Both hypotheses were supported. For both the Happify scale and GAD-2, the initial multivariable model without an interaction demonstrated an effect for time from baseline, and the addition of the interaction term between time and recommended use was significant as well. CONCLUSIONS: This analysis of real-world data provides preliminary evidence that Happify users with self-reported CVD risk factors including high blood pressure or cholesterol, diabetes, and heart disease experienced improved well-being and anxiety over time and that those who used Happify as recommended experienced greater improvements in these aspects of mental health than those who completed fewer activities. These findings extend previous research, which demonstrated that engagement with Happify as recommended was associated with improved well-being among physically healthy users and in those with chronic conditions, to a new population for whom mental health is especially critical: those at risk of developing CVD.

Psychological Problems among 12th-Grade Students Predicting Military Enlistment: Findings from the Monitoring the Future Survey.

Objective: Rates of some psychological disorders are higher among enlisted U.S. military personnel than socio-demographically matched civilians. Indirect evidence suggests some internalizing and externalizing psychological problems among enlistees onset prior to enlistment. However, the consistency and strength of the associations between pre-enlistment psychological problems and enlistment over time is unknown. We address this uncertainty by examining whether internalizing and externalizing problems in high school predicted subsequent military enlistment using a large cohort-sequential panel study. Method: The Monitoring the Future study administered baseline surveys from 1989-2014 and biennial follow-up surveys two and four years later to national samples of high-school seniors (N = 20,823). Validated self-report scales assessed internalizing (depression, low self-esteem) and externalizing (risk-taking, school misbehavior, conduct disorder, interpersonal violence, alcohol, and drug use) problems in each survey. Follow-up surveys assessed military enlistment. Logistic regression models were used to estimate associations of problems scales with subsequent enlistment. Results: School misbehavior in 12th grade, and risk-taking in 12th grade and two years after graduation were associated with significantly elevated odds of enlistment at follow-up. Although modest, these associations were linear and invariant across respondent sex and baseline survey year. Conclusions: School misbehavior and risk-taking predicted subsequent enlistment and there was no evidence of historical changes in these associations over the course of 25 years; these pre-enlistment psychological problems do not fully explain the high rates of psychological disorders among enlisted military personnel. Further research is needed to determine whether these predictors are associated with negative outcomes during or after military service.

Nonprofessional Peer Support to Improve Mental Health: Randomized Trial of a Scalable Web-Based Peer Counseling Course.

BACKGROUND: Millions of people worldwide are underserved by the mental health care system. Indeed, most mental health problems go untreated, often because of resource constraints (eg, limited provider availability and cost) or lack of interest or faith in professional help. Furthermore, subclinical symptoms and chronic stress in the absence of a mental illness diagnosis often go unaddressed, despite their substantial health impact. Innovative and scalable treatment delivery methods are needed to supplement traditional therapies to fill these gaps in the mental health care system. OBJECTIVE: This study aims to investigate whether a self-guided web-based course can teach pairs of nonprofessional peers to deliver psychological support to each other. METHODS: In this experimental study, a community sample of 30 dyads (60 participants, mostly friends), many of whom presented with mild to moderate psychological distress, were recruited to complete a web-based counseling skills course. Dyads were randomized to either immediate or delayed access to training. Before and after training, dyads were recorded taking turns discussing stressors. Participants' skills in the helper role were assessed before and after taking the course: the first author and a team of trained research assistants coded recordings for the presence of specific counseling behaviors. When in the client role, participants rated the session on helpfulness in resolving their stressors and supportiveness of their peers. We hypothesized that participants would increase the use of skills taught by the course and decrease the use of skills discouraged by the course, would increase their overall adherence to the guidelines taught in the course, and would perceive posttraining counseling sessions as more helpful and their peers as more supportive. RESULTS: The course had large effects on most helper-role speech behaviors: helpers decreased total speaking time, used more restatements, made fewer efforts to influence the speaker, and decreased self-focused and off-topic utterances (ds=0.8-1.6). When rating the portion of the session in which they served as clients, participants indicated that they made more progress in addressing their stressors during posttraining counseling sessions compared with pretraining sessions (d=1.1), but they did not report substantive changes in feelings of closeness and supportiveness of their peers (d=0.3). CONCLUSIONS: The results provide proof of concept that nonprofessionals can learn basic counseling skills from a scalable web-based course. The course serves as a promising model for the development of web-based counseling skills training, which could provide accessible mental health support to some of those underserved by traditional psychotherapy.

