Evelien Snippe

Individual Mindfulness-Based Cognitive Therapy and Cognitive Behavior Therapy for Treating Depressive Symptoms in Patients With Diabetes: Results of a Randomized Controlled Trial

OBJECTIVE Depression is a common comorbidity of diabetes, undesirably affecting patients’ physical and mental functioning. Psychological interventions are effective treatments for depression in the general population as well as in patients with a chronic disease. The aim of this study was to assess the efficacy of individual mindfulness-based cognitive therapy (MBCT) and individual cognitive behavior therapy (CBT) in comparison with a waiting-list control condition for treating depressive symptoms in adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS In this randomized controlled trial, 94 outpatients with diabetes and comorbid depressive symptoms (i.e., Beck Depression Inventory-II [BDI-II] ≥14) were randomized to MBCT (n = 31), CBT (n = 32), or waiting list (n = 31). All participants completed written questionnaires and interviews at pre- and postmeasurement (3 months later). Primary outcome measure was severity of depressive symptoms (BDI-II and Toronto Hamilton Depression Rating Scale). Anxiety (Generalized Anxiety Disorder 7), well-being (Well-Being Index), diabetes-related distress (Problem Areas In Diabetes), and HbA1c levels were assessed as secondary outcomes. RESULTS Results showed that participants receiving MBCT and CBT reported significantly greater reductions in depressive symptoms compared with patients in the waiting-list control condition (respectively, P = 0.004 and P < 0.001; d = 0.80 and 1.00; clinically relevant improvement 26% and 29% vs. 4%). Both interventions also had significant positive effects on anxiety, well-being, and diabetes-related distress. No significant effect was found on HbA1c values. CONCLUSIONS Both individual MBCT and CBT are effective in improving a range of psychological symptoms in individuals with type 1 and type 2 diabetes.

The Temporal Order of Change in Daily Mindfulness and Affect During Mindfulness-Based Stress Reduction

Increases in mindfulness are assumed to lead to improvements in psychological well-being during mindfulness-based treatments. However, the temporal order of this association has received little attention. This intensive longitudinal study examines whether within-person changes in mindfulness precede or follow changes in negative affect (NA) and positive affect (PA) during a mindfulness based stress reduction (MBSR) program. This study also examines interindividual differences in the association between mindfulness and affect and possible predictors of these differences. Mindfulness, NA, and PA were assessed on a daily basis in 83 individuals from the general population who participated in an MBSR program. Multilevel autoregressive models were used to investigate the temporal order of changes in mindfulness and affect. Day-to-day changes in mindfulness predicted subsequent day-to-day changes in both NA and PA, but reverse associations did not emerge. Thus, changes in mindfulness seem to precede rather than to follow changes in affect during MBSR. The magnitude of the effects differed substantially between individuals, showing that the strength of the relationship between mindfulness and affect is not the same for all participants. These between-subjects differences could not be explained by gender, age, level of education, average level of mindfulness home practice, or baseline levels of mindfulness and affect. Mindfulness home practice during the day did predict subsequent increases in mindfulness. The findings suggest that increasing mindfulness on a daily basis can be a beneficial means to improve daily psychological well-being.

The Therapeutic Alliance Predicts Outcomes of Cognitive Behavior Therapy but Not of Mindfulness-Based Cognitive Therapy for Depressive Symptoms

