Christian A. Webb

Therapist Adherence/Competence and Treatment Outcome: A Meta-Analytic Review

OBJECTIVE The authors conducted a meta-analytic review of adherence-outcome and competence-outcome findings, and examined plausible moderators of these relations. METHOD A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. RESULTS R-type effect size estimates were derived from 32 adherence-outcome and 17 competence-outcome findings. Neither the mean weighted adherence-outcome (r = .02) nor competence-outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence-outcome and competence-outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence-outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. CONCLUSIONS One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence-outcome and competence-outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.

Two Aspects of the Therapeutic Alliance: Differential Relations With Depressive Symptom Change

OBJECTIVE The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). METHOD Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n = 105, mean age = 40 years, female = 62%, White = 82%). We examined the relations of 2 factor-analytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist-patient dyad. RESULTS Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist-patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. CONCLUSIONS These findings may reflect the importance, in CT, of therapist-patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed.

Conceptualizing the Prospective Relationship Between Social Support, Stress, and Depressive Symptoms Among Adolescents

The goal of the current study is to examine the relationship amongst social support, stress, and depressive symptoms within a transactional and diathesis-stress framework using a multi-wave, longitudinal design. At the initial assessment, adolescents (n = 258) completed self-report measures assessing social support (peer, classmate, parent, and total), dependent interpersonal stress, anxious symptoms, and depressive symptoms. Additionally, participants reported stress and symptomology in each of the four waves spanning six months. Results of time-lagged, idiographic, multilevel modeling indicated that stress mediated the relationship between lower parental, classmate, and total social support and subsequent depressive, but not anxious, symptoms. In contrast, lower levels of peer support were not associated with higher levels of stress and subsequent depressive symptoms. Additionally, only classmate support deficits significantly moderated the relationship between stress and depressive symptoms. Overall, the results suggest that deficits in parental and classmate support may play a greater role in contributing to adolescent depression as compared to deficits in peer support.

The Role of Self-Criticism, Dependency, and Hassles in the Course of Depressive Illness: A Multiwave Longitudinal Study

The current study utilized a multiwave longitudinal design to examine whether dependency and/or self-criticism influence the course of depressive symptoms in a community sample of adults with a history of major depression. In addition, the authors examined whether self-esteem serves as a buffer against the development of depressive symptoms following increases in hassles in individuals possessing such traits. At Time 1, 102 participants completed measures assessing depressive symptoms, self-criticism, dependency, and self-esteem. Every 6 weeks for the next year, participants completed measures assessing depressive symptoms and hassles. High self-criticism was associated with greater elevations in depressive symptoms following elevations in hassles in low but not high-self-esteem individuals. Results with respect to dependency, however, were contrary to hypotheses. High dependency was associated with elevations in depressive symptoms following elevations in hassles in high-self-esteem individuals. In contrast, high dependency was associated with chronically elevated depressive symptoms in low-self-esteem individuals.

Reduced gray matter volume in the anterior cingulate, orbitofrontal cortex and thalamus as a function of mild depressive symptoms: a voxel-based morphometric analysis

BACKGROUND Studies investigating structural brain abnormalities in depression have typically employed a categorical rather than dimensional approach to depression [i.e., comparing subjects with Diagnostic and Statistical Manual of Mental Disorders (DSM)-defined major depressive disorder (MDD) v. healthy controls]. The National Institute of Mental Health, through their Research Domain Criteria initiative, has encouraged a dimensional approach to the study of psychopathology as opposed to an over-reliance on categorical (e.g., DSM-based) diagnostic approaches. Moreover, subthreshold levels of depressive symptoms (i.e., severity levels below DSM criteria) have been found to be associated with a range of negative outcomes, yet have been relatively neglected in neuroimaging research. METHOD To examine the extent to which depressive symptoms--even at subclinical levels--are linearly related to gray matter volume reductions in theoretically important brain regions, we employed whole-brain voxel-based morphometry in a sample of 54 participants. RESULTS The severity of mild depressive symptoms, even in a subclinical population, was associated with reduced gray matter volume in the orbitofrontal cortex, anterior cingulate, thalamus, superior temporal gyrus/temporal pole and superior frontal gyrus. A conjunction analysis revealed concordance across two separate measures of depression. CONCLUSIONS Reduced gray matter volume in theoretically important brain regions can be observed even in a sample that does not meet DSM criteria for MDD, but who nevertheless report relatively elevated levels of depressive symptoms. Overall, these findings highlight the need for additional research using dimensional conceptual and analytic approaches, as well as further investigation of subclinical populations.