A test of the interpersonal theory of suicide in a large, representative, retrospective and prospective study: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The interpersonal theory of suicide hypothesizes that perceived burdensomeness, thwarted belongingness, and hopelessness lead to active suicidal thoughts and individuals with active suicidal thoughts and elevated capability for suicide are most likely to attempt suicide. We retrospectively and prospectively tested this theory in a large sample of 7677 U.S. Army soldiers followed post-deployment for up to nine months. The interaction of perceived burdensomeness and hopelessness (OR = 2.59) was significantly associated with lifetime suicidal thoughts; however, the interactions of thwarted belongingness and perceived burdensomeness and of thwarted belongingness and hopelessness were not. Consistent with the theory, capability for suicide prospectively predicted suicide attempts during and following deployment (OR = 1.22); however, among soldiers reporting lifetime suicidal thoughts, capability did not predict attempts, only perceived burdensomeness did (OR = 1.36). Results supported some, but not all, theory hypotheses, suggesting that additional constructs may be needed to better identify the psychological factors that lead soldiers to attempt suicide.

Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers.

Importance: Brief cognitive behavioral therapy (BCBT) is a clinically effective intervention for reducing risk of suicide attempts among suicidal US Army soldiers. However, because specialized treatments can be resource intensive, more information is needed on costs and benefits of BCBT compared with existing treatments. Objective: To evaluate the cost-effectiveness of BCBT compared with treatment as usual for suicidal soldiers in the US Army. Design, Setting, and Participants: A decision analytic model compared effects and costs of BCBT vs treatment as usual from a US Department of Defense (DoD) perspective. Model input data were drawn from epidemiologic data sets and a clinical trial among suicidal soldiers conducted from January 31, 2011, to April 3, 2014. Data were analyzed from July 3, 2018, to March 25, 2019. Interventions: The strategies compared were treatment as usual alone vs treatment as usual plus 12 individual BCBT sessions. Treatment as usual could include a range of pharmacologic and psychological treatment options. Main Outcomes and Measures: Costs in 2017 US dollars, suicide attempts averted (self-directed behavior with intent to die, but with nonfatal outcome), suicide deaths averted, and incremental cost-effectiveness ratios, assuming a 2-year time horizon for treatment differences but including lifetime costs. Results: In the base-case analysis, BCBT was expected to avert approximately 23 to 25 more suicide attempts and 1 to 3 more suicide deaths per 100 patients treated than treatment as usual. Sensitivity analyses assuming a range of treatment effects showed BCBT to be cost saving in most scenarios. Using the federal discount rate, the DoD was estimated to save from $15 000 to $16 630 per patient with BCBT vs treatment as usual. In a worst-case scenario (ie, assuming the weakest plausible BCBT effect sizes), BCBT cost an additional $1910 to $2250 per patient compared with treatment as usual. Conclusions and Relevance: Results suggest BCBT may be a cost-saving intervention for suicidal active-duty soldiers. The costs of ensuring treatment fidelity would also need to be considered when assessing the implications of disseminating BCBT across the entire DoD.

Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers.

BACKGROUND: Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide attempt (SA) during and shortly after deployment. METHODS: Data came from the Army Study to Assess Risk and Resilience in Servicemembers Pre-Post Deployment Survey (PPDS). Soldiers completed a baseline survey shortly before deploying to Afghanistan in 2011-2012. Survey measures were used to predict SAs, defined using administrative and subsequent survey data, through 30 months after deployment. Models were built using penalized regression and ensemble machine learning methods. RESULTS: Significant pre-deployment risk factors were history of traumatic brain injury, 9 + mental health treatment visits in the 12 months before deployment, young age, female, previously married, and low relationship quality. Cross-validated AUC of the best penalized and ensemble models were .75-.77. 21.3-40.4% of SAs occurred among the 5-10% of soldiers with highest predicted risk and positive predictive value (PPV) among these high-risk soldiers was 4.4-5.7%. CONCLUSIONS: SA can be predicted significantly from pre-deployment data, but intervention planning needs to take PPV into consideration.

