Lotte H.J.M. Lemmens

Predicting Optimal Outcomes in Cognitive Therapy or Interpersonal Psychotherapy for Depressed Individuals Using the Personalized Advantage Index Approach.

Introduction Although psychotherapies for depression produce equivalent outcomes, individual patients respond differently to different therapies. Predictors of outcome have been identified in the context of randomized trials, but this information has not been used to predict which treatment works best for the depressed individual. In this paper, we aim to replicate a recently developed treatment selection method, using data from an RCT comparing the effects of cognitive therapy (CT) and interpersonal psychotherapy (IPT). Methods 134 depressed patients completed the pre- and post-treatment BDI-II assessment. First, we identified baseline predictors and moderators. Second, individual treatment recommendations were generated by combining the identified predictors and moderators in an algorithm that produces the Personalized Advantage Index (PAI), a measure of the predicted advantage in one therapy compared to the other, using standard regression analyses and the leave-one-out cross-validation approach. Results We found five predictors (gender, employment status, anxiety, personality disorder and quality of life) and six moderators (somatic complaints, cognitive problems, paranoid symptoms, interpersonal self-sacrificing, attributional style and number of life events) of treatment outcome. The mean average PAI value was 8.9 BDI points, and 63% of the sample was predicted to have a clinically meaningful advantage in one of the therapies. Those who were randomized to their predicted optimal treatment (either CT or IPT) had an observed mean end-BDI of 11.8, while those who received their predicted non-optimal treatment had an end-BDI of 17.8 (effect size for the difference = 0.51). Discussion Depressed patients who were randomized to their predicted optimal treatment fared much better than those randomized to their predicted non-optimal treatment. The PAI provides a great opportunity for formal decision-making to improve individual patient outcomes in depression. Although the utility of the PAI approach will need to be evaluated in prospective research, this study promotes the development of a treatment selection approach that can be used in regular mental health care, advancing the goals of personalized medicine.

Effectiveness, relapse prevention and mechanisms of change of cognitive therapy vs. interpersonal therapy for depression: Study protocol for a randomised controlled trial

BackgroundMajor depression is a common mental disorder that substantially impairs quality of life and has high societal costs. Although psychotherapies have proven to be effective antidepressant treatments, initial response rates are insufficient and the risk of relapse and recurrence is high. Improvement of treatments is badly needed. Studying the mechanisms of change in treatment might be a good investment for improving everyday mental health care. However, the mechanisms underlying therapeutic change remain largely unknown. The objective of the current study is to assess both the effectiveness of two commonly used psychotherapies for depression in terms of reduction of symptoms and prevention of relapse on short and long term, as well as identifying underlying mechanisms of change.MethodsIn a randomised trial we will compare (a) Cognitive Therapy (CT) with (b) Interpersonal therapy (IPT), and (c) an 8-week waiting list condition followed by treatment of choice. One hundred eighty depressed patients (aged 18-65) will be recruited in a mental health care centre in Maastricht (the Netherlands). Eligible patients will be randomly allocated to one of the three intervention groups. The primary outcome measure of the clinical evaluation is depression severity measured by the Beck Depression Intenvory-II (BDI-II). Other outcomes include process variables such as dysfunctional beliefs, negative attributions, and interpersonal problems. All self-report outcome assessments will take place on the internet at baseline, three, seven, eight, nine, ten, eleven, twelve and twenty-four months. At 24 months a retrospective telephone interview will be administered. Furthermore, a rudimentary analysis of the cost-effectiveness will be embedded. The study has been ethically approved and registered.DiscussionBy comparing CT and IPT head-to-head and by investigating multiple potential mediators and outcomes at multiple time points during and after therapy, we hope to provide new insights in the effectiveness and mechanisms of change of CT and IPT for depression, and contribute to the improvement of mental health care for adults suffering from depression.Trial registrationThe study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN67561918)

Mechanisms of change in psychotherapy for depression: An empirical update and evaluation of research aimed at identifying psychological mediators

We present a systematic empirical update and critical evaluation of the current status of research aimed at identifying a variety of psychological mediators in various forms of psychotherapy for depression. We summarize study characteristics and results of 35 relevant studies, and discuss the extent to which these studies meet several important requirements for mechanism research. Our review indicates that in spite of increased attention for the topic, advances in theoretical consensus about necessities for mechanism research, and sophistication of study designs, research in this field is still heterogeneous and unsatisfactory in methodological respect. Probably the biggest challenge in the field is demonstrating the causal relation between change in the mediator and change in depressive symptoms. The field would benefit from a further refinement of research methods to identify processes of therapeutic change. Recommendations for future research are discussed. However, even in the most optimal research designs, explaining psychotherapeutic change remains a challenge. Psychotherapy is a multi-dimensional phenomenon that might work through interplay of multiple mechanisms at several levels. As a result, it might be too complex to be explained in relatively simple causal models of psychological change.

