Pretreatment depression severity in breast cancer patients and its relation to treatment response to behavior therapy.

OBJECTIVE: Major depressive disorder is prevalent in breast cancer patients. There is a paucity of research on variables associated with depression severity and the link between depression severity and response to psychotherapy. To provide optimal mental health services to breast cancer patients, examining correlates of depression severity and its relation to treatment response is critical. METHOD: In the context of a randomized trial of behavior activation and problem-solving therapy for depressed breast cancer patients, this study evaluated demographic (marital status, age, education), psychosocial (social support, environmental reward, anxiety, number of coexistent anxiety disorders), and cancer-related (bodily pain, length of diagnosis, cancer stage) variables associated with pretreatment depression severity. Second, the relation of pretreatment depression severity with posttreatment and 12-month response and remission was assessed. RESULTS: For pretreatment depression severity, the overall regression model accounted for 40% of the variance, F(5, 74) = 9.87, p < .001. Less environmental reward and greater somatic anxiety were significantly and uniquely associated with depression severity. Depression severity was unrelated to treatment remission but was a significant moderator of treatment response at posttreatment and 12-month follow-up; individuals with higher depression severity were more responsive to therapy. For patients treated with behavior activation, environmental reward significantly mediated the relationship between pre- and posttreatment depression. CONCLUSIONS: Consistent with behavioral models of depression, less environmental reward and greater anxiety might influence depression severity in breast cancer patients. Data support the efficacy of behavior therapy for breast cancer patients, particularly those with more severe depression.

Evaluation of underlying mechanisms in the link between childhood ADHD symptoms and risk for early initiation of substance use.

Although there has been support for attention-deficit/hyperactivity disorder (ADHD) as a risk for early substance use, this link is not fully established or understood. Furthermore, the potential mechanisms explaining these associations are unclear. The current study examined peer rejection, school bonding, and internalizing problems as potential mediators of the association between childhood ADHD symptoms and risk for early initiation of substance use. The sample included a control group of 126 students with problematic aggression (79% African American, 66% male) from an intervention study following children from fourth to ninth grade. Results suggested that ADHD symptoms follow a path to early initiation of tobacco use through the combined effects of peer rejection and internalizing problems as well as through internalizing problems alone. ADHD symptoms were also associated with the cubic slope of marijuana use initiation, such that increased ADHD symptoms were associated with a strong cubic trend (e.g., a more rapid acceleration of risk for initiation). ADHD symptoms were not associated with risk for early initiation of alcohol use. Identification of important vulnerability factors in children with ADHD symptoms highlight the need for primary prevention and psychological interventions that target these factors and decrease the likelihood of early tobacco and marijuana use initiation.

Behavioral activation for depressed breast cancer patients: the impact of therapeutic compliance and quantity of activities completed on symptom reduction.

OBJECTIVE: Behavioral activation (BA) is an empirically validated treatment that reduces depression by increasing overt behaviors and exposure to reinforcing environmental contingencies. Although research has identified an inverse correlation between pleasant or rewarding activities and depression, the causal relation between increased structured activities and reduced depression has not directly been studied. METHOD: In the context of a recent randomized trial (Hopko, Armento, et al., 2011), this study used longitudinal data and growth curve modeling to examine relationships among the quantity of activities completed, proportion of activities completed (i.e., therapeutic compliance), environmental reward, and depression in breast cancer patients treated with BA treatment for depression (n = 23). RESULTS: Therapeutic compliance with assigned activities was causally related to depression reduction, whereas the specific quantity of completed activities was not systematically related. Logistic regression indicated that for patients completing all assigned activities, treatment response and remission were achieved for all patients. Neither therapeutic compliance nor the quantity of completed activities was directly associated with self-reported environmental reward during the BA interval (Session 3 to posttreatment), and environmental reward did not mediate the relation between activation and depression. CONCLUSIONS: Patient compliance with BA assignments is causally associated with depression reduction, whereas the quantity of completed activities is less relevant toward conceptualizing positive treatment outcome. Study findings are discussed in the context of behavioral models of depression and BA therapy.

Pragmatic psychodynamic psychotherapy for a patient with depression and breast cancer: functional MRI evaluation of treatment effects.