Assessment of a Risk Index for Suicide Attempts Among US Army Soldiers With Suicide Ideation: Analysis of Data From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

Importance: The Department of Veterans Affairs recently began requiring annual suicide ideation (SI) screening of all patients and additional structured questions for patients reporting SI. Related changes are under consideration at the Department of Defense. These changes will presumably lead to higher SI detection, which will require hiring additional clinical staff and/or developing a clinical decision support system to focus in-depth suicide risk assessments on patients considered high risk. Objective: To carry out a proof-of-concept study for whether a brief structured question battery from a survey of US Army soldiers can help target in-depth suicide risk assessments by identifying soldiers with self-reported lifetime SI who are at highest risk of subsequent administratively recorded nonfatal suicide attempts (SAs). Design, Setting, and Participants: Cohort study with prospective observational design. Data were collected from May 2011 to February 2013. Participants were followed up through December 2014. Analyses were conducted from March to November 2018. A logistic regression model was used to assess risk for subsequent administratively recorded nonfatal SAs. A total of 3649 Regular Army soldiers in 3 Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) surveys who reported lifetime SI were followed up for 18 to 45 months from baseline to assess administratively reported nonfatal SAs. Main Outcomes and Measures: Outcome was administratively recorded nonfatal SAs between survey response and December 2014. Predictors were survey variables. Results: The 3649 survey respondents were 80.5% male and had a median (interquartile range) age of 29 (25-36) years (range, 18-55 years); 69.4% were white non-Hispanic, 14.6% were black, 9.0% were Hispanic, 7.0% were another racial/ethnic group. Sixty-five respondents had administratively recorded nonfatal SAs between survey response and December 2014. One additional respondent died by suicide without making a nonfatal SA but was excluded from analysis based on previous evidence that predictors are different for suicide death and nonfatal SAs. Significant risk factors were SI recency (odds ratio [OR], 7.2; 95% CI, 2.9-18.0) and persistence (OR, 2.6; 95% CI, 1.0-6.8), positive screens for mental disorders (OR, 26.2; 95% CI, 6.1-112.0), and Army career characteristics (OR for junior enlisted rank, 30.0; 95% CI, 3.3-272.5 and OR for senior enlisted rank, 6.7; 95% CI, 0.8-54.9). Cross-validated area under the curve was 0.78. The 10% of respondents with highest estimated risk accounted for 39.2% of subsequent SAs. Conclusions and Relevance: Results suggest the feasibility of developing a clinically useful risk index for SA among soldiers with SI using a small number of self-report questions. If implemented, a continuous quality improvement approach should be taken to refine the structured question series.

Predicting suicide attempts among soldiers who deny suicidal ideation in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

Most nonfatal suicide attempts and suicide deaths occur among patients who deny suicidal ideation (SI) during suicide risk screenings. Little is known about risk factors for suicidal behaviors among such patients. We investigated this in a representative sample of U.S. Army soldiers who denied lifetime SI in a survey and were then followed through administrative records for up to 45 months to learn of administratively-recorded suicide attempts (SA). A novel two-stage risk assessment approach was used that combined first-stage prediction from administrative records to find the subsample of SI deniers with highest subsequent SA risk and then used survey reports to estimate a second-stage model identifying the subset of individuals in the high-risk subsample at highest SA risk. 70% of survey respondents denied lifetime SI. Administrative data identified 30% of this 70% who accounted for 81.2% of subsequent administratively-recorded SAs. A relatively small number of self-report survey variables were then used to create a prediction model that identified 10% of the first-stage high-risk sample (i.e., 3% of all soldiers) at highest SA risk (accounting for 45% of SAs in the total sample). We close by discussing potential applications of this approach for identifying future SI deniers at highest SA risk.

Patient baseline interpersonal problems as moderators of outcome in two psychotherapies for bulimia nervosa.

