Phase Cognitive Therapy Research Articles

The Role of Dyadic Discord in Outcomes in Acute Phase Cognitive Therapy for Adults With Recurrent Major Depressive Disorder

Major depressive disorder (MDD) and relationship discord between cohabiting partners frequently co-occur, with bidirectional effects established. As relationship quality influences understanding and treatment of MDD, the current analyses clarified the relations of pretreatment dyadic discord with outcomes during and at the end of acute phase cognitive therapy (CT) for adults with recurrent MDD. Married or cohabiting patients (n = 219) completed the Dyadic Adjustment Scale (DYS) before and after a 16–20 session, 12–14 week CT protocol. Lower levels of dyadic adjustment indicated higher levels of dyadic discord. Response to CT was defined as the absence of a major depressive episode and ≤ 12 on the 17-item Hamilton Rating Scale for Depression. Pretreatment dyadic discord, whether defined as a continuous or categorical variable (using DYS cutoff score of 97), was not associated with treatment completion or response but was positively associated with levels of depressive symptoms at the end of acute phase CT. Furthermore, CT was associated with declines in dyadic discord, with 23.3% of initially discordant couples moving to nondiscordant status at the end of CT. Depressive symptoms did not significantly mediate changes in dyadic discord. Finally, pre- (but not mid-) treatment dyadic discord was associated with subsequent changes in depressive symptoms, suggesting limited mediation. These findings replicate prior research indicating that individual CT is associated with reductions in depressive symptoms and dyadic discord while clarifying that lower pre-treatment dyadic discord may predict initial improvement in depressive symptoms.

A prognostic index for long-term outcome after successful acute phase cognitive therapy and interpersonal psychotherapy for major depressive disorder.

BackgroundMajor depressive disorder (MDD) has a highly recurrent nature. After successful treatment, it is important to identify individuals who are at risk of an unfavorable long‐term course. Despite extensive research, there is no consensus yet on the clinically relevant predictors of long‐term outcome in MDD, and no prediction models are implemented in clinical practice. The aim of this study was to create a prognostic index (PI) to estimate long‐term depression severity after successful and high quality acute treatment for MDD.MethodsData come from responders to cognitive therapy (CT) and interpersonal psychotherapy (IPT) in a randomized clinical trial (n = 85; CT = 45, IPT = 40). Primary outcome was depression severity, assessed with the Beck Depression Inventory II, measured throughout a 17‐month follow‐up phase. We examined 29 variables as potential predictors, using a model‐based recursive partitioning method and bootstrap resampling in conjunction with backwards elimination. The selected predictors were combined into a PI. Individual PI scores were estimated using a cross‐validation approach.ResultsA total of three post‐treatment predictors were identified: depression severity, hopelessness, and self‐esteem. Cross‐validated PI scores evidenced a strong correlation (r = 0.60) with follow‐up depression severity.ConclusionLong‐term predictions of MDD are multifactorial, involving a combination of variables that each has a small prognostic effect. If replicated and validated, the PI can be implemented to predict follow‐up depression severity for each individual after acute treatment response, and to personalize long‐term treatment strategies.

A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression

Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology–Self-Reported Scale (QIDS-SR), and the QIDS–Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.

Longitudinal social-interpersonal functioning among higher-risk responders to acute-phase cognitive therapy for recurrent major depressive disorder

