Daniel R. Strunk

Patients' Competence in and Performance of Cognitive Therapy Skills: Relation to the Reduction of Relapse Risk Following Treatment for Depression

Cognitive therapy (CT) for depression is designed to teach patients material that is believed to help prevent relapse following successful treatment. This study of 35 moderately to severely depressed patients who responded to CT provides the 1st evidence to suggest that both development and independent use of these competencies predict reduced risk for relapse. Among patients who responded to treatment, both CT coping skills and in-session evidence of the independent implementation of CT material predicted lower risk for relapse in the year following treatment. These relationships were not accounted for by either symptom severity at the end of treatment or symptom change from pre- to posttreatment. Self-esteem, assessed at posttreatment, failed to predict risk for relapse in the year following treatment. Thus, CT coping skills and independent use of CT principles, but not overall satisfaction with oneself, appear to play an important role in relapse prevention.

Cognitive biases in three prediction tasks: A test of the cognitive model of depression

Cognitive therapy for depression is based on an assumption that depressed individuals have inaccurate, negative biases. Whether this assumption is accurate remains unresolved. Thus, this study sought to examine the relationship between depressive symptoms and bias in three sets of predictions (i.e., predictions of future life events, how one would be rated by a significant other, and performance on a vocabulary test). Following study announcements made to a subset of people pre-screened for depressive symptoms, 85 participants with widely varying depressive symptoms (17 of whom met diagnostic criteria for depression) made predictions on three judgment tasks and the outcomes for these tasks were assessed. Optimistic/pessimistic biases were related to depressive symptoms for each of the three tasks. Participants with high levels of depressive symptoms and depressed participants exhibited substantial pessimistic bias. Those high in depressive symptoms exhibited significant pessimistic bias on all three tasks. Participants meeting diagnostic criteria for depression exhibited pessimistic bias on two of three tasks. There was no evidence that depressive symptoms were associated with greater accuracy in judgments. Results are largely consistent with cognitive models of depression which postulate that depression is associated with pessimistic biases.

Cancer Patients with Major Depressive Disorder: Testing a Biobehavioral/Cognitive Behavior Intervention.

OBJECTIVE In this Phase II trial, we evaluated a novel psychological treatment for depressed patients coping with the stresses of cancer. Effectiveness of a combined biobehavioral intervention (BBI) and cognitive behavior therapy (CBT) was studied. METHOD Participants were 36 cancer survivors (mean age = 49 years; 88% Caucasian; 92% female) diagnosed with major depressive disorder. A single group pre-post design was used. Treatment consisted of up to 20 individual 75-min combined BBI/CBT sessions. Outcomes were change in interviewer (Hamilton Rating Scale for Depression; Williams, 1988) and self-rated depressive symptoms (Beck Depression Inventory-Second Edition; Beck, Steer, & Brown, 1996) as well as change in cancer relevant symptoms (Fatigue Symptom Inventory [Hann et al., 1998] and Brief Pain Questionnaire [Daut, Cleeland, & Flanery, 1983]) and quality of life (Medical Outcomes Study Short Form-36; Ware et al., 1995). Mixed-effects modeling, a reliability change index, and generalized linear models were used. All analyses were intent-to-treat. RESULTS Depressive symptoms significantly improved. In addition, 19 of 21 study completers met criteria for remission. Significant improvements were also noted in fatigue and mental health quality of life. Both concurrent anxiety disorders and high levels of cancer stress (Impact of Events Scale; Horowitz, Wilner, & Alvarez, 1979) were each associated with beginning and concluding treatment with greater depressive symptoms. CONCLUSIONS CBT components were successfully incorporated into a previously efficacious intervention for reducing cancer stress. The BBI/CBT intervention warrants further research in evaluating its efficacy compared with well-established treatments for depression.

Cognitive Therapy for Depression: A Review of Its Efficacy

The empirical status of cognitive therapy for depression, based on Aaron T. Beck’s model, is reviewed. Available evidence suggests that cognitive therapy is at least as effective in the short run as other psychotherapies, as well as pharmacotherapy. Patients in cognitive therapy experience a large reduction in depressive symptoms and a substantial portion meet recovery criteria at the end of a 12- or 16-week acute treatment period. Moreover, there is evidence that cognitive therapy produces a prophylactic effect. Thus, we conclude that cognitive therapy works well and should be strongly considered as a first-line treatment for depressed people.

Assessing Patients’ Cognitive Therapy Skills: Initial Evaluation of the Competencies of Cognitive Therapy Scale

In cognitive therapy (CT), therapists work to help patients develop skills to cope with negative affect. Most current methods of assessing patients’ skills are cumbersome and impractical for clinical use. To address this issue, we developed and conducted an initial psychometric evaluation of self- and therapist-reported versions of a new measure of CT skills: the Competencies of Cognitive Therapy Scale (CCTS). We evaluated the CCTS at intake and post-treatment in a sample of 67 patients participating in CT. The CCTS correlated with a preexisting measure of CT skills (the Ways of Responding Questionnaire) and was also related to concurrent depressive symptoms. Across CT, self-reported improvements in CT competencies were associated with greater changes in depressive symptoms. These findings offer initial evidence for the validity of the CCTS. We discuss the CCTS in comparison with other measures of CT skills and suggest future research directions.