Objective: We tested an aptitude by treatment interaction; namely, whether patients' baseline interpersonal problems moderated the comparative efficacy of cognitive-behavioral therapy (CBT) vs. interpersonal psychotherapy (IPT) for bulimia nervosa (BN). Method: Data derived from a randomized-controlled trial. Patients reported on their interpersonal problems at baseline; purge frequency at baseline, midtreatment, and posttreatment; and global eating disorder severity at baseline and posttreatment. We estimated the rate of change in purge frequency across therapy, and the likelihood of attaining clinically meaningful improvement (recovery) in global eating disorder severity by posttreatment. We then tested the interpersonal problem by treatment interactions as predictors of both outcomes. Results: Patients with more baseline overly communal/friendly problems showed steeper reduction in likelihood of purging when treated with CBT vs. IPT. Patients with more problems of being under communal/cold had similar reductions in likelihood of purging across both treatments. Patients with more baseline problems of being overly agentic were more likely to recover when treated with IPT vs. CBT, whereas patients with more problems of being under agentic were more likely to recover when treated with CBT vs. IPT. Conclusions: Interpersonal problems related to communion and agency may inform treatment fit among two empirically supported therapies for BN.

Improving risk prediction accuracy for new soldiers in the U.S. Army by adding self-report survey data to administrative data.

BACKGROUND: High rates of mental disorders, suicidality, and interpersonal violence early in the military career have raised interest in implementing preventive interventions with high-risk new enlistees. The Army Study to Assess Risk and Resilience in Servicemembers (STARRS) developed risk-targeting systems for these outcomes based on machine learning methods using administrative data predictors. However, administrative data omit many risk factors, raising the question whether risk targeting could be improved by adding self-report survey data to prediction models. If so, the Army may gain from routinely administering surveys that assess additional risk factors. METHODS: The STARRS New Soldier Survey was administered to 21,790 Regular Army soldiers who agreed to have survey data linked to administrative records. As reported previously, machine learning models using administrative data as predictors found that small proportions of high-risk soldiers accounted for high proportions of negative outcomes. Other machine learning models using self-report survey data as predictors were developed previously for three of these outcomes: major physical violence and sexual violence perpetration among men and sexual violence victimization among women. Here we examined the extent to which this survey information increases prediction accuracy, over models based solely on administrative data, for those three outcomes. We used discrete-time survival analysis to estimate a series of models predicting first occurrence, assessing how model fit improved and concentration of risk increased when adding the predicted risk score based on survey data to the predicted risk score based on administrative data. RESULTS: The addition of survey data improved prediction significantly for all outcomes. In the most extreme case, the percentage of reported sexual violence victimization among the 5% of female soldiers with highest predicted risk increased from 17.5% using only administrative predictors to 29.4% adding survey predictors, a 67.9% proportional increase in prediction accuracy. Other proportional increases in concentration of risk ranged from 4.8% to 49.5% (median = 26.0%). CONCLUSIONS: Data from an ongoing New Soldier Survey could substantially improve accuracy of risk models compared to models based exclusively on administrative predictors. Depending upon the characteristics of interventions used, the increase in targeting accuracy from survey data might offset survey administration costs.

For whom does interpersonal psychotherapy work? A systematic review.

The efficacy of interpersonal psychotherapy (IPT) to treat depression and other disorders is well established, yet it remains unknown which patients will benefit more from IPT than another treatment. This review summarizes 46years of clinical trial research on patient characteristics that moderate the relative efficacy of IPT vs. different treatments. Across 57 studies from 33 trials comparing IPT to pharmacotherapy, another psychotherapy, or control, there were few consistent indicators of when IPT would be more or less effective than another treatment. However, IPT may be superior to school counseling for adolescents with elevated interpersonal conflict, and to minimal controls for patients with severe depression. Cognitive-behavioral therapy may outpace IPT for patients with avoidant personality disorder symptoms. There was some preliminary evidence that IPT is more beneficial than alternatives for patients in some age groups, African-American patients, and patients in an index episode of depression. The included studies suffered from several limitations and high risk of Type I and II error. Obstacles that may explain the difficulty in identifying consistent moderators, including low statistical power and heterogeneity in samples and treatments, are discussed. Possible remedies include within-subjects designs, manipulation of single treatment ingredients, and strategies for increasing power such as improving measurement.

Therapeutic alliance, subsequent change, and moderators of the alliance-outcome association in interpersonal psychotherapy for depression.