BackgroundSocial-interpersonal dysfunction increases disability in major depressive disorder (MDD). Here we clarified the durability of improvements in social-interpersonal functioning made during acute-phase cognitive therapy (CT), whether continuation CT (C-CT) or fluoxetine (FLX) further improved functioning, and relations of functioning with depressive symptoms and relapse/recurrence. MethodAdult outpatients (N=241) with recurrent MDD who responded to acute-phase CT with higher risk of relapse (due to unstable or partial remission) were randomized to 8 months of C-CT, FLX, or pill placebo plus clinical management (PBO) and followed 24 additional months. We analyzed repeated measures of patients’ social adjustment, interpersonal problems, dyadic adjustment, depressive symptoms, and major depressive relapse/recurrence. ResultsLarge improvements in social-interpersonal functioning occurring during acute-phase CT (median d=1.4) were maintained, with many patients (median=66%) scoring in normal ranges for 32 months. Social-interpersonal functioning did not differ significantly among C-CT, FLX, and PBO arms. Beyond concurrently measured residual symptoms, deterioration in social-interpersonal functioning preceded and predicted upticks in depressive symptoms and major depressive relapse/recurrence. LimitationsResults may not generalize to other patient populations, treatment protocols, or measures of social-interpersonal functioning. Mechanisms of risk connecting poorer social-interpersonal functioning with depression were not studied. ConclusionsAverage improvements in social-interpersonal functioning among higher-risk responders to acute phase CT are durable for 32 months. After acute-phase CT, C-CT or FLX may not further improve social-interpersonal functioning. Among acute-phase CT responders, deteriorating social-interpersonal functioning provides a clear, measurable signal of risk for impending major depressive relapse/recurrence and opportunity for preemptive intervention.

Improvement in self-reported quality of life with cognitive therapy for recurrent major depressive disorder

BackgroundMajor depressive disorder (MDD) is common, often recurrent and/or chronic. Theoretically, assessing quality of life (QoL) in addition to the current practice of assessing depressive symptoms has the potential to offer a more comprehensive evaluation of the effects of treatment interventions and course of illness. MethodsBefore and after acute-phase cognitive therapy (CT), 492 patients from Continuation Phase Cognitive Therapy Relapse Prevention trial (Jarrett et al., 2013; Jarrett and Thase, 2010) completed the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), Inventory of Depressive Symptomatology Self-report (IDS-SR) and Beck Depression Inventory (BDI); clinicians completed Hamilton Rating Scale for Depression-17-items. Repeated measures analysis of variance evaluated the improvement in QoL before/after CT and measured the effect sizes. Change analyses to assess clinical significance (Hageman and Arrindell, 1999) were conducted. ResultsAt the end of acute-phase CT, a repeated measure analysis of variance produced a statistically significant increase in Q-LES-Q scores with effect sizes of 0.48–1.3%; 76.9–91.4% patients reported clinically significant improvement. Yet, only 11–38.2% QoL scores normalized. An analysis of covariance showed that change in depression severity (covariates=IDS-SR, BDI) completely accounted for the improvement in Q-LES-Q scores. LimitationsThere were only two time points of observation; clinically significant change analyses lacked matched normal controls; and generalizability is constrained by sampling characteristics. ConclusionsQuality of life improves significantly in patients with recurrent MDD after CT; however, this improvement is completely accounted for by change in depression severity. Normalization of QoL in all patients may require targeted, additional, and/or longer treatment.

Extreme Nonresponse to Acute Phase Cognitive Therapy for Depression: An Attempt to Replicate and Extend

As with other interventions for major depressive disorder (MDD), cognitive therapy (CT) results in treatment failure for about half of all participants. In 2007, Coffman and colleagues in Seattle studied this topic by identifying a group of patients who demonstrated an extremely poor response to CT (i.e., posttreatment BDI score≥31). They called these patients “extreme nonresponders” (ENR) and described the pretreatment characteristics that predicted response status.In the current study, we attempt a replication of the Seattle study with a larger sample of adults with recurrent MDD (N=473) who received a 16–20 session (12–14week) course of CT.The rate of ENR in this large sample was only 6.3% (30/473), compared to 22.2% (10/45) in the Seattle sample. Four pretreatment measures of symptom severity and functioning differed significantly among ENR and non-ENR participants. In each case, higher symptoms or poorer functioning were associated with ENR status. However, the combination of these factors in a regression model did not predict actual ENR status with the high degree of sensitivity or specificity observed in the Seattle study.These findings suggest that extreme nonresponse to CT is not as common as previously described and, although poor outcomes are associated with pretreatment clinical status, it is difficult to predict posttreatment symptom severity with a high degree of accuracy across different research samples.

