Cognitive and attentional vulnerability to depression in youth: A review.

Although depressive disorders are among the most common disorders in youth, highly efficacious treatments for childhood affective disorders are lacking. There is significant need to better understand the factors that contribute to the development and maintenance of depression in youth so that treatments can be targeted at optimal mechanisms. The aim of the current paper was to synthesize research on cognitive and neurobiological factors associated with youth depression, guided by De Raedt and Koster's model (2010) for vulnerability to depression in adults. Consistent with model predictions, there is evidence that attentional impairments are greatest in the context of negative information, relative to positive or neutral information, and some evidence that attentional deficits are associated with rumination in depressed youth. However, we found little evidence for the model's assumption that attentional bias is an etiological and maintenance factor for depression. There are several other model predictions that require additional study as current data are lacking. Overall, De Raedt and Koster's (2010) integrative cognitive and biological framework has tremendous potential to move the field forward in understanding the development of depression in youth. Additional longitudinal studies incorporating measures across biological and cognitive levels of analysis are needed.

Latent Class Profiles of Anxiety Symptom Trajectories From Preschool Through School Age.

Anxiety typically arises early in childhood and decreases during school age. However, little is known about the earlier developmental course of anxiety in preschool, especially in at risk children, posing a clinically important problem. Given that anxiety in youth has a chronic course for some and also predicts later development of other mental health problems, it is important to identify factors early in development that may predict chronic anxiety symptoms. At-risk children (oversampled for depression) and caregivers completed 6 assessment waves beginning at preschool age (between 3-5.11 years of age) up through 6.5 years later. Growth mixture models revealed 4 distinct trajectories: 2 stable groups (high and moderate) and 2 decreasing groups (high and low). Important to note, the high stable anxiety group had greater baseline depression and social adversity/risk, higher average maternal depression over time, and poorer average social functioning over time compared to the high decreasing group. The high decreasing group also had greater externalizing/attention deficit hyperactivity disorder scores than the low decreasing group. Children with anxiety in early childhood who also experience high depression, social adversity/risk, maternal depression, and poor social functioning may be at risk for chronic symptoms over time.

Investigating the latent structure of distress intolerance.

Distress intolerance (DI) is defined as a perceived or actual inability to withstand distressing emotional or somatic states, which motivates the use of avoidance strategies. Despite widespread interest in DI, key questions about its underlying structure remain unanswered. The current study evaluated the latent structure of DI in two large samples using four-indicators and three taxometric procedures (MAMBAC, MAXEIG, and L-Mode). Data interpretation relied primarily on the Comparison Curve Fit Indices (CCFI). Overall, results from the three non-redundant procedures suggested that DI was more accurately characterized by a dimensional rather than a categorical conceptualization. Implications for assessment and conceptual models of DI are discussed.

Examining the effects of a novel training program and use of psychiatric service dogs for military-related PTSD and associated symptoms.

This study explored an intensive 3-week training program and use of psychiatric service dogs for military-related posttraumatic stress disorder (PTSD) and associated symptoms. The sample included 2 separate cohorts of military veterans (n = 7 and n = 5) with prior diagnoses of PTSD. Participants completed self-report measures assessing PTSD, depression, perception of social support, anger, and overall quality of life 1 month prior to the training (baseline), at arrival to the training site, and 6-month follow-up. Results indicated that, for this sample, there was a statistically significant decrease in PTSD and depression symptoms from pre- to posttreatment, as well as 6-month follow-up. For most participants decreases were both clinically significant and reliable changes. Further, participants reported significant reductions in anger and improvement in perceived social support and quality of life. Limitations of the study include a lack of control group, a limitation of most naturalistic studies, as well as small sample size. Despite this, the findings indicate that utilizing psychiatric service dogs, coupled with an intensive trauma resilience training program for veterans with ongoing symptoms, is feasible as a complementary treatment for PTSD that could yield beneficial results in terms of symptom amelioration and improvement to overall quality of life. (PsycINFO Database Record

The association between attention control, anxiety, and depression: the indirect effects of repetitive negative thinking and mood recovery.