The therapeutic alliance has historically emerged as a pantheoretical correlate of favorable psychotherapy outcomes. However, uncertainty remains about the direction of the alliance-outcome link, and whether it is affected by other contextual variables. The present study explored (a) if early alliance quality predicted subsequent symptom change while controlling for the effect of prior symptom change in interpersonal psychotherapy (IPT) for depression, and (b) whether baseline patient characteristics moderated the alliance-outcome relation (to help specify conditions under which alliance predicts change). Data derived from an open trial of 16 sessions of individual IPT delivered naturalistically to adult outpatients (N = 119) meeting criteria for major depression. Patients rated their sociodemographic, clinical, and interpersonal characteristics at baseline, their alliance with their therapist at Session 3, and their depressive symptoms at baseline, after every session, and at posttreatment. Data were analyzed using hierarchical linear modeling. Results indicated that alliance quality did not predict subsequent depression change, controlling for prior depression change. However, a significant education by alliance interaction emerged in predicting quadratic depression change (γ = .0007, p = .03); patients with higher levels of education who reported good early alliances with their therapists had the most positively accelerated change trajectory (i.e., faster depression reduction), whereas patients with higher levels of education who reported poorer early alliances had the most negatively accelerated change trajectory (i.e., slower depression reduction). The findings may help clarify a specific condition under which alliance quality influences subsequent improvement in an evidence-based treatment for depression. (PsycINFO Database Record

A Web-Disseminated Self-Help and Peer Support Program Could Fill Gaps in Mental Health Care: Lessons From a Consumer Survey.

BACKGROUND: Self-guided mental health interventions that are disseminated via the Web have the potential to circumvent barriers to treatment and improve public mental health. However, self-guided interventions often fail to attract consumers and suffer from user nonadherence. Uptake of novel interventions could be improved by consulting consumers from the beginning of the development process in order to assess their interest and their preferences. Interventions can then be tailored using this feedback to optimize appeal. OBJECTIVE: The aim of our study was to determine the level of public interest in a new mental health intervention that incorporates elements of self-help and peer counseling and that is disseminated via a Web-based training course; to identify predictors of interest in the program; and to identify consumer preferences for features of Web-based courses and peer support programs. METHODS: We surveyed consumers via Amazon's Mechanical Turk to estimate interest in the self-help and peer support program. We assessed associations between demographic and clinical characteristics and interest in the program, and we obtained feedback on desired features of the program. RESULTS: Overall, 63.9% (378/592) of respondents said that they would try the program; interest was lower but still substantial among those who were not willing or able to access traditional mental health services. Female gender, lower income, and openness to using psychotherapy were the most consistent predictors of interest in the program. The majority of respondents, although not all, preferred romantic partners or close friends as peer counselors and would be most likely to access the program if the training course were accessed on a stand-alone website. In general, respondents valued training in active listening skills. CONCLUSIONS: In light of the apparent public interest in this program, Web-disseminated self-help and peer support interventions have enormous potential to fill gaps in mental health care. The results of this survey can be used to inform the design of such interventions.

Attachment style as a moderating influence on the efficacy of cognitive-behavioral and interpersonal psychotherapy for depression: A failure to replicate.

Research on aptitude-treatment interactions, or patient characteristics that are associated with better outcome in one treatment than another, can help assign patients to the treatments that will be most personally effective. Theory and one past study suggest that adult attachment style might influence whether depressed patients respond better to cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT). Spurred by inconsistency in past aptitude-treatment interaction research in general, as well as concerns about the reproducibility of psychological research, we sought to replicate and extend the previous study that showed that high attachment avoidance was associated with greater depression reduction in CBT than in IPT and to improve upon that study methodologically. Using longitudinal hierarchical linear modeling, the present study examined whether, among 69 adults randomly assigned to CBT or IPT, rate of change in severity of depression symptoms was predicted by treatment condition, attachment style, and their interaction. We also conducted regression analyses to determine whether posttreatment depression was predicted by the same variables. As expected, CBT and IPT were equivalent in efficacy; however, unlike in the previous trial, there were no moderation effects of attachment. Interestingly, in some analyses, anxious attachment was associated with more positive outcomes and avoidant attachment with more negative outcomes across both treatments. The findings highlight the need for researchers to attempt replications of past studies using methods that might elucidate the reasons for discrepancies in results, and they also suggest that alternative approaches to aptitude-treatment interaction research may be more fruitful.