Preventing Depressive Relapse and Recurrence in Higher-Risk Cognitive Therapy Responders

Strategies to improve the course of recurrent major depressive disorder have great public health relevance. To reduce the risk of relapse/recurrence after acute phase cognitive therapy (CT), a continuation phase model of therapy may improve outcomes. To test the efficacy of continuation phase CT (C-CT) and fluoxetine for relapse prevention in a pill placebo (PBO)-controlled randomized trial and compare the durability of prophylaxis after discontinuation of treatments. A sequential, 3-stage design with an acute phase (all patients received 12 weeks of CT); 8-month experimental phase (responders at higher risk were randomized to C-CT, fluoxetine, or PBO); and 24 months of longitudinal, posttreatment follow-up. Two university-based specialty clinics. A total of 523 adults with recurrent major depressive disorder began acute phase CT, of which 241 higher-risk responders were randomized and 181 subsequently entered the follow-up. Cognitive therapy responders at higher risk for relapse were randomized to receive 8 months of C-CT (n = 86), fluoxetine (n = 86), or PBO (n = 69). Survival analyses of relapse/recurrence rates, as determined by blinded evaluators using DSM-IV criteria and the Longitudinal Interval Follow-up Evaluation. RESULTS As predicted, the C-CT or fluoxetine groups were significantly less likely to relapse than the PBO group across 8 months. Relapse/recurrence rates for C-CT and fluoxetine were nearly identical during the 8 months of treatment, although C-CT patients were more likely to accept randomization, stayed in treatment longer, and attended more sessions than those in the fluoxetine and PBO groups. Contrary to prediction, relapse/recurrence rates following the discontinuation of C-CT and fluoxetine did not differ. Relapse risk was reduced by both C-CT and fluoxetine in an enriched randomization sampling only CT responders. The preventive effects of C-CT were not significantly more durable than those of fluoxetine after treatment was stopped, suggesting that some higher-risk patients may require alternate longer-term interventions. clinicaltrials.gov Identifiers: NCT00118404, NCT00183664, and NCT00218764.

Acute phase cognitive therapy for recurrent major depressive disorder: Who drops out and how much do patient skills influence response?

ObjectiveThe aims were to predict cognitive therapy (CT) noncompletion and to determine, relative to other putative predictors, the extent to which the patient skills in CT for recurrent major depressive disorder predicted response in a large, two-site trial. MethodAmong 523 outpatients aged 18–70, exposed to 12–14 weeks of CT, 21.6% dropped out. Of the 410 completers, 26.1% did not respond. To predict these outcomes, we conducted logistic regression analyses of demographics, pre-treatment illness characteristics and psychosocial measures, and mid-treatment therapeutic alliance. ResultsThe 17-item Hamilton Rating Scale for Depression (HRSD17) scores at entry predicted dropout and nonresponse. Patients working for pay, of non-Hispanic white race, who were older, or had more education were significantly more likely to complete. Controlling for HRSD17, significant predictors of nonresponse included: lower scores on the Skills of Cognitive Therapy-Observer Version (SoCT-O), not working for pay, history of only two depressive episodes, greater pre-treatment social impairment. Mid-phase symptom reduction was a strong predictor of final outcome. ConclusionsThese prognostic indicators forecast which patients tend to be optimal candidates for standard CT, as well as which patients may benefit from changes in therapy, its focus, or from alternate modalities of treatment. Pending replication, the findings underscore the importance of promoting patients' understanding and use of CT skills, as well as reducing depressive symptoms early. Future research may determine the extent to which these findings generalize to other therapies, providers who vary in competency, and patients with other depressive subtypes or disorders.