Time-limited psychodynamic psychotherapy is garnering empirical support as an intervention for clinical depression. However, research is needed to examine the efficacy of psychodynamic approaches among patients presenting with diverse psychiatric and medical problems. This case study examined the efficacy of eight sessions of pragmatic psychodynamic psychotherapy (PPP) in treating a woman with major depression and breast cancer. Pre- to posttreatment assessment indicated significant reductions in depression and weekly assessment indicated increased environmental reward was associated with reduced depression. Secondary aims involved piloting a functional magnetic resonance imaging (fMRI) task as a neurobiological indicator of depression attenuation as a function of PPP. This assessment was conducted to explore alternative means of evaluating treatment responsiveness and addressing the problem of arbitrary metrics in measuring change. Clinical and assessment implications are discussed, with a focus on innovative approaches to evaluate treatment outcome and behavioral and neurobiological mechanisms of change associated with PPP.

Neural Changes following Behavioral Activation for a Depressed Breast Cancer Patient: A Functional MRI Case Study.

Functional neuroimaging is an innovative but at this stage underutilized method to assess the efficacy of psychotherapy for depression. Functional magnetic resonance imaging (fMRI) was used in this case study to examine changes in brain activity in a depressed breast cancer patient receiving an 8-session Behavioral Activation Treatment for Depression (BATD), based on the work of Hopko and Lejuez (2007). A music listening paradigm was used during fMRI brain scans to assess reward responsiveness at pre- and posttreatment. Following treatment, the patient exhibited attenuated depression and changes in blood oxygenation level dependence (BOLD) response in regions of the prefrontal cortex and the subgenual cingulate cortex. These preliminary findings outline a novel means to assess psychotherapy efficacy and suggest that BATD elicits functional brain changes in areas implicated in the pathophysiology of depression. Further research is necessary to explore neurobiological mechanisms of change in BATD, particularly the potential mediating effects of reward responsiveness and associated brain functioning.

Gender Differences in Depression: Assessing Mediational Effects of Overt Behaviors and Environmental Reward through Daily Diary Monitoring.

Gender differences in the prevalence of depression are well documented. To further explore the relation between gender and depression, this study used daily diaries to examine gender differences within thirteen behavioral domains and whether differential frequency of overt behaviors and environmental reward mediated the relationship between gender and depression severity. The sample included 82 undergraduate students [66% females; 84% Caucasian; Mean age = 20.2 years]. Overall, females engaged in a significantly greater breadth of behavioral domains and reported a higher level of environmental reward. Females spent more time in the domains of health/hygiene, spiritual activities, and eating with others. Males spent more time in the domains of physical activity, sexual activity, and hobbies and recreational experiences. Females found social activities, passive/sedentary behaviors, eating with others, and engagement in "other" activities more rewarding. Gender had a significant direct effect on depression severity, with females reporting increased depression. This effect was attenuated by the mediator (total environmental reward) such that to the extent females exhibited increased environmental reward, the gender effect on depression was attenuated. These data support behavioral models of depression, indicate increased reinforcement sensitivity among females, and have clinical relevance in the context of assessment and behavioral activation interventions for depression.

Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial.

OBJECTIVE: Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression. METHOD: In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes. RESULTS: Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group. CONCLUSIONS: BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.

Treatment failure in behavior therapy: focus on behavioral activation for depression.

Behavioral activation (BA) has come to be recognized as an empirically supported treatment for depression. Despite the general success of the approach, many patients experience treatment failure. Based on behavioral models of depression, we present several reasons for treatment failure in BA, including patient inability to understand and adopt the treatment rationale, lack of awareness or ability to articulate and behave according to life values, behavioral noncompliance, and ineffectiveness of contingency management to increase exposure to environmental rewards and reduce contact with both aversive environmental events and reinforcement of depressed behavior. A case study of treatment failure with a depressed breast cancer patient is presented, along with recommendations to reduce failure rates in BA.

The reward probability index: design and validation of a scale measuring access to environmental reward.

Behavioral models of depression implicate decreased response-contingent positive reinforcement (RCPR) as critical toward the development and maintenance of depression (Lewinsohn, 1974). Given the absence of a psychometrically sound self-report measure of RCPR, the Reward Probability Index (RPI) was developed to measure access to environmental reward and to approximate actual RCPR. In Study 1 (n=269), exploratory factor analysis supported a 20-item two-factor model (Reward Probability, Environmental Suppressors) with strong internal consistency (α=.90). In Study 2 (n=281), confirmatory factor analysis supported this two-factor structure and convergent validity was established through strong correlations between the RPI and measures of activity, avoidance, reinforcement, and depression (r=.65 to .81). Discriminant validity was supported via smaller correlations between the RPI and measures of social support and somatic anxiety (r=-.29 to -.40). Two-week test-retest reliability was strong (r=.69). In Study 3 (n=33), controlling for depression symptoms, hierarchical regression supported the incremental validity of the RPI in predicting daily diary reports of environmental reward. The RPI represents a parsimonious, reliable, and valid measure that may facilitate understanding of the etiology of depression and its relationship to overt behaviors.