Bridging the common factors and empirically supported treatment camps: comment on Laska, Gurman, and Wampold.

We comment on Laska, Gurman, and Wampold's (2014, pp. 467-481) article, "Expanding the Lens of Evidence-Based Practice in Psychotherapy: A Common Factors Perspective." Our reactions to this scholarly review of the 2 foremost approaches to evidence-based psychotherapy (i.e., the common factors [CF] and the empirically supported treatment [EST] perspectives) include substantial agreement on many points, some attempts to reframe the ostensible gap between the perspectives, and our own attempt to conceptually and empirically bridge the perspectives in the form of a model that we call context-responsive psychotherapy integration. We also offer potential future research directions that can help elevate the scientific credibility of the CF model and allow CF and EST researchers to unite in uncovering clinical change mechanisms.

A meta-analysis of the relation between patient adult attachment style and the working alliance.

This meta-analysis synthesizes research on the relation between patient adult attachment style and patient-rated working alliance. A random-effects model was used to calculate the mean weighted product-moment correlation (r) for 24 studies (12 published in peer-reviewed journals and 12 unpublished doctoral dissertations) of individual outpatient therapy with adults. The mean weighted r for attachment avoidance and alliance was -.137, p<.001, and the mean weighted r for attachment anxiety and alliance was -.121, p<.001. These findings suggest that therapists should attend to attachment in order to foster alliance and have additional implications for theory and future research.

Patient interpersonal and cognitive changes and their relation to outcome in interpersonal psychotherapy for depression.

OBJECTIVE: Despite interpersonal psychotherapy's (IPT) efficacy for depression, little is known about its change-promoting ingredients. This exploratory study examined candidate change mechanisms by identifying whether patients' interpersonal and cognitive characteristics change during IPT and whether such changes relate to outcomes. METHOD: Patients were 95 depressed adults receiving manualized IPT. We used multilevel modeling to assess the relation between change in each interpersonal and cognitive domain and outcome. RESULTS: Across all interpersonal and cognitive variables measured, patients showed significant improvement. Unexpectedly, reduced romantic relationship adjustment was related to posttreatment depression reduction (ß = 2.028, p = .008, self-rated; ß = 1.474, p = .022, clinician-rated). For the other measured domains, change was not significantly associated with outcome (though changes in some interpersonal variables evidenced a trend-level relation to outcome). CONCLUSIONS: Possible reciprocal influences among IPT, depression, and romantic relationship functioning are discussed, as are implications for future research.

Baseline patient characteristics as predictors of remission in interpersonal psychotherapy for depression.

We examined patient characteristics as remission predictors in interpersonal psychotherapy (IPT) for depression (n=95). Four characteristic domains (sociodemographic, clinical/diagnostic, interpersonal, cognitive) were analyzed using receiver operating characteristic analysis. Remission was defined two ways: (a) posttreatment BDI-II beyond population-based cut-scores for reliable and clinically significant change, and (b) posttreatment BDI-II≤10. Across both definitions, patients most likely to remit had lower mean item ratings (<3.75 and<3.25, respectively) on the fearful attachment dimension of the Relationship Scales Questionnaire (χ2 =7.172, p<.01 and χ2 =7.792, p<.01, respectively). For the second definition only, more fearfully attached patients who were ≤25 years of age at index depression onset were more likely to remit (χ2 =7.617, p<.01) than those >25. The findings contribute to the scant literature on patient factors related to remission following IPT.

Attachment style.

Attachment theory, developed by Bowlby to explain human bonding, has profound implications for conducting and adapting psychotherapy. We summarize the prevailing definitions and measures of attachment style. We review the results of three meta-analyses examining the association between attachment anxiety, avoidance, and security and psychotherapy outcome. Fourteen studies were synthesized, which included 19 separate therapy cohorts with a combined sample size of 1,467. Attachment anxiety showed a d of -.46 with posttherapy outcome, while attachment security showed a d of.37 association with outcome. Attachment avoidance was uncorrelated with outcome. The age and gender composition of the samples moderated the relation between attachment security and outcome: samples with a higher proportion of female clients and a higher mean age showed a smaller relation between security and outcome. We discuss the practice implications of these findings and related research on the link between attachment and the therapy relationship.