K. Annika Tovote

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 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

How Modernization Instigates Social Change: Laptop Usage as a Driver of Cultural Value Change and Gender Equality in a Developing Country

This research examines how technology usage can instigate social change in a developing country. We expected that technology usage leads to changes in modern cultural values and attitudes toward gender equality while traditional values persist. This was tested in an information and communication technology (ICT) for Development Aid project among Ethiopian children who had received a laptop. A longitudinal field experiment compared children who received a laptop (n = 573) with a matched control group without a laptop (n = 485). Measures were taken before laptop introduction and 6 months later. Laptops had medium to strong effects on value and attitude change, particularly in rural areas. Children with laptops endorsed modern values more strongly, but traditional values were bolstered as well. Modern value change mediated the effect of laptop usage on the endorsement of gender equality. Theoretical and practical implications for cultural changes related to gender equality are discussed.

Missed Opportunity to Rectify or Withdraw a Flawed Metaanalysis of Longer-Term Psychodynamic Psychotherapy

as they described in their letter, merely ‘suboptimal’ or ‘ambiguous’, but wildly inaccurate. We provided a power analysis of the individual randomized trials entered into their metaanalysis, appropriately calculated not on the basis of the overall sample size, but on the smaller of the intervention or comparison groups. None of the smaller groups had over 30 patients, 1 had only 10. Perhaps we should have been clearer on the implications: if LTPP indeed had a moderate effect, none of these studies had an over 50% chance of detecting it, and 1 had a less than 25% chance of detecting it. Thus, even if all of the studies tested a moderately effective form of LTPP, most should not have obtained a significant effect. That most had significant findings attests to the likelihood of publication bias. Leichsenring and Rabung claimed to have ruled out publication bias, a pervasive problem in the psychosocial intervention [5] and medical [6] literatures. They entered their miscalculated effect sizes into calculation of a failsafe-N estimate, i.e. how many studies with null results would have to be left unpublished to unseat their conclusion concerning the superiority of LTPP to shorter-term therapies. Many sources including the authoritative Cochrane Handbook [7] recommend against acceptance of the failsafe-N. Nonetheless, here as elsewhere, Leichsenring and Rabung and prepublication reviewers should have been alerted by the implausible estimate that 921 null studies had to be reclaimed from file drawers in order to unseat claims based on 8 modestsized randomized trials and 23 observational studies. Leichsenring and Rabung used summary Jadad [8] scores to rate the quality of studies entered into their metaanalysis. Yet, the Jadad checklist was developed to rate the quality in which a study is reported, not the likelihood that study results are free of bias. Moreover, summary scale scores have been empirically shown to lack validity [9] . We used Cochrane Collaboration guidelines to rate the studies and found that they lacked internal validity and the usual safeguards against bias expected of quality evidence. For instance, only 1 of 8 studies met the important criterion of being low in bias toward completeness of outcome data. Such flaws can prove particularly decisive in studies with small sample sizes, serving to undo the benefits of the study being randomized. Leichsenring and Rabung are correct that we did not consider the quality of the 23 observational studies included in their larger metaanalysis. But if we had, the quality ratings would have been even lower. Some of the observational studies lost substantial numbers of patients to follow-up [10] , with results for the final sample not being generalizable to the initial sample. It is naïve to assume that combining such similarly small and flawed studies into a metaanalysis can produce meaningful conclusions [11] . Leichsenring and Rabung included studies in their metaanalysis that were clinically heterogeneous in terms of comparison treatments and patient populations. They claimed to have demonstrated the appropriateness of combining these studies by showing a lack of statistical heterogeneity using the Q statistic. We eagerly anticipated the response by Leichsenring and Rabung to our sweeping critique [1] of their 2008 metaanalysis [2] in which they claimed longer-term psychodynamic psychotherapy (LTPP) was more effective than shorter-term psychotherapies. Yet, we were disappointed that Leichsenring and Rabung [3] , like Ehrenthal and Grande [4] , dealt with so little of the specifics of our critique. Much of the substance of the response by Leichsenring and Rabung refers to an unfinished manuscript and another, still undergoing review in some unnamed journal, limiting the opportunity for independent evaluation by anyone open-minded but skeptical about each of our perspectives. The crux of our critique was statistical and technical because it is in these areas that serious flaws in their metaanalysis initially occurred, undermining any of their substantive interpretations. Perhaps our readers were as confused as Leichsenring and Rabung seemingly were, and thus we will use the 1,000 words allotted to us to briefly summarize our critique in substantive terms. A basic criticism was that Leichsenring and Rabung consistently miscalculated summary effect sizes in a way that was grossly inflationary and favorable to LTPP. We find no basis for such an approach in the extensive literature of metaanalyses. We generated a hypothetical set of 10 studies in which there were only trivial differences in effect sizes for intervention and comparison groups. Using the computational method by Leichsenring and Rabung, we nonetheless generated a large summary effect size favoring the intervention that would have been unprecedented in the psychotherapy literature. Apparently neither Leichsenring and Rabung nor prepublication reviewers of their paper noticed that the summary effect sizes Leichsenring and Rabung claimed for LTPP were greater than any of the effect sizes for individual studies. Moreover, they claimed one implausible between-group effect size of 6.9, equivalent to 93% of the variance explained, for a set of studies in which none reported an effect size of more than approximately 2. Such figures should have aroused suspicion: their estimates were not, Received: June 21, 2010 Accepted: June 21, 2010 Published online: November 18, 2010

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.

PS12 - 1. Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) for treating depression in patients with diabetes: A randomized controlled trial

Depression is a common comorbidity of diabetes and it has several implications for patients’ physical and mental functioning. It is associated with lower adherence to medication, dietary, and exercise recommendations and poorer physical performance. Patients suffering from depressive symptoms rarely receive adequate psychological help as part of routine clinical care.