BACKGROUND AND OBJECTIVES: Attention control deficits and repetitive negative thinking (RNT; i.e., rumination) may be key factors in the development and persistence of depression and anxiety, although their role in symptom development remains poorly understood. This represents a gap in the literature, as interventions targeting attention control and associated RNT may enhance interventions and prevent costly relapse. The current study was designed to examine the serial indirect effects of transdiagnostic RNT and negative affect recovery following a lab-induced stressor on the association between attention control deficits and trait anxiety and depression. METHODS: Participants were N = 583 university students who completed validated measures of RNT, anxiety, depression, and mood ratings pre- and post-stressor. Stress was induced using a modified version of the Trier Social Stress Test. RESULTS: Results of cross-sectional indirect effects models indicated that RNT and mood recovery explained the association between attention control deficits and trait anxiety and depression. Results from reversed models indicated that only the indirect effect of RNT was significant. CONCLUSIONS: Findings suggest that RNT and mood recovery processes play an important role in explaining anxiety and depression symptoms. Additional work is needed to examine their role in symptom development and maintenance over time.

Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement.

OBJECTIVE: Studies have reported associations between cognitive behavioral therapy (CBT) skill use and symptom improvement in depressed outpatient samples. However, little is known regarding the temporal relationship between different subsets of therapeutic skills and symptom change among relatively severely depressed patients receiving treatment in psychiatric hospital settings. METHOD: Adult patients with major depression (N = 173) receiving combined psychotherapeutic and pharmacological treatment at a psychiatric hospital completed repeated assessments of traditional CBT skills, DBT skills and psychological flexibility, as well as depressive and anxiety symptoms. RESULTS: Results indicated that only use of behavioral activation (BA) strategies significantly predicted depressive symptom improvement in this sample; whereas DBT skills and psychological flexibility predicted anxiety symptom change. In addition, a baseline symptom severity X BA strategies interaction emerged indicating that those patients with higher pretreatment depression severity exhibited the strongest association between use of BA strategies and depressive symptom improvement. CONCLUSIONS: Findings suggest the importance of emphasizing the acquisition and regular use of BA strategies with severely depressed patients in short-term psychiatric settings. In contrast, an emphasis on the development of DBT skills and the cultivation of psychological flexibility may prove beneficial for the amelioration of anxiety symptoms.

Cognitive Control Deficits in Shifting and Inhibition in Preschool Age Children are Associated with Increased Depression and Anxiety Over 7.5 Years of Development.

Although depression and anxiety are common in youth (Costello et al. 2003), factors that put children at risk for such symptoms are not well understood. The current study examined associations between early childhood cognitive control deficits and depression and anxiety over the course of development through school age. Participants were 188 children (at baseline M = 5.42 years, SD = 0.79 years) and their primary caregiver. Caregivers completed ratings of children's executive functioning at preschool age and measures of depression and anxiety severity over seven assessment waves (a period of approximately 7.5 years). Longitudinal multilevel linear models were used to examine the effect of attention shifting and inhibition deficits on depression and anxiety. Inhibition deficits at preschool were associated with significantly greater depression severity scores at each subsequent assessment wave (up until 7.5 years later). Inhibition deficits were associated with greater anxiety severity from 3.5 to 7.5 years later. Greater shifting deficits at preschool age were associated with greater depression severity up to 5.5 years later. Shifting deficits were also associated with significantly greater anxiety severity up to 3.5 years later. Importantly, these effects were significant even after accounting for the influence of other key predictors including assessment wave/time, gender, parental education, IQ, and symptom severity at preschool age, suggesting that effects are robust. Overall, findings indicate that cognitive control deficits are an early vulnerability factor for developing affective symptoms. Timely assessment and intervention may be beneficial as an early prevention strategy.

Trauma and event centrality: Valence and incorporation into identity influence well-being more than exposure.

Although the association between trauma exposure and posttraumatic stress disorder (PTSD) symptoms is well established, how such trauma is incorporated into identity, or the centrality of the negative event, is also of considerable importance in understanding the development of psychological symptoms. Alternatively, positive event centrality may have positive effects on well-being in the face of trauma. Thus, the current study examined associations between positive and negative event centrality, and both adaptive and maladaptive outcomes, above and beyond the impact of traumatic experience. A sample of 214 college students completed a series of self-report questionnaires. As anticipated, negative event centrality predicted PTSD and other maladaptive measures of functioning, even after controlling for traumatic experience. High levels of positive event centrality predicted adaptive, as opposed to maladaptive, psychological functioning. Results also suggested that both positive and negative event centrality predicted posttraumatic growth, controlling for traumatic experience. These findings suggest that assessing centrality of trauma may also be valuable in the prediction of psychological symptoms. The implications of these findings and proposals for future work are discussed further.