Outcomes of Acute Phase Cognitive Therapy in Outpatients with Anxious versus Nonanxious Depression

Objective: Compared to nonanxious depressed patients, anxious depressed patients respond less to pharmacotherapy, prompting consideration of alternate treatments. Based on the transdiagnostic principles of cognitive therapy (CT), we predicted that anxious depressed patients would respond as well to CT as nonanxious depressed patients. Method: Adults (n = 523) with recurrent major depressive disorder received 12–14 weeks of CT as part of the Continuation Phase Cognitive Therapy Relapse Prevention Trial. Anxious depressed patients (n = 264; 50.4%) were compared to nonanxious depressed patients (n = 259; 49.6%) on demographic variables, initial severity, attrition, and rates and patterns of response and remission. Results: Anxious depressed patients presented with greater illness severity and had significantly lower response (55.3 vs. 68.3%) and remission rates (26.9 vs. 40.2%) based on clinician-administered measures. By contrast, smaller between-group differences for attrition, and for response (59.1 vs. 64.9%) and remission (41.7 vs. 48.7%) rates on self-report measures were not significant. Further, anxious depressed patients had greater speed of improvement on self-reported anxiety symptom severity and clinician-rated depressive and anxiety symptom severity measures. Conclusion: Consistent with prior reports, anxious depressed patients presented with greater severity and, following CT, had lower response and remission rates on clinician-administered scales. However, anxious depressed patients improved more rapidly and response and remission rates on self-report measures were not significantly different from nonanxious depressed patients. Our findings suggest that anxious depressed patients may simply need additional time or more CT sessions to reach outcomes fully comparable to those of less anxious patients.

Cognitive reactivity, dysfunctional attitudes, and depressive relapse and recurrence in cognitive therapy responders

Dysfunctional attitudes can foreshadow depressive relapse/recurrence. Priming mood, through induction paradigms, is hypothesized to activate dysfunctional attitudes. Cognitive reactivity (CR) refers to mood-linked increases in dysfunctional attitudes after priming. Here we explored the extent to which CR as well as residual, unprimed, dysfunctional attitudes predicted depressive relapse/recurrence among depressed patients who responded to acute phase cognitive therapy (CT). Consenting adults, aged 18–70, with recurrent major depressive disorder (n = 523) participated in a two-site randomized controlled trial examining the durability of continuation phase treatments. Patients received 16–20 sessions of CT. Among the 245 incompletely remitted responders, 213 agreed to undergo a mood induction paradigm. After 8 months of continuation phase treatments, participants were followed an additional 24 months. Although the mood induction significantly lowered mood in 80% of responders, the expected CR was not evident. By contrast, higher unprimed dysfunctional attitudes following CT did predict relapse/recurrence over 20 and 32 months post-randomization. The findings of this large longitudinal study of incompletely remitted CT responders challenge the notion that it is necessary to prime mood in order to maximize dysfunctional attitudes’ prediction of relapse and/or recurrence. While findings cannot be generalized beyond CT responders, they emphasize the clinical importance of reducing dysfunctional attitudes in preventing depression.

Skills of Cognitive Therapy (SoCT): A new measure of patients' comprehension and use.

The authors describe the development and psychometric properties of a new measure called the Skills of Cognitive Therapy (SoCT) in depressed adults and their cognitive therapists. The 8-item SoCT assesses patients' understanding and use of basic cognitive therapy (CT) skills rated from the perspectives of both observers (SoCT-O; therapists in this report) and patients (SoCT-P). Ratings of patients' skill usage are made on 5-point Likert-type scales ranging from 1 (never) to 5 (always or when needed). Higher scores reflect greater patient skill in applying cognitive therapy principles and coping strategies. To develop this scale, a 33-item pool was used, rated by both patients and their therapists at the middle and end of CT (Ns = 359-416), and evaluated the reliability and concurrent and predictive validity of both versions of the scale. The SoCT has excellent internal consistency reliability and moderate correlations between the observer and patient versions. It is important to note that the SoCT showed good predictive validity for response when collected at the midpoint of acute phase CT. Considering both patients' self-ratings and clinicians' SoCT ratings, the odds ratio for responding to CT was 2.6. The practical utility of the SoCT is discussed, as well as its theoretical importance in research of patient CT skills (e.g., acquisition, comprehension, and generalization) as putative moderators or mechanisms of symptom change in the therapy.