Client Characteristics as Moderators of the Relation Between the Therapeutic Alliance and Outcome in Cognitive Therapy for Depression

OBJECTIVE Little is known about the variability of the alliance-outcome correlation across identifiable client subsets. This question was explored in a sample of 60 clients receiving cognitive therapy for depression, from which an overall correlation of .23 was observed between alliance ratings and subsequent symptom change. METHOD We examined interactions between the observer-rated version of the Working Alliance Inventory-Short Observer-Rated version (WAI-O; Tracey & Kokotovic, 1989) and client demographics, features of depression, personality, and other clinical features in predicting subsequent symptom change. RESULTS After correcting for multiple comparisons, interactions between the WAI-O and the number of prior depressive episodes, as well as the severity of baseline anxiety symptoms, were significant predictors of symptom change. When both interactions were controlled for, number of prior depressive episodes emerged as a statistically significant moderator. The alliance predicted outcome in the subgroup of clients with 0-2 prior episodes (r = .52), but not in those with 3 or more prior episodes (r = -.02). These findings were obtained despite similar univariate distributions on the alliance and symptom change in the 2 subgroups. DISCUSSION Differences that were observed in the predictive relation of alliance to outcome as a function of number of prior episodes suggest that different therapy processes may account for change in these subgroups. If the pattern observed in the present study is replicated, it would suggest that the alliance-outcome association has been both under- and overestimated.

Processes of Change in CBT of Adolescent Depression: Review and Recommendations

A growing body of research supports the efficacy of cognitive-behavioral therapy (CBT) for adolescent depression. The mechanisms through which CBT exerts its beneficial effects on adolescent patients suffering from depression, however, remain unclear. The current article reviews the CBT for adolescent depression process literature. Our review focuses on several process variables: the therapeutic alliance, patient cognitive change, and therapist adherence to, and competence in, the theory-specified techniques of therapy. Given that the vast majority of CBT process research has been conducted in the context of adult psychotherapy, we also review relevant adult research as a framework for understanding adolescent process research and to inform future investigations. Methodological issues are addressed and recommendations for future process research are raised.

Neural Correlates of Three Promising Endophenotypes of Depression: Evidence from the EMBARC Study

Major depressive disorder (MDD) is clinically, and likely pathophysiologically, heterogeneous. A potentially fruitful approach to parsing this heterogeneity is to focus on promising endophenotypes. Guided by the NIMH Research Domain Criteria initiative, we used source localization of scalp-recorded EEG resting data to examine the neural correlates of three emerging endophenotypes of depression: neuroticism, blunted reward learning, and cognitive control deficits. Data were drawn from the ongoing multi-site EMBARC study. We estimated intracranial current density for standard EEG frequency bands in 82 unmedicated adults with MDD, using Low-Resolution Brain Electromagnetic Tomography. Region-of-interest and whole-brain analyses tested associations between resting state EEG current density and endophenotypes of interest. Neuroticism was associated with increased resting gamma (36.5–44 Hz) current density in the ventral (subgenual) anterior cingulate cortex (ACC) and orbitofrontal cortex (OFC). In contrast, reduced cognitive control correlated with decreased gamma activity in the left dorsolateral prefrontal cortex (dlPFC), decreased theta (6.5–8 Hz) and alpha2 (10.5–12 Hz) activity in the dorsal ACC, and increased alpha2 activity in the right dlPFC. Finally, blunted reward learning correlated with lower OFC and left dlPFC gamma activity. Computational modeling of trial-by-trial reinforcement learning further indicated that lower OFC gamma activity was linked to reduced reward sensitivity. Three putative endophenotypes of depression were found to have partially dissociable resting intracranial EEG correlates, reflecting different underlying neural dysfunctions. Overall, these findings highlight the need to parse the heterogeneity of MDD by focusing on promising endophenotypes linked to specific pathophysiological abnormalities.

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.

Habitual ‘sleep credit’ is associated with greater grey matter volume of the medial prefrontal cortex, higher emotional intelligence and better mental health

In modern society, people often fail to obtain the amount of sleep that experts recommend for good health and performance. Insufficient sleep can lead to degraded cognitive performance and alterations in emotional functioning. However, most people also acknowledge that on a regular basis they obtain more sleep than they subjectively perceive they need at a minimum to stave off performance decrements, a construct we describe as subjective ‘sleep credit’. Few people would contest the notion that getting more sleep is better, but data on both behavioural and neuroanatomical correlates of ‘sleep credit’ are surprisingly limited. We conducted a voxel‐based morphometric study to assess cerebral grey matter correlates of habitually sleeping more than ones subjective requirements. We further tested whether these structural correlates are associated with perceived emotional intelligence and indices of psychopathology while controlling for age, gender, and total intracranial volume. In a sample of 55 healthy adults aged 18–45 years (28 males, 27 females), whole‐brain multiple regression showed that habitual subjective ‘sleep credit’ was correlated positively with grey matter volume within regions of the left medial prefrontal cortex and right orbitofrontal gyrus. Volumes were extracted and regressed against self‐report emotion and psychopathology indices. Only grey matter volume of the medial prefrontal cortex cluster correlated with greater emotional intelligence and lower scores on several indices of psychopathology. Findings converge with previous evidence of the role of the medial prefrontal cortex in the relationship between sleep and emotional functioning, and suggest that behaviour and brain structure vary with habitual ‘sleep credit’.