Repetitive negative thinking predicts depression and anxiety symptom improvement during brief cognitive behavioral therapy.

Repetitive negative thinking (RNT) is a common symptom across depression and anxiety disorders and preliminary evidence suggests that decreases in rumination and worry are related to improvement in depression and anxiety symptoms. However, despite its prevalence, relatively little is known about transdiagnostic RNT and its temporal associations with symptom improvement during treatment. The current study was designed to examine the influence of RNT on subsequent depression and anxiety symptoms during treatment. Participants (n = 131; 52% female; 93% White; M = 34.76 years) were patients presenting for treatment in a brief, cognitive behavior therapy based, partial hospitalization program. Participants completed multiple assessments of depression (Center for the Epidemiological Studies of Depression-10 scale), anxiety (the 7-item Generalized Anxiety Disorder Scale), and repetitive negative thinking (Perseverative Thinking Questionnaire) over the course of treatment. Results indicated statistically significant between and within person effects of RNT on depression and anxiety, even after controlling for the effect of time, previous symptom levels, referral source, and treatment length. RNT explained 22% of the unexplained variability in depression scores and 15% of the unexplained variability in anxiety scores beyond that explained by the control variables. RNT may be an important transdiagnostic treatment target for anxiety and depression.

Testing Cognitive and Emotion-Focused Models of Worry in Black and White Samples.

Several models have been proposed to conceptualize worry. Broadly, the models can be classified as cognitive (including the Avoidance Model, the Intolerance of Uncertainty Model, and the Metacognitive Model) and emotion-focused (including Emotion Dysregulation and Acceptance-Based models). Although these models have received strong empirical investigation in primarily non-Hispanic White samples, no known study has examined the applicability to racial and ethnic minority groups. The current study compared the proportion of variance explained by cognitive and emotion-focused models of worry in White and Black samples. Results indicated that cognitive and emotion-focused models significantly predicted worry in both Black and White samples. However, the overall amount of variance in worry explained by the models was less for Black samples. Specifically, controlling for gender, the cognitive models explained 53% of the variance in worry in the White sample compared with 19% in the Black sample. Similarly, the emotion-focused models explained 34% of the variance in worry in the White sample but only 13% in the Black sample. These findings suggest that well-established conceptual frameworks for worry failed to explain the bulk of the variance in worry in Black samples, leaving much unknown. Additional research is needed to identify key variables that may further explain worry in ethnic minority samples.

Distress intolerance and worry: the mediating role of cognitive variables.

BACKGROUND AND OBJECTIVES: Distress intolerance (DI) has been identified as a potential risk factor for a variety of maladaptive avoidance behaviors, including worry. However, mechanisms linking DI to specific behaviors remain poorly understood. One hypothesis is that DI is a general vulnerability that confers risk of particular avoidance behaviors via more specific, lower-order vulnerabilities. The current study examined associations between DI and worry-related cognitions. DESIGN: A multiple mediator model tested the hypothesis that worry-related variables (intolerance of uncertainty [IU], cognitive avoidance, beliefs about worry, and negative problem orientation) mediated the association between DI and worry. METHODS: An undergraduate student (n = 281) and a clinical (n = 123) sample completed self-report measures. RESULTS: Across samples, worry was associated with higher levels of DI, IU, cognitive avoidance, beliefs about worry, and negative problem orientation. Mediation results differed somewhat between the two samples. In the undergraduate sample, IU, negative beliefs about worry, and positive beliefs about worry mediated the association between DI and worry. In the clinical sample, negative problem orientation and negative beliefs about worry mediated the association between DI and worry. CONCLUSIONS: Results provide initial evidence that DI may be associated with worry via unique risk factors.

Psychometric properties of abbreviated and ultra-brief versions of the Penn State Worry Questionnaire.