Comparative efficacy and durability of continuation phase cognitive therapy for preventing recurrent depression: Design of a double-blinded, fluoxetine- and pill placebo-controlled, randomized trial with 2-year follow-up

Background Major Depressive Disorder (MDD) is highly prevalent and associated with disability and chronicity. Although cognitive therapy (CT) is an effective short-term treatment for MDD, a significant proportion of responders subsequently suffer relapses or recurrences. Purpose This design prospectively evaluates: 1) a method to discriminate CT-treated responders at lower vs. higher risk for relapse; and 2) the subsequent durability of 8-month continuation phase therapies in randomized higher risk responders followed for an additional 24 months. The primary prediction is: after protocol treatments are stopped, higher risk patients randomly assigned to continuation phase CT (C-CT) will have a lower risk of relapse/recurrence than those randomized to fluoxetine (FLX). Methods Outpatients, aged 18 to 70 years, with recurrent MDD received 12–14 weeks of CT provided by 15 experienced therapists from two sites. Responders (i.e., no MDD and 17-item Hamilton Rating Scale for Depression ≤ 12) were stratified into higher and lower risk groups based on stability of remission during the last 6 weeks of CT. The lower risk group entered follow-up for 32 months; the higher risk group was randomized to 8 months of continuation phase therapy with either C-CT or clinical management plus either double-blinded FLX or pill placebo. Following the continuation phase, higher risk patients were followed by blinded evaluators for 24 months. Results The trial began in 2000. Enrollment is complete ( n = 523). The follow-up continues. Conclusions The trial evaluates the preventive effects and durability of acute and continuation phase treatments in the largest known sample of CT responders collected worldwide.

Moderators of continuation phase cognitive therapy's effects on relapse, recurrence, remission, and recovery from depression

About half of patients who respond to acute-phase cognitive therapy (CT) for major depressive disorder (MDD) will relapse/recur within 2 years; continuation-phase CT lowers this risk. We analyzed demographic, clinical, cognitive, social-interpersonal, and personality variables to clarify which patients continuation-phase CT helps to avoid relapse and recurrence and achieve remission and recovery. Participants had recurrent MDD, responded to acute-phase CT, were randomized to 8 months of continuation-phase CT ( n = 41) or assessment control ( n = 43), and were assessed 16 additional months ( Jarrett et al., 2001). Consistent with an underlying risk-reduction model, continuation-phase CT was helpful for responders to acute-phase CT with greater risk and/or dysfunction as follows: Younger patients with earlier MDD onset who displayed greater dysfunctional attitudes and lower self-efficacy; personality traits suggesting low positive activation (e.g., reduced energy, enthusiasm, gregariousness); and transiently elevated depressive symptoms late in acute-phase CT and residual symptoms after acute-phase CT response. We emphasize the need for replication of these results before clinical application.

Which depressive symptoms remain after response to cognitive therapy of depression and predict relapse and recurrence?

BackgroundMajor Depressive Disorder (MDD) is highly prevalent, severely debilitating, and often recurrent. Greater residual depressive symptoms after acute phase treatment predict greater relapse and recurrence. It is unknown, however, which specific depressive symptoms remain and are most predictive. MethodThe current study examined (a) which specific residual symptoms remained after effective treatment with acute phase cognitive therapy (A-CT) for recurrent depression and (b) if any of those specific residual symptoms were risk factors for relapse and recurrence over a 2-year follow-up. ResultsAfter completing 20 sessions of A-CT, a substantial proportion of adult responders continued to endorse somatic anxiety (42%), psychological anxiety (37%), middle insomnia (36%), depressed mood (29%), loss of libido (29%), late insomnia (24%), anergia (21%), guilt feelings (18%), early insomnia (17%), and anhedonia (14%), as defined by the 17-item Hamilton Rating Scale for Depression (HRSD). Decreased agitation, increased psychological anxiety, increased loss of appetite, increased loss of libido, and increased hypochondriasis were all risk factors for relapse and recurrence over a 2-year follow-up (all p<.05), after stratifying on number of previous episodes and controlling for age at onset and whether A-CT responders received continuation phase CT instead of assessment only control. LimitationsThese findings are based on a limited sample size (n=84), which was modestly restricted in terms of gender, ethnicity, region, and mean education level. ConclusionsThese results confirm that residual symptoms are common after A-CT. We hypothesize that treatments, intervention modules, or durations that effect and/or target specific residual symptoms may further reduce depression relapse and recurrence.