However, based on previous research [4, 6] , we expected that this latter association would be weaker than the associations for agreement on tasks and goals. In the original trial, 94 patients with diabetes (type I or II) and depressive symptoms [Beck Depression Inventory-II (BDI-II) score ≥ 14] were randomized to CBT, MBCT, or a 3-month waiting list control condition, after which patients were again randomized to CBT or MBCT (more details on the study are presented elsewhere [7] ). Both treatments consisted of eight individual sessions. Therapist adherence to the treatment manuals was sufficient (MBCT: 86%; CBT: 79%). Both CBT and MBCT were efficacious in reducing depressive symptoms in comparison with the control condition (Cohen’s d = 1.00 and d = 0.80, respectively) [7] . The current study included 76 participants (CBT: n = 38; MBCT: n = 38) who received treatment immediately or after the waiting period (if BDI-II score ≥ 14) and completed at least one assessment of the therapeutic alliance. The therapeutic alliance was assessed with the validated Dutch patient-rated 12-item version of the Working Alliance Inventory (WAI) [8, 9] . The WAI consists of three 4-item subscales (rated 1–5): (a) agreement on goals; (b) agreement on tasks, and (c) the bond between the patient and therapist. The WAI was administered after the second (MBCT: mean = 3.4, SD = 0.7; CBT: mean = 3.4, SD = 0.8) and fourth (MBCT: mean = 3.5, SD = 0.8; CBT: mean = 3.5, SD = 0.7) treatment sessions. Depressive symptoms were assessed using the 21-item BDI-II [10] . The BDI-II was completed before treatment and after the second, fourth, and eighth (last) session (details on mean levels are presented elsewhere [7] ). In separate regression analyses, WAI total and WAI subscale scores were examined as predictors of end-of-treatment BDI-II scores while controlling for pretreatment BDI-II scores and BDI-II scores assessed at the same time as the WAI. Missing BDI-II scores (n = 6) were estimated by means of multiple imputations. The results are presented in table 1 . In CBT, lower end-of-treatment BDI-II scores were predicted by higher WAI total scores as well as higher ratings of the Task and Bond subscales after session 4. Alliance ratings after session 2 were not associated with subsequent BDI-II scores in CBT, except for the Task subscale. In MBCT, neither WAI total scores nor the separate WAI subscales were associated with end-of-treatment BDI-II scores. Our findings in diabetic patients with depressive symptoms showed that patients’ ratings of the therapeutic alliance predict depressive symptom improvement in CBT but not in MBCT. The WAI total scores and the WAI subscales explained more variance in outcomes of CBT when assessed after the fourth session than when assessed after the second session. This result is consistent with earlier research demonstrating an alliance-outcome association when the WAI was administered at the third session or later in treatment [1] . In MBCT, neither the total alliance score nor the different components of the alliance were associated with subsequent symptom change. Meta-analyses have indicated a consistent correlation between the therapeutic alliance and treatment outcomes across various psychological treatments and patient populations, including treatments for depression [1] . However, few studies have directly compared two active treatments with respect to the alliance-outcome association. A recent randomized trial demonstrated that the alliance was more strongly related to depressive symptom improvement in the cognitive behavioral analysis system of psychotherapy (which focuses more on enhancing collaborative working relationships) than in brief supportive psychotherapy for depression [2] . This result suggests that the extent to which aspects of the therapeutic alliance (i.e. mutual agreement on therapeutic goals, mutual agreement on tasks, and the bond between the patient and therapist [3] ) are central to a treatment might affect the predictive value of the alliance. The present study compares the alliance-outcome association in cognitive behavior therapy (CBT) and mindfulness-based cognitive therapy (MBCT) for depressive symptoms in diabetic patients while controlling for prior symptom change. It is important to control for the possibility that patients’ ratings of the alliance reflect early symptom improvement, because this may confound the alliance-outcome association [4] . As CBT focuses more on collaboratively ascertaining the treatment goals and designing treatment tasks than MBCT [5] , we hypothesized that the two alliance components ‘agreement on tasks’ and ‘agreement on goals’ are more strongly associated with outcomes of CBT than MBCT. Because both CBT and MBCT therapists aim to form a therapeutic bond by adopting an open, empathic, accepting, and nonjudging attitude towards patients [5] , we hypothesized that the therapeutic bond predicts the subsequent symptom change in both treatments. Received: July 16, 2014 Accepted after revision: February 6, 2015 Published online: August 6, 2015

Preserving Subjective Wellbeing in the Face of Psychopathology: Buffering Effects of Personal Strengths and Resources

Background Many studies on resilience have shown that people can succeed in preserving mental health after a traumatic event. Less is known about whether and how people can preserve subjective wellbeing in the presence of psychopathology. We examined to what extent psychopathology can co-exist with acceptable levels of subjective wellbeing and which personal strengths and resources moderate the association between psychopathology and wellbeing. Methods Questionnaire data on wellbeing (Manchester Short Assessment of Quality of Life/Happiness Index), psychological symptoms (Depression Anxiety Stress Scales), and personal strengths and resources (humor, Humor Style questionnaire; empathy, Empathy Quotient questionnaire; social company; religion; daytime activities, Living situation questionnaire) were collected in a population-based internet study (HowNutsAreTheDutch; N = 12,503). Data of the subset of participants who completed the above questionnaires (n = 2411) were used for the present study. Regression analyses were performed to predict wellbeing from symptoms, resources, and their interactions. Results Satisfactory levels of wellbeing (happiness score 6 or higher) were found in a substantial proportion of the participants with psychological symptoms (58% and 30% of those with moderate and severe symptom levels, respectively). The association between symptoms and wellbeing was large and negative (-0.67, P < .001), but less so in persons with high levels of self-defeating humor and in those with a partner and/or pet. Several of the personal strengths and resources had a positive main effect on wellbeing, especially self-enhancing humor, having a partner, and daytime activities. Conclusions Cultivating personal strengths and resources, like humor, social/animal company, and daily occupations, may help people preserve acceptable levels of wellbeing despite the presence of symptoms of depression, anxiety, and stress.