The Penn State Worry Questionnaire (PSWQ) is a 16-item self-report measure considered the gold-standard assessment instrument for worry. Two abbreviated versions of the PSWQ have also been developed. An 8-item measure (PSWQ-A) was designed to address poor model fit of the full version with older adult samples, and a 3-item version (PSWQ-3) was developed in a clinical setting to avoid problems related to the reverse-scored items and to increase clinical utility. Preliminary examinations of the abbreviated forms have been promising, but additional psychometric evaluation is needed to confirm their reliability and validity. The current study compared psychometric properties of the 3 versions of the PSWQ in a heterogeneous clinical sample of 272 patients presenting for treatment in a partial hospital setting. Results suggested that scores for all 3 versions had good internal consistency; convergent validity with anxiety, stress, intolerance of uncertainty, negative problem orientation, and negative beliefs about worry; as well as adequate discriminant validity with depression, emotional lability, and substance abuse. On all 3 versions, individuals with generalized anxiety disorder (GAD) scored higher than those without the disorder, and across all participants, scores decreased from pre- to posttreatment. Finally, scores on the 3 versions showed similar levels of sensitivity and specificity as screening tools for GAD. Overall, the PSWQ-A and PSWQ-3 scores appear to be internally consistent and valid measures of worry that performed similarly to the full 16-item PSWQ. Given the strong psychometric properties of the shorter form scores, clinicians may prefer such forms, as they are quick to administer and easy to score in session.

Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: a benchmarking study.

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, "real world" settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Changes in distress intolerance and treatment outcome in a partial hospital setting.

Despite the well-established role of distress intolerance (DI) in a wide range of psychological disorders, few studies have examined whether DI improves during treatment and whether these changes are associated with symptom outcomes. Patients (N=626) enrolled in a brief cognitive-behavioral partial hospital program completed pre- and posttreatment measures of DI. Results indicated that DI decreased significantly during treatment, with more than 30% of the sample exhibiting a reduction of more than 2 standard deviations from the sample mean. Women reported higher DI than men at baseline; however, there were no gender differences in changes in DI over time. Participants also completed a pre- and posttreatment measure of depression and a subset completed a measure of anxiety (n=167). DI was associated with more severe depression and anxiety at pre- and posttreatment, with participants who reported a decrease in DI also reporting lower depression and anxiety symptoms at post-treatment. These results further highlight the transdiagnostic relevance of DI and suggest that DI may be a relevant factor in treatment outcome for depression and anxiety.

Examining the latent structure of worry and generalized anxiety in a clinical sample.

Generalized anxiety disorder (GAD) is characterized by "pathological" worry, suggesting that GAD worriers differ qualitatively from non-GAD worriers. However, results from taxometric studies of worry in undergraduate and community samples have been mixed and to date, no studies have utilized clinical samples. The current study examined the latent structure of worry and GAD symptoms in a diagnostically heterogeneous clinical sample. Indicators were selected from the Penn State Worry Questionnaire-Abbreviated (n=1175) and the GAD-7 (n=638) and submitted to three taxometric procedures: MAXCOV, MAMBAC, and L-Mode. Results from all three procedures suggested that both worry and generalized anxiety are best conceptualized as dimensional constructs. Findings also indicated that ongoing conceptualization, assessment, and treatment of worry and GAD may be hampered by the application of a categorical framework.

The role of pretreatment outcome expectancies and cognitive-behavioral skills in symptom improvement in an acute psychiatric setting.

BACKGROUND: Prior research has found that pretreatment expectations of symptom improvement are positively correlated with depressive symptom change. The current investigation extends previous research by examining whether pretreatment outcome expectancies predict symptom change across several diagnostic categories within the context of an acute, naturalistic psychiatric setting. METHODS: Analyses were conducted to examine whether pretreatment outcome expectancies (credibility/expectancy questionnaire [CEQ]) predicted symptom improvement within major depression (N=420), bipolar disorder (N=120) and psychosis (N=36). Bootstrap mediation analyses were conducted to examine whether acquisition of cognitive behavioral therapy (CBT) skills (cognitive behavior therapy skills questionnaire [CBTSQ]) may mediate expectancy-outcome relations. RESULTS: Results indicated a differential pattern of associations across diagnoses. Patient CBT skills emerged as a significant mediator of expectancy-outcome relations, but only in the major depression group. Both behavioral and cognitive skills were significantly, and independently, associated with symptom improvement. LIMITATIONS: Sample sizes were small in the bipolar manic subgroup and psychosis group. CBT skills and symptom measures were assessed at concurrent time points. CONCLUSIONS: The present findings suggest that patient expectancies and CBT skills may have a differential impact on symptom change as a function of diagnostic category. The implication of these results and directions for future research are discussed.

Psychometric properties of the CES-D-10 in a psychiatric sample.