Deterioration in psychosocial functioning predicts relapse/recurrence after cognitive therapy for depression

BackgroundAssociations between major depressive disorder (MDD) and psychosocial functioning are incompletely understood across time and during continuation phase cognitive therapy (C-CT). We examined the validity of the Range of Impaired Functioning Tool (RIFT; [Leon, A.C., Solomon, D.A., Mueller, T.I., Turvey, C.L., Endicott, J., Keller, M.B., 1999. The Range of Impaired Functioning Tool (LIFE-RIFT): A brief measure of functional impairment. Psychol. Med. 29, 869–878.]) as a measure of psychosocial functioning and its relations to depressive symptoms in C-CT and assessment-only control conditions. MethodsOutpatients with recurrent MDD who responded to acute-phase cognitive therapy (A-CT) were randomized to 8 months of C-CT (n=41) or assessment-only (n=43) and followed 16 additional months [Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: A randomized clinical trial. Arch. Gen. Psychiatry 58, 381–388.]. Interviewers rated depressive symptoms and psychosocial functioning monthly. Patients completed additional self-reports. ResultsThe RIFT converged appropriately with other measures of psychosocial functioning, depressive symptoms, cognitive content, and personality. About half (55%) of patients were psychosocially “well” (RIFT≤8) during the first month post-A-CT. C-CT improved psychosocial functioning only transiently compared to the assessment control. Examined prospectively, depressive symptom level did not predict monthly changes in psychosocial functioning significantly, whereas psychosocial dysfunction level predicted monthly changes in depressive symptoms and relapse/recurrence. LimitationsFindings may not generalize to other patient populations, treatments, and assessment methods. The cross-lagged correlational data structure allows only tentative conclusions about the causal effect of psychosocial functioning on depressive symptoms. ConclusionsThe RIFT is a valid measure of psychosocial functioning among responders to A-CT for depression. After such response, deteriorations in psychosocial functioning may signal imminent major depressive relapse/recurrence and provide targets for change during treatments focused on relapse/recurrence prevention.

How much cognitive therapy, for which patients, will prevent depressive relapse?

Background Although clinicians accept that relapse is probable when successful acute phase pharmacotherapy is discontinued, less is known about when to stop versus continue successful cognitive therapy. This report describes the development of “translational tools” to bridge the gap between research and practice on this and similar decisions that practitioners make daily. We aim to provide patients, clinicians, and public health administrators' practical tools to facilitate informed decisions about when to stop versus continue cognitive therapy with responders who presented with recurrent major depressive disorder (MDD). Method Data are drawn from a randomized clinical trial [Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch. Gen. Psychiatry, 58, 381–388] showing that continuation-phase cognitive therapy (C-CT; [Jarrett, R.B., 1989. Cognitive therapy for recurrent unipolar depressive disorder: The continuation/maintenance phase]) reduced relapse more over 8 months than an assessment-only control, for responders to acute phase cognitive therapy (A-CT; [Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitive therapy of depression. New York, Guilford Press]). We provide tools to translate the additional finding that, over 2 years, responders to A-CT for recurrent depression with higher residual symptoms were more likely to require C-CT to avoid relapse/recurrence than responders with lower or no residual symptoms. Results To measure residual symptoms we provide the specific scores from six readily available measures of depressive symptom severity taken at the last acute phase session and their associated probabilities of relapse or recurrence over 8, 12, and 24 months. Conclusions These tools can aid individual patient and providers in making informed decisions when they decide to continue versus discontinue cognitive therapy. Limitations The results are limited to a 20-session trial of A-CT for recurrent depression conducted by highly experienced therapists and require replication.

Validity of Sudden Gains in Acute Phase Treatment of Depression.