Sudden gains in Cognitive Therapy and Interpersonal Psychotherapy for adult depression

OBJECTIVE We examined the rates, baseline predictors and clinical impact of sudden gains in a randomized comparison of individual Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for adult depression. METHOD 117 depressed outpatients received 16-20 sessions of either CT or IPT. Session-by-session symptom severity was assessed using the BDI-II. Sudden gains were examined using the original criteria as defined by Tang and DeRubeis (1999b). Furthermore, we examined whether the duration of the between-session interval at which sudden gains were recorded affected the results. RESULTS There were significantly more patients with sudden gains in CT (42.2%) as compared to IPT (24.5%). The difference appeared to be driven by the criterion representing the stability of the gain. No between-group differences were found with regard to the magnitude, timing and predictors of the gains. Those with sudden gains were less depressed at post-treatment and follow-up. After controlling for the duration of the between-session interval, the difference in rates between the two conditions became a non-significant trend. Other sudden gains characteristics were similar to those observed when allowing for longer intervals as well. CONCLUSIONS The current study indicates differences in occurrence of sudden gains in two treatment modalities that overall showed similar results, which might reflect different mechanisms of change.

The value of an implicit self-associative measure specific to core beliefs of depression

BACKGROUND AND OBJECTIVES The present study examined differences in explicit and implicit measures of self-esteem between depressed patients and healthy controls using an indirect measurement procedure especially adapted to measure self-esteem aspects of core beliefs of depression. Furthermore, we examined whether our implicit and explicit self-associative measures were associated with each other and with depressive symptoms, and investigated the effect of a discrepancy between the implicit and explicit measure on depression. METHODS Participants were 87 depressed patients and 30 healthy controls. The Self-Liking and Self-Competence Scale was administered as a measure of explicit self-esteem. A depression-specific variant of the Single Category Implicit Association Test served as a measure of implicit self-esteem. RESULTS Patients showed significantly lower levels of explicit self-esteem as compared to healthy controls. In spite of our adaptations, no differences were found on the implicit measure. The implicit measure of self-esteem was neither related to the explicit measure nor to depressive symptoms. Furthermore, although both the explicit measure of self-esteem and the difference score of the explicit and implicit measure were related to symptoms of depression, the relation between the explicit measure and depression was found to be significantly stronger. LIMITATIONS Results should be interpreted with caution because it is not clear yet to what extent these implicit measures really reflect self-esteem. CONCLUSIONS This study suggests that only the explicit measure of self-esteem - and not the implicit - is related to depression. Future research using well-designed measurement procedures for obtaining implicit and explicit measures could contribute to a better insight in the nature of these constructs.

The influence of comorbid anxiety on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

BACKGROUND Anxious depression is an important subtype of Major Depressive Disorder (MDD) defined by both syndromal (anxiety disorders) and dimensional (anxiety symptoms) criteria. A debated question is how anxiety affects MDD treatment. This study examined the impact of comorbid anxiety disorders and symptoms on the effectiveness of and dropout during Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for MDD. METHODS Depressed individuals were randomized to CT (n = 76) or IPT (n = 75). Outcome was depression severity measured with the Beck Depression Inventory-II (BDI-II) at the start of each therapy session, post treatment, and monthly up to five months follow-up. Anxiety disorders were assessed with the Structured Clinical Interview for DSM-IV Axis I disorders, (phobic) anxiety symptoms were assessed with Brief Symptom Inventory subscales. RESULTS Approximately one third of participants had a comorbid anxiety disorder. Comorbid anxiety disorders and anxiety symptoms were associated with less favorable depression change during IPT as compared to CT in the treatment phase, but not in the trial follow-up phase. Individuals with a comorbid anxiety disorder had significantly higher treatment dropout during both treatments. LIMITATIONS Not all therapists and participants were blind to the assessment of comorbid anxiety disorders and the assessments were performed by one rater. CONCLUSIONS A preference for CT over IPT for MDD is justifiable when comorbid anxiety is present, although long-term differences are not established and replication of this finding is needed. Clinicians should be aware of the risk of dropout for depressed individuals with an anxiety disorder.