The impact of decreased environmental reward in predicting depression severity: support for behavioral theories of depression.

Insufficient response-contingent positive reinforcement and decreased environmental reward have been hypothesized to directly contribute to the onset and persistence of depression. The present study examined whether decreased environmental reward was significantly associated with self-reported depression and diagnosed major depression relative to other well-established risk factors that included gender, stressful life events, traumatic life events, childhood maltreatment, and cognitive vulnerability. Based on hierarchical regression analyses, all variables except gender were significantly associated with self-reported depression, and stressful life events, cognitive vulnerability, and decreased environmental reward were associated with diagnosed depression. Of all variables, decreased environmental reward was most strongly related to both self-reported depression and diagnosed clinical depression. The incremental validity of environmental reward in predicting self-reported depression and clinical depression was established, accounting for significant unique variance (12%) in each regression equation. Implications for conceptualizing and treating depression are discussed.

Behavioral theory of depression: reinforcement as a mediating variable between avoidance and depression.

Behavioral theory posits that certain environmental changes and avoidant behaviors inhibit individuals from experiencing environmental reward and reinforcement and subsequently leads to the development and maintenance of depressive symptoms. Using self-report and behavioral (daily diary) indices of environmental reward as proxy measures for positive reinforcement, this investigation examined whether environmental reward mediated the relationship between avoidance and depression. When controlling for anxiety, both indices of environmental reward significantly mediated the relationships of depression with cognitive, behavioral and total avoidance. Post-hoc mediation analyses were conducted to examine potential gender differences. Self-reported environmental reward significantly mediated the relationship between avoidance and depression across both genders. Among females, however, daily diary-measured reward only mediated the relation between cognitive avoidance and depression. In males daily diary reward was a mediator with all three forms of avoidance and depression. This investigation provides initial support for reinforcement as a significant mediator between avoidance and depression and further highlights the relevance of avoidance and reinforcement in behavioral conceptualizations of depression.

Ten year revision of the brief behavioral activation treatment for depression: revised treatment manual.

Following from the seminal work of Ferster, Lewinsohn, and Jacobson, as well as theory and research on the Matching Law, Lejuez, Hopko, LePage, Hopko, and McNeil developed a reinforcement-based depression treatment that was brief, uncomplicated, and tied closely to behavioral theory. They called this treatment the brief behavioral activation treatment for depression (BATD), and the original manual was published in this journal. The current manuscript is a revised manual (BATD-R), reflecting key modifications that simplify and clarify key treatment elements, procedures, and treatment forms. Specific modifications include (a) greater emphasis on treatment rationale, including therapeutic alliance; (b) greater clarity regarding life areas, values, and activities; (c) simplified (and fewer) treatment forms; (d) enhanced procedural details, including troubleshooting and concept reviews; and (e) availability of a modified Daily Monitoring Form to accommodate low literacy patients. Following the presentation of the manual, the authors conclude with a discussion of the key barriers in greater depth, including strategies for addressing these barriers.

Examining the effect of the Life Enhancement Treatment for Substance Use (LETS ACT) on residential substance abuse treatment retention.

Effective, parsimonious behavioral interventions that target reinforcement are needed for substance users with depression to improve mood as well as treatment retention. The Life Enhancement Treatment for Substance Use (LETS ACT; Daughters et al., 2008) is a behavioral activation-based approach tailored to increase levels of positive reinforcement among depressed substance users while in substance abuse treatment. The current study tested the efficacy of LETS ACT compared to a contact-time matched control condition, supportive counseling (SC), examining effects on depressed mood, substance abuse treatment retention, and behavioral activation outcomes. Fifty-eight adult substance users in residential substance abuse treatment presenting with depressive symptoms (BDI≥12) were randomly assigned to LETS ACT or SC. Assessments were administered at pre- and post-treatment and included assessment of DSM-IV psychiatric diagnoses, depression severity, treatment motivation, overall activation, environmental reward, and substance abuse treatment retention. Patients in LETS ACT had significantly higher rates of substance abuse treatment retention and significantly greater increases in activation on the Behavioral Activation for Depression Scale (BADS) compared to those in SC. Both groups had decreased depression severity at post-treatment, although the group by time interaction was not significant. This study was the first to compare LETS ACT to a contact-time matched control treatment to evaluate effects on substance abuse treatment retention and two distinct measures of behavioral activation: overall activation and environmental reward. Findings suggest preliminary support for the feasibility, tolerability, and efficacy of a brief behavioral activation-based protocol that may be particularly useful to improve substance abuse treatment retention.

Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms.

OBJECTIVE: Depressive symptoms are associated with poor smoking cessation outcomes, and there remains continued interest in behavioral interventions that simultaneously target smoking and depressive symptomatology. In this pilot study, we examined whether a behavioral activation treatment for smoking (BATS) can enhance cessation outcomes. METHOD: A sample of 68 adult smokers with mildly elevated depressive symptoms (M = 43.8 years of age; 48.5% were women; 72.7% were African American) seeking smoking cessation treatment were randomized to receive either BATS paired with standard treatment (ST) smoking cessation strategies including nicotine replacement therapy (n = 35) or ST alone including nicotine replacement therapy (n = 33). BATS and ST were matched for contact time and included 8 sessions of group-based treatment. Quit date was assigned to occur at Session 4 for each treatment condition. Participants completed a baseline assessment; furthermore, measures of smoking cessation outcomes (7-day verified point-prevalence abstinence), depressive symptoms (Beck Depression Inventory-II; Beck, Steer, & Brown, 1996), and enjoyment from daily activities (Environmental Reward Observation Scale; Armento & Hopko, 2007) were obtained at 1, 4, 16, and 26 weeks post assigned quit date. RESULTS: Across the follow-ups over 26 weeks, participants in BATS reported greater smoking abstinence (adjusted odds ratio = 3.59, 95% CI [1.22, 10.53], p = .02) than did those in ST. Participants in BATS also reported a greater reduction in depressive symptoms (B = -1.99, SE = 0.86, p = .02) than did those in ST. CONCLUSIONS: Results suggest BATS is a promising intervention that may promote smoking cessation and improve depressive symptoms among underserved smokers of diverse backgrounds.

Sudden gains in depressed cancer patients treated with behavioral activation therapy.

Many patients who receive cognitive-behavioral therapy experience sudden gains that are associated with improved treatment response and decreased risk of relapse. Extending prior research, this study examined sudden gains among depressed cancer patients receiving brief (9-session) behavioral activation therapy. Fifty percent of patients experienced sudden gains of large magnitude (M=11.8 BDI-II points), with sudden gains associated with improved treatment response and maintenance of gains at 3-month follow-up. Relative to those without sudden gains, at pretreatment assessment, cancer patients with sudden gains were more likely to present with less severe depression, less somatic anxiety, fewer coexistent anxiety disorders, as well as less bodily pain, better overall physical functioning, and fewer problems with daily activities as a result of emotional problems. These findings provide increasing support for behavioral activation with a difficult-to-treat population but raise important questions regarding mechanism of change. Clinical implications for treating depressed cancer patients are discussed.

Predicting high school truancy among students in the Appalachian south.

Truancy is a considerable problem among adolescents. Considering the historical emphasis on studying truancy in urban regions, a concerted effort is needed to extend this research into rural areas to examine cultural generalizability of findings. The purpose of this study was to assess variables associated with truancy in a rural sample (N = 367) of students attending high school in a southern rural region of the Appalachian Mountains. The primary objective was to assess the relative predictive strength of the following variables: academic performance, religiosity, environmental factors (family structure, parental education, and adolescent perceptions of family functioning), internalizing problems (anxiety, depression, thought problems, attentional problems), externalizing problems (substance use and rule-breaking behaviors), and prosocial overt behaviors (participation in school and leadership activities). Regression analysis indicated that truancy was significantly associated with poor school performance, increased depression, social problems, having a less educated mother, a less structured home environment, higher grade, and decreased participation in school sports. EDITORS' STRATEGIC IMPLICATIONS: These findings are critical for the understanding of truancy in rural areas, and they highlight contextual factors that must be identified and addressed through systematic prevention programs targeting adolescents at risk for truancy.

Experiential avoidance: a moderator of the relationship between age and emotional expression.

OBJECTIVES: Experiential avoidance (EA) is the unwillingness to remain in contact with particular private experiences, and higher levels of EA are associated with increased psychopathology. This study explored relationships between EA, age, and the use of emotion words in positive and negative autobiographical narratives. METHOD: Participants included younger (n = 60) and older adults (n = 60) who completed a measure of EA and described a positive and negative autobiographical narrative. RESULTS: In the positive autobiographical narrative, there was a significant interaction between age and EA whereby among low EA participants, younger adults used more emotion words than older adults. In the negative autobiographical narrative, there was a main effect of age in which older adults utilized fewer emotional words and a significant interaction whereby among high EA participants, younger adults used more emotion words than older adults. CONCLUSION: Results are explained in the developmental context of Socioemotional Selectivity Theory (Carstensen, 1991), which posits that older adults may be more likely to verbally communicate in a style characterized by emotion regulation. Research and clinical implications are discussed.