The authors examined the validity of sudden gains identified with T. Z. Tang and R. J. DeRubeis's (1999) method in 2 clinical data sets that involved treatment of major depressive disorder (N=227). Sudden gains replicated among self- and clinician reports of depressive symptoms and predicted better psychosocial functioning at the acute phase treatment end point, in support of their validity. However, sudden gains occurred with roughly the same moderate frequency in pill placebo and pharmacotherapy with clinical management as in cognitive therapy. Furthermore, sudden gains predicted more depressive symptoms and negative failure attributions in longitudinal follow-up of responders to acute phase cognitive therapy. On the basis of these findings, the authors conceptualize sudden gains as one of several possible patterns of acute phase treatment response.

Relational Measures in Psychotherapy Researchon Process and Outcome: A Commentary on the Studies

Using Benjamin's (2000) Structural Analysis of Social Behavior, we evaluated change in "self-directed" affiliation and autonomy and prediction of treatment response and relapse/recurrence among adult outpatients with recurrent major depressive disorder consenting to acute phase cognitive therapy (A-CT; Beck, Rush, Shaw, & Emery, 1979; N = 156); A-CT responders randomized (N = 84) to 8 months of continuation phase cognitive therapy (C-CT; Jarrett, 1989; Jarrett et al., 1998; Jarrett & Kraft, 1997) or assessment-only control; and C-CT and control patients entering a 16-month, assessment-only follow-up (N = 74). Self-directed affiliation and autonomy increased after A-CT, and C-CT further increased affiliation and autonomy. Affiliation and autonomy did not predict A-CT response, but lower affiliation and higher autonomy pre-A-CT predicted relapse/recurrence post-A-CT. We discuss potential clinical implications of these results and present case examples to illustrate patterns of change.

Improvement in social-interpersonal functioning after cognitive therapy for recurrent depression.

Cognitive therapy reduces depressive symptoms of major depressive disorder, but little is known about concomitant reduction in social-interpersonal dysfunction. We evaluated social-interpersonal functioning (self-reported social adjustment, interpersonal problems and dyadic adjustment) and depressive symptoms (two self-report and two clinician scales) in adult outpatients (n=156) with recurrent major depressive disorder at several points during a 20-session course of acute phase cognitive therapy. Consenting acute phase responders (n=84) entered a 2-year follow-up phase, which included an 8-month experimental trial comparing continuation phase cognitive therapy to assessment-only control. Social-interpersonal functioning improved after acute phase cognitive therapy (dyadic adjustment d=0.47; interpersonal problems d=0.91; social adjustment d=1.19), but less so than depressive symptoms (d=1.55). Improvement in depressive symptoms and social-interpersonal functioning were moderately to highly correlated (r=0.39-0.72). Improvement in depressive symptoms was partly independent of social-interpersonal functioning (r=0.55-0.81), but improvement in social-interpersonal functioning independent of change in depressive symptoms was not significant (r=0.01-0.06). In acute phase responders, continuation phase therapy did not further enhance social-interpersonal functioning, but improvements in social-interpersonal functioning were maintained through the follow-up. Social-interpersonal functioning is improved after acute phase cognitive therapy and maintained in responders over 2 years. Improvement in social-interpersonal functioning is largely accounted for by decreases in depressive symptoms.

Self-Directed Affiliation and Autonomy Across Acute and Continuation Phase Cognitive Therapy for Recurrent Depression

Using Benjamin's (2000) Structural Analysis of Social Behavior, we evaluated change in "self-directed" affiliation and autonomy and prediction of treatment response and relapse/recurrence among adult outpatients with recurrent major depressive disorder consenting to acute phase cognitive therapy (A-CT; Beck, Rush, Shaw, & Emery, 1979; N = 156); A-CT responders randomized (N = 84) to 8 months of continuation phase cognitive therapy (C-CT; Jarrett, 1989; Jarrett et al., 1998; Jarrett & Kraft, 1997) or assessment-only control; and C-CT and control patients entering a 16-month, assessment-only follow-up (N = 74). Self-directed affiliation and autonomy increased after A-CT, and C-CT further increased affiliation and autonomy. Affiliation and autonomy did not predict A-CT response, but lower affiliation and higher autonomy pre-A-CT predicted relapse/recurrence post-A-CT. We discuss potential clinical implications of these results and present case examples to illustrate patterns of change.