The impact of personality disorder pathology on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

BACKGROUND Despite extensive research, there is no consensus how Personality Disorders (PD) and PD features affect outcome for Major Depressive Disorder (MDD). The present study evaluated the effects of PD (features) on treatment continuation and effectiveness in Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for MDD. METHODS Depressed outpatients were randomized to CT (n=72) and IPT (n=74). Primary outcome was depression severity measured repeatedly with the Beck Depression Inventory-II (BDI-II) at baseline, three months, at the start of each therapy session, at post-treatment and monthly during five months follow-up. RESULTS Comorbid PD and PD features did not affect dropout. Multilevel and Cox regression models indicated no negative effect of PD on BDI-II change and remission rates during treatment and follow-up, irrespective of the treatment received. For both therapies, higher dependent PD features predicted overall lower BDI-II scores during treatment, however this effect did not sustain through follow-up. Cluster A PD features moderated treatment outcome during treatment and follow-up: individuals with high cluster A PD features had greater BDI-II reductions over time in CT as compared to IPT. LIMITATIONS Not all therapists and participants were blind to the assessment of PD (features), and assessments were performed by one rater. Further research must investigate the state and trait dependent changes of PD and MDD over time. CONCLUSIONS We found no negative impact of PD on the effectiveness and treatment retention of CT and IPT for MDD during treatment and follow-up. If replicated, cluster A PD features can be used to optimize treatment selection.

Machine learning techniques in eating behavior e-coaching

The rise of internet and mobile technologies (such as smartphones) provide a harness of data and an opportunity to learn about peoples’ states, behavior, and context in regard to several application areas such as health. Eating behavior is an area that can benefit from the development of effective e-coaching applications which utilize psychological theories and data science techniques. In this paper, we propose a framework of how machine learning techniques can effectively be used in order to fully exploit data collected from a mobile application (“Think Slim”) which is designed to assess eating behavior using experience sampling methods. The overall goal is to analyze individual states of a person status (emotions, location, activity, etc.) and assess their impact on unhealthy eating. Building on data collected from different participants, a classification algorithm (decision tree tailored to longitudinal data) is used to warn people prior to a possible unhealthy eating event and a clustering algorithm (hierarchical agglomerative clustering) is used for profiling the participants and generalize for new users of the application. Finally, a framework to offer feedback via adaptive messages (intervention) and recommendations prior to possible unhealthy eating events is presented. Results from applying our methods reveal that participants can be clustered to six robust groups based on their eating behavior and that there are specific rules that discriminate which conditions lead to healthy versus unhealthy eating. Consequently, these rules can be utilized to provide adaptive semi-tailored feedback to users who, through this method, are assisted in learning under which conditions are more prone to unhealthy eating. Effectiveness of the approach is confirmed by observing a decreasing trend in rule activation towards the end of intervention period.

On the link between perceived parental rearing behaviors and self-conscious emotions in adolescents

This study examined relationships between the self-conscious emotions of guilt and shame in both clinical (N = 104) and non-clinical (N = 477) (young) adolescents aged 11–18 years, who completed a questionnaire to assess perceived parental rearing behaviors (EMBU-C) and a scenario-based instrument to measure proneness to guilt and shame (SCEMAS). Results indicated that parental rearing dimensions were positively related to self-conscious emotions. Regarding the non-clinical sample, both favourable (emotional warmth) and unfavourable (rejection) paternal and maternal rearing dimensions were significant correlates of guilt- and shame-proneness. The results for the clinical sample were less conclusive: only maternal emotional warmth and rejection were found to be significantly associated with guilt and shame. Interestingly, no associations between any of the paternal rearing dimensions and self-conscious emotions emerged. Taken together, these results are in keeping with the notion that parental rearing factors are involved in the development of both adaptive and maladaptive self-conscious emotions in adolescents.