Exploring the relation of depression and overt behavior with daily diaries.

Behavioral models of depression highlight decreased response-contingent positive reinforcement as critical toward conceptualizing depressive affect, decreased reinforcement being caused by changes in the quantitative (i.e., number or intensity) or qualitative (i.e., type or function) aspects of reinforcing events, availability of reinforcement, inadequate instrumental behaviors, and/or an increased frequency of punishment [Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. M. Friedman, & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. New York: Wiley]. Building on previous research and addressing methodological limitations, this study utilized a daily diary method and behavioral coding system to directly assess whether qualitative aspects (or types) of human behavior differed as a function of depression level. Relative to non-depressed individuals, mildly depressed participants engaged less frequently in social, physical, and educational behaviors and more frequently in employment-related activities. These data support behavioral models of depression and have clinical relevance as highlighted with reference to behavioral activation interventions for depression.

Cognitive-behavior therapy for depressed cancer patients in a medical care setting.

Major depression is the most common psychiatric disorder among cancer patients and is associated with decreased quality of life, significant deterioration in recreational and physical activities, relationship difficulties, sleep problems, more rapidly progressing cancer symptoms, and more metastasis and pain relative to nondepressed cancer patients. Although some research has explored the utility of psychological interventions with cancer patients, only one study to date has explored the potential benefits of cognitive-behavior therapy among cancer patients with well-diagnosed depression. Addressing this gap in the literature, this study represents an open clinical trial to assess the effectiveness of a brief Cognitive-Behavioral Treatment for Depression (CBTD) among depressed cancer patients in a medical care setting. Results revealed strong treatment integrity, good patient compliance, excellent patient satisfaction with the CBTD protocol, and significant pre-post treatment gains across a breadth of outcome measures assessing depression, anxiety, quality of life, and medical outcomes. These gains also were associated with strong effect sizes and generally maintained at 3-month follow-up. Behavioral activation interventions, especially when paired with cognitive techniques, may represent a practical medical care treatment that may improve psychological outcomes and quality of life among cancer patients. Study limitations and future research directions are discussed.

Effectiveness of a brief behavioral treatment for inner-city illicit drug users with elevated depressive symptoms: the life enhancement treatment for substance use (LETS Act!).

OBJECTIVE: Depression is highly prevalent among illicit drug users, and this co-occurrence is associated with poorer treatment outcomes. However, there has been limited empirical attention toward developing and assessing behavioral interventions for depression among illicit drug users. The objective of the current study was to test the efficacy of integrating a brief behavioral intervention for depression into standard inpatient substance abuse treatment. METHOD: Forty-four adult illicit drug users with mild to moderate depressive symptoms (Beck Depression Inventory-II [BDI-II] score >or= 10) who were receiving inpatient substance abuse treatment were randomly assigned to either treatment as usual (TAU) alone or TAU plus brief behavioral therapy for depression (i.e., Life Enhancement Treatment for Substance Use [LETS Act!]). Patients were assessed at baseline for DSM-IV psychiatric diagnoses, depressive symptoms (Hamilton Rating Scale for Depression, BDI-II), anxiety symptoms (Beck Anxiety Inventory), and enjoyment and reward value of activities (Environmental Reward Observation Scale). Patients were again assessed at posttreatment and at 2-week follow-up. Treatment satisfaction and attrition rates also were assessed at posttreatment. Data were collected from November 2005 to March 2006. RESULTS: Patients who received the LETS Act! intervention (N = 22) evidenced significantly greater improvements than the TAU group (N = 22) in severity of depression, anxiety symptoms, and enjoyment and reward value of activities at posttreatment and in depressive symptoms at 2-week follow-up. The LETS Act! group also reported significantly higher treatment satisfaction ratings. CONCLUSIONS: This study supports the efficacy of LETS Act! in treating depressive symptoms and improving the enjoyment and reward value of activities among illicit drug users currently receiving inpatient substance use treatment. Data also indicate the intervention may help prevent treatment attrition. LETS Act! appears to be a feasible and parsimonious intervention to improve the treatment of depression and overall quality of care within inpatient substance abuse treatment settings.