Affective reactivity to daily life stress: Relationship to positive psychotic and depressive symptoms in a general population sample

INTRODUCTION Increased affective reactivity to daily life stress has been found in individuals with psychosis and depression, and in those at risk for these conditions. Because depressive and psychotic symptoms often co-occur, increased affective reactivity in these disorders may be explained by the presence of depressive symptoms, psychotic symptoms, or both. Therefore, we examined whether affective reactivity to daily stress is related to positive psychotic symptoms, independently of depressive symptoms, and vice versa. METHODS We used data from an intensive sampling study in the general population (n = 411), with three measurements a day (t = 90). The following subjective stressors were assessed: appraisal of activities, appraisal of social interactions, and experienced physical discomfort. Affective reactivity was conceptualized as both the positive affect (PA) and negative affect (NA) response to these stressors. By means of mixed model analyses, it was examined whether affective reactivity was independently related to depressive and/or positive psychotic symptoms. RESULTS The PA response to activities and NA response to social interactions were negatively and positively related to depressive symptoms, respectively, independent of psychotic symptoms. In contrast, no (in)dependent association was found between positive psychotic symptoms and affective reactivity to any of the daily life stressors. These findings were confirmed in a subsample with increased symptoms. LIMITATIONS The prevalence of positive psychotic symptoms was relatively low in this general population sample. CONCLUSIONS Increased affect reactivity predicts depressive symptoms, but not positive psychotic symptoms. Affective reactivity may still facilitate the development of psychotic symptomatology via its impact on depressive symptoms.

Exploring the emotional dynamics of subclinically depressed individuals with and without anhedonia: An experience sampling study

BACKGROUND Anhedonia has been linked to worse prognosis of depression. The present study aimed to construct personalized models to elucidate the emotional dynamics of subclinically depressed individuals with versus without symptoms of anhedonia. METHODS Matched subclinically depressed individuals with and without symptoms of anhedonia (N = 40) of the HowNutsAreTheDutch sample completed three experience sampling methodology assessments per day for 30 days. For each individual, the impact of physical activity, stress experience, and high/low arousal PA/NA on each other was estimated through automated impulse response function analysis (IRF). These individual IRF associations were combined to compare anhedonic versus non-anhedonic individuals. RESULTS Physical activity had low impact on affect in both groups. In non-anhedonic individuals, stress experience increased NA and decreased PA and physical activity more strongly. In anhedonic individuals, PA high arousal showed a diminished favorable impact on affect (increasing NA/stress experience, decreasing PA/physical activity). Finally, large heterogeneity in the personalized models of emotional dynamics were found. LIMITATIONS Stress experience was measured indirectly by assessing level of distress; the timeframe in between measurements was relatively long with 6h; and only information on one of the two hallmarks of anhedonia, loss of interest, was gathered. CONCLUSIONS Our results suggest different pathways of emotional dynamics underlie depressive symptomatology. Subclinically depressed individuals with anhedonic complaints are more strongly characterized by diminished favorable impact of PA high arousal and heightened NA reactivity, whereas subclinically depressed individuals without these anhedonic complaints seem more characterized by heightened stress reactivity. The automatically generated personalized models may offer patient-specific insights in emotional dynamics, which may show clinical relevance.

Reciprocal associations between positive emotions and motivation in daily life: Network analyses in anhedonic individuals and healthy controls

Anhedonia reflects a dysfunction in the reward system, which can be manifested in an inability to enjoy pleasurable situations (i.e., lack of positive emotions), but also by a lack of motivation to engage in pleasurable activities (i.e., lack of motivation). Little is known about the interrelations between positive emotions and motivation in daily life, and whether these associations are altered in anhedonic individuals. In the present study, we used a network approach to explore the reciprocal, lagged associations between positive emotions and motivation in anhedonic individuals (N = 66) and controls (N = 68). Participants (aged between 18 and 24 years) filled out momentary assessments of affect 3 times per day for 30 consecutive days. Our results showed that (a) anhedonic individuals and controls had similar moment-to-moment transfer of positive emotions; (b) in the anhedonic network feeling cheerful was the node with the highest outstrength, both within this group and compared with the control group; (c) feeling relaxed had the highest outstrength in the control network, and (d) anhedonic individuals had stronger pathways from positive emotions to motivation than controls. Taken together, our findings suggest that low levels of positive emotions lead to decreased motivation in the anhedonic group, which could instigate a negative spiral of low pleasure and low motivation. On a more positive note, we showed that cheerfulness had the highest outstrength in the network of anhedonic participants. Hence, interventions may focus on increasing cheerfulness in anhedonic individuals, as this will likely have the greatest impact on other positive emotions and motivations.

