Lawrence P. Riso

Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

Cognitive aspects of chronic depression.

Previous research on chronic depression has focused on its link with other mood disorders and Axis II personality disorders. However, there are few data examining whether the cognitive perspective applies to this condition. In this cross-sectional study, 42 outpatients with chronic depression were compared with 27 outpatients with nonchronic major depressive disorder and 24 never psychiatrically ill controls on cognitive variables thought to be related to vulnerability to depression (e.g., dysfunctional attitudes, attributional style, a ruminative response style, and maladaptive core beliefs). Both depressed groups were more elevated than a never-ill comparison group. However, chronically depressed individuals were generally more elevated on measures of cognitive variables than those with major depressive disorders even after controlling for mood state and personality disorder symptoms.

The search for determinants of chronic depression: a review of six factors

While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.

The Long-Term Stability of Early Maladaptive Schemas

J. E. Young’s (1995) Early Maladaptive Schemas (EMS) are assumed to be highly stable and enduring beliefs that are responsible for the persistence and poor treatment response of a variety of clinical problems. EMS are now the basis for a growing number of specialized “schema-focused” treatments. However, the critical assumption that they are stable constructs remains largely unexamined and open to question. This study examined the long-term stability of Young’s EMS in 55 depressed outpatients over a 2.5 to 5-year interval. EMS exhibited moderate to good levels of stability, even after controlling for severity of depression and neuroticism at both time points, and moderate levels of discriminant validity. A comparison of these results with existing literature revealed that the stability and discriminant validity of EMS are quite similar to the stability and discriminant validity of personality disorder features. Additional work is needed to examine the stability of EMS across greater fluctuations in mood and in different clinical populations. Our findings for the stability of EMS may be generalizable to the more general notion of core beliefs. Future work needs to focus on further theoretical development and improved measurement of EMS.

Group Comparisons of DSM-IV Subtypes of Chronic Depression: Validity of the Distinctions, Part 2.

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.

Cognitive schemas and core beliefs in psychological problems : a scientist-practitioner guide

This book provides up-to-date information on the evaluation and utility of the schema concept and core beliefs as they apply to the research and treatment of a variety of clinical problems, including both major and chronic depression, posttraumatic stress disorder, substance use disorders, obsessive - compulsive disorder, schizophrenia, eating disorders, and dissatisfaction in intimate relationships.

Select comorbid personality disorders and the treatment of chronic depression with nefazodone, targeted psychotherapy, or their combination.

BACKGROUND Individuals with chronic depression respond poorly to both medication and psychotherapy. The reasons for the poorer response, however, remain unclear. One potential factor is the presence of comorbid Axis II personality disorders (PDs), which occur at high rates among these patients. METHODS This study examines the moderating influence of co-occurring PDs, primarily in cluster C, among 681 chronically depressed adult outpatients who were randomly assigned to 12 weeks of treatment with nefazodone, a specialized psychotherapy for chronic depression, or their combination. RESULTS At baseline, 50.4% (n=343) of patients met criteria for one or more Axis II disorders. Following 12 weeks of treatment, patients with comorbid PDs had statistically lower depression scores (M=12.2, SD=+9.2) than patients without comorbid PDs (M=13.5, SD=+8.7). There was no differential impact of a comorbid PD on responsiveness to medication versus psychotherapy. The results did not change when the data were analyzed using an intent-to-treat sample or when individual personality disorders were examined separately. LIMITATIONS Patients with severe borderline, antisocial, and schizotypal PDs were excluded from study entry; therefore, these data primarily apply to patients with cluster C PDs and may not generalize to other Axis II conditions. CONCLUSIONS Comorbid Axis II disorders did not negatively affect treatment outcome and did not differentially affect response to psychotherapy versus medication. Treatment formulations for chronically depressed patients with certain PDs may not need to differ from treatment formulations of chronically depressed patients without co-occurring PDs.

Therapeutic Reactance as a Predictor of Outcome in the Treatment of Chronic Depression

This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude * Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology.

The Therapeutic Alliance and CBASP-Specific Skill Acquisition in the Treatment of Chronic Depression

This study examined the influences of proposed specific and common psychotherapeutic factors in a sample of chronically depressed adult outpatients. Participants (N = 324) were drawn from a multi-site clinical trial that compared the efficacies of the cognitive behavioral analysis system of psychotherapy (CBASP), nefazodone, and their combination. This report is limited to patients receiving CBASP alone or combination treatment. A series of regression analyses were performed to test whether: (1) the ability to utilize the skills taught in CBASP mediated the relationship between the early therapeutic alliance and endpoint depression, and (2) the therapeutic alliance moderated the relationship between skill utilization and endpoint depression. Neither model was supported. Instead, each of these factors contributed independently and additively to alleviation of depressive symptoms.

Urinary free cortisol levels among depressed men and women: differential relationships to age and symptom severity?

SummaryBackground: Preclinical and clinical models of depression suggest sex differences may be mediated at least in part, by differences in hormonal modulation of hypothalamic-pituitary-adrenal (HPA) axis activity. Unraveling the consequences of moderating influences from the effect of sexual dimorphism will be vital to elaborating models of pathophysiology. Methods: The current study investigated urinary free cortisol (UFC) among younger adults with mild to moderate major depressive disorder to clarify the relationship with potential demographic and clinical moderators. Results: Male patients had higher mean UFC levels than female patients. Moreover, significant interactions between age and severity were found among men, but not women. In contrast to prior findings, neither age nor severity effects on UFC levels were found among female patients. Limitations: Conclusions from the current study are limited by the absence of cortisol data from matched controls. Thus it was not possible to disentangle sex differences in baseline physiology from that of pathophysiological differences tied specifically to depression. Conclusions: Despite several methodological limitations, the interactions between sex and both age and severity in this large sample of depressed patients are suggestive of differential pathophysiology for regulation of UFC excretion, and could reflect a neuroprotective effect for estrogen among younger depressed women.