The 10-item Center for the Epidemiological Studies of Depression Short Form (CES-D-10) is a widely used measure to screen for depression in primary care settings. The 10-item measure has demonstrated strong psychometric properties, including predictive accuracy and high correlations with the original 20-item version, in community populations. However, clinical utility and psychometric properties have yet to be assessed in an acutely symptomatic psychiatric population. This study examined the psychometric properties of the CES-D-10 in a sample of 755 patients enrolled in a psychiatric partial hospital program. Participants completed a diagnostic interview and a battery of self-report measures on admission and discharge. Exploratory factor analysis and confirmatory factor analysis suggested that a one-factor structure provided a good fit to the data. High item-total correlations indicated high internal consistency, and the CES-D-10 demonstrated both convergent validity and divergent validity. Previously suggested cutoff scores of 8 and 10 resulted in good sensitivity (.91 and .89, respectively) but poor specificity (.35 and .47). These data suggest that although the CES-D-10 has generally strong psychometric properties in this psychiatric sample, the measure should be primarily used to assess depression symptom severity rather than as a diagnostic screening tool.

A test of faith in God and treatment: the relationship of belief in God to psychiatric treatment outcomes.

BACKGROUND: Belief in God is very common and tied to mental health/illness in the general population, yet its relevance to psychiatric patients has not been adequately studied. We examined relationships between belief in God and treatment outcomes, and identified mediating mechanisms. METHODS: We conducted a prospective study with n=159 patients in a day-treatment program at an academic psychiatric hospital. Belief in God, treatment credibility/expectancy, emotion regulation and congregational support were assessed prior to treatment. Primary outcomes were treatment response as well as degree of reduction in depression over treatment. Secondary outcomes were improvements in psychological well-being and reduction in self-harm. RESULTS: Belief in God was significantly higher among treatment responders than non-responders F(1,114)=4.81, p<.05. Higher levels of belief were also associated with greater reductions in depression (r=.21, p<.05) and self-harm (r=.24, p<.01), and greater improvements in psychological well-being (r=.19, p<.05) over course of treatment. Belief remained correlated with changes in depression and self-harm after controlling for age and gender. Perceived treatment credibility/expectancy, but not emotional regulation or community support, mediated relationships between belief in God and reductions in depression. No variables mediated relationships to other outcomes. Religious affiliation was also associated with treatment credibility/expectancy but not treatment outcomes. CONCLUSIONS: Belief in God, but not religious affiliation, was associated with better treatment outcomes. With respect to depression, this relationship was mediated by belief in the credibility of treatment and expectations for treatment gains.

A sequential analysis of parent-child interactions in anxious and nonanxious families.

Although theoretical work has suggested that reciprocal behavior patterns between parent and child may be important in the development of childhood anxiety, most empirical work has failed to consider the bidirectional nature of interactions. The current study sought to address this limitation by utilizing a sequential approach to exploring parent-child interactions. Participants included 161 children (ages 3-12 years) and their parents. Parent and child dyads were classified into four categories: anxious parent-anxious child (n = 45), anxious parent-nonanxious child (n = 45), nonanxious parent-anxious child (n = 21), and nonanxious parent-nonanxious child (n = 50). Parent and child behaviors were coded from two 10-min interactions. Results indicated that anxious parents of children with anxiety disorders were more likely to respond with negative behaviors, which their child then mirrored. Nonanxious parents of nonanxious children responded with more warmth, which was then mirrored by their child. These results provide evidence for differential patterns of behaviors between anxious and nonanxious parents and children following critical moments in their interactions.

The importance of worry across diagnostic presentations: prevalence, severity and associated symptoms in a partial hospital setting.

Although excessive worry has been linked primarily with Generalized Anxiety Disorder (GAD), recent work suggests worry is dimensional, with potential relevance to a range of psychiatric disorders. The current study examined associations between worry and psychological symptoms across several primary diagnoses and tested worry's hypothesized unique relation to GAD in an acute psychiatric setting. Participants were 568 patients with primary diagnoses of Major Depression, Bipolar Disorder-Depressed, Bipolar Disorder-Manic, and Psychosis. Participants completed a structured diagnostic interview and questionnaires at admission. Partial correlations controlling for GAD diagnosis indicated that worry correlated with higher depression and poorer overall well-being in the Depressed, Bipolar-Depressed, and Psychosis groups and decreased functioning in the Depressed, Bipolar-Manic, and Psychosis groups. Depressed and Bipolar-Depressed groups endorsed the highest level of worry. A comorbid anxiety disorder was associated with higher worry across primary diagnoses, even after controlling for GAD. Of the anxiety disorders, GAD and Panic Disorder diagnoses predicted higher worry scores. Results discussed in terms of conceptual implications for worry as a transdiagnostic concept and clinical interventions.