What works best for whom? : Cognitive Behavior Therapy and Mindfulness-Based Cognitive Therapy for depressive symptoms in patients with diabetes

Objective Cognitive Behavior Therapy (CBT) and Mindfulness-Based Cognitive Therapy (MBCT) have shown to be effective interventions for treating depressive symptoms in patients with diabetes. However, little is known about which intervention works best for whom (i.e., moderators of efficacy). The aim of this study was to identify variables that differentially predicted response to either CBT or MBCT (i.e., prescriptive predictors). Methods The sample consisted of 91 adult outpatients with type 1 or type 2 diabetes and comorbid depressive symptoms (i.e., BDI-II ≥ 14) who were randomized to either individual 8-week CBT (n = 45) or individual 8-week MBCT (n = 46). Patients were followed for a year and depressive symptoms were measured at pre-treatment, post-treatment, and at 9-months follow-up. The predictive effect of demographics, depression related characteristics, and disease specific characteristics on change in depressive symptoms was assessed by means of hierarchical regression analyses. Results Analyses showed that education was the only factor that differentially predicted a decrease in depressive symptoms directly after the interventions. At post-treatment, individuals with higher educational attainment responded better to MBCT, as compared to CBT. Yet, this effect was not apparent at 9-months follow-up. Conclusions This study did not identify variables that robustly differentially predicted treatment effectiveness of CBT and MBCT, indicating that both CBT and MBCT are accessible interventions that are effective for treating depressive symptoms in broad populations with diabetes. More research is needed to guide patient-treatment matching in clinical practice.

The IFP Young Researcher Award

however, we lack knowledge about what characterizes a more or less effective therapist. Five studies were conducted with the aim of increasing our understanding of how the individual therapist contributes to the process and outcome of psychotherapy [3–7] . These studies were run in a naturalistic treatment setting [8] with 370 ordinary patients suffering from a wide range of mental health problems, most of whom had a high level of clinical disturbance, including 50% with at least one personality disorder. The therapists (n = 70), who were mostly clinical psychologists and psychiatrists, were assessed using concepts developed by the SPR Collaborative Research Network by means of the Development of Psychotherapists Common Core Questionnaire (DPCCQ) [9] . In summary, some of these concepts robustly predicted the process and outcome of therapy, but not necessarily in the direction expected (possibly because the therapists’ characteristics were self-reported). The effect of the therapists’ experiences of difficulties in practice was particularly strong. One aspect, termed ‘negative personal reaction’, involved deficient empathy towards clients, and the trouble of finding something to like and respect in a client had a negative influence on process and outcome measures. However, a surprising positive influence was found for another difficulty encountered by therapists termed ‘professional self-doubt’ (PSD), which reflected the therapists’ doubts about whether they can have a beneficial effect on a client. This latter finding led to an interpretation of PSD as reflecting an attitude of the therapists’ humbleness and sensitivity, which seems to facilitate alliance building and patient change. Also, the therapists’ private experiences of distress (e.g., personal conflict and loss) were strongly and negatively related to the growth of the alliance as rated by the patients but unrelated to the therapist-rated alliance. Conversely, the therapists’ experiences of personal satisfaction were clearly and positively associated with therapist-rated alliance growth but unrelated to the patients’ ratings of the alliance. Thus, it seems that patients are particularly IFP Research Awards seek to foster a broad spectrum of psychotherapy research that furthers the purposes of the International Federation for Psychotherapy (IFP), with special emphasis on studies relating to cultural issues, psychotherapy delivery, clinical excellence, and training. The IFP Research Committee accepts nominations for the following 3 awards, which will rotate each year: (1) Young researchers who have completed a doctoral dissertation and published a minimum of 3 research papers in refereed journals. (2) Mid-career researchers who have conducted and published important research beyond the post-dissertation level. (3) Distinguished senior researchers whose research and publications represent a lifetime of significant achievements. For 2015, nominations for the Mid-Career Researcher Award were asked (http://www.ifp.name/newsletter.htm). In 2014, nominations were invited for the Young Researcher Award, and the award was delivered in May 2014 at the IFP World Congress in Shanghai. Helene A. Nissen-Lie had the honor to win the first Young Researcher Award for her PhD work on ‘the contribution of the psychotherapist to psychotherapy’ [1] . Please find below a brief summary of the results and a comment by Dr. Nissen-Lie.

Studying learning in the healthcare setting

Quantitative diary methods are longitudinal approaches that involve the repeated measurement of aspects of peoples’ experience of daily life. In this article, we outline the main characteristics and applications of quantitative diary methods and discuss how their use may further research in the field of medical education. Quantitative diary methods offer several methodological advantages, such as measuring aspects of learning with great detail, accuracy and authenticity. Moreover, they enable researchers to study how and under which conditions learning in the health care setting occurs and in which way learning can be promoted. Hence, quantitative diary methods may contribute to theory development and the optimization of teaching methods in medical education.