A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?

Homework is a key component of Cognitive Therapy (CT) for depression. Although previous research has found evidence for a positive relationship between homework compliance and treatment outcome, the methods used in previous studies have often not been optimal. In this study, we examine the relation of specific aspects of homework engagement and symptom change over successive session-to-session intervals. In a sample of 53 depressed adults participating in CT, we examined the relation of observer-rated homework engagement and session-to-session symptom change across the first five sessions. Within patient (and not between patient) variability in homework engagement was significantly related to greater session-to-session symptom improvements. These findings were similar when homework engagement was assessed through a measure of general engagement with homework assignments and a measure assessing engagement in specific assignments often used in CT. Secondary analyses suggested that observer ratings of the effort patients made on homework and the completion of cognitive homework were the numerically strongest predictors of depressive symptom improvements. Patient engagement with homework assignments appears to be an important predictor of early session-to-session symptom improvements. Future research is needed to identify what therapist behaviors promote homework engagement.

Self-Esteem Accessibility as Attitude Strength: On the Durability and Impactfulness of Accessible Self-Esteem

The present research examines the accessibility of one’s self-esteem as a predictor of the “strength” (durability and impactfulness) of that self-esteem. Based on attitude accessibility research, the authors predicted that accessibility of self-esteem (i.e., a self-attitude) would be positively related to self-esteem’s ability to resist change and guide information processing. In Study 1, accessibility of self-esteem was positively related to resistance to change in a paradigm where participants listed either positive or negative self-attributes. Self-esteem was also associated with biases in judgments of ambiguous personality feedback (Study 2) and in explanatory style and future event predictions (Study 3), but did so to a greater extent as self-esteem accessibility increased. In addition, these patterns were obtained after controlling for other variables, including general reaction time, evaluative extremity, self-concept clarity, and self-esteem certainty. Results are discussed in relation to past literature, self-strength, and applied implications.

Attitude formation in depression: Evidence for deficits in forming positive attitudes

While a wealth of research has found that depressive symptoms are related to current attitudes, new evidence suggests depressive symptoms may be related to a fundamental deficit in forming new attitudes. Researchers investigating individual differences in attitude formation have found that depressive symptoms are strongly correlated with poorer learning of positive stimuli. This study extended these findings to a sample including clinically depressed participants. Results show that, as compared to nondepressed individuals, depressed individuals are characterized by a large deficit in their learning of positive stimuli. Implications of this fundamental deficit are discussed.

A Comparison of Three Theoretically Important Constructs: What Accounts For Symptoms of Borderline Personality Disorder?

OBJECTIVE Theories point to different mechanisms through which borderline personality disorder (BPD) symptoms may be developed and maintained: (a) emotion regulation dysfunction, (b) problematic relations, and (c) nonintegrated self. However, researchers have not investigated the relative contribution of these mechanisms simultaneously in accounting for the variance observed in BPD symptoms. METHOD Drawing from university students and Internet users, 462 adults (63% female, 77% Caucasian) completed self-report measures of emotion regulation, interpersonal problems, sense of self, BPD symptoms, and depressive symptoms. RESULTS All predictors were independently associated with BPD symptoms, with emotion regulation difficulties having the strongest relation. For high BPD individuals (N = 94), emotional regulation difficulties was the only predictor uniquely associated with BPD symptoms and interpersonal problems was the sole unique predictor of depressive symptoms. CONCLUSION These results suggest that emotion regulation difficulties and interpersonal problems may be particularly problematic for those with high BPD symptoms in different ways. Implications and future directions are discussed.

Can pharmacotherapists be too supportive? A process study of active medication and placebo in the treatment of depression.

BACKGROUND This study examined therapist-patient interactions during clinical management with antidepressant medication and pill-placebo. METHOD The sample consisted of 80 patients on active medication and 40 patients in a pill-placebo condition from a randomized controlled trial for moderate to severe depression. Pharmacotherapist-patient interactions were characterized using observer ratings of the therapeutic alliance, pharmacotherapist-offered facilitative conditions, pharmacotherapist adherence to clinical management treatment guidelines and pharmacotherapist competence. Patients, therapists and raters were blind to treatment condition and outcome. RESULTS Provision of greater non-specific support (facilitative conditions) in early sessions predicted less subsequent improvement in depressive symptoms for patients receiving pill-placebo but not those receiving active medications, for which none of the process ratings predicted subsequent change. Early symptom change predicted later alliance and adherence in both conditions and therapist competence in the active condition. CONCLUSIONS Higher levels of support in early sessions predict poorer subsequent response among placebo patients. It remains unclear whether patients who are likely to be refractory elicit greater non-specific support or whether the provision of such support has a deleterious effect in unmedicated patients. Differences in treatment process variables between conditions late in treatment are likely to be largely a consequence of symptom relief produced by active medications.