Peter D. McLean

Treatment of obsessions: a randomized controlled trial.

This study tested Rachmans cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment.

Group and Individual Treatment of Obsessive-Compulsive Disorder Using Cognitive Therapy and Exposure Plus Response Prevention: A 2-Year Follow-Up of Two Randomized Trials.

Relatively little is known about the long-term durability of group treatments for obsessive-compulsive disorder (OCD) and contemporary cognitive treatments. The current study investigated the 2-year follow-up results for participants who completed randomized trials of group or individual treatment and received either cognitive therapy (CT) or exposure plus response prevention (ERP). Yale-Brown Obsessive Compulsive Scale (YBOCS) scores for individual ERP and CT were not significantly different over 2 years. However, YBOCS scores were consistently lower over time for group ERP participants than for group CT participants. With a single exception in the group treatment study, secondary cognitive and depression scores were stable, indicating that gains achieved during acute treatment were maintained over 2 years. Less than 10% of treatment completers relapsed in each of the treatment trials. Approximately 50% of the completer sample was rated as recovered at 2 years. Additionally, a tentative cross-study comparison suggests that CT was better tolerated and resulted in less dropout than did ERP. Despite the overall positive results, efficacy of OCD treatments has reached a plateau and may require a fresh perspective to move forward.

Relative endurance of unipolar depression treatment effects: longitudinal follow-up.

This study represents a 2.25-year follow-up to a treatment study reported earlier (McLean & Hakstian, 1979) in which 121 unipolar depressed outpatients were treated by either (a) nondirective psychotherapy, (b) behavior therapy, (c) pharmacotherapy, or (d) relaxation therapy. A nondepressed, normal control group was evaluated on the same 28 measures and 6 intervals for contrast purposes. Behavior therapy patients alone were significantly improved in the areas of mood, personal productivity, and social activity, relative to treatment control patients over the follow-up period. Also, twice as many behavior therapy patients (i.e., 64%) fell within one standard deviation of the normal, nondepressed control group distribution on depressed mood, compared with non-directive psychotherapy and pharmacotherapy patients, when scores were aggregated across the 6 assessment points.

Cognitive Restructuring in the Treatment of Social Phobia: Efficacy and Mode of Action

Cognitive restructuring (CR) is commonly used to treat social phobia, although its contribution to treatment efficacy has not been established. CR requires the person to think about and discuss feared social events with his or her therapist and thus entails some degree of exposure to social stimuli. CR also is thought to enhance the efficacy of therapeutic exposure exercises (EXP). Four predictions were tested based on this model: Relative to a control intervention matched for the exposure inherent in CR, CR is more effective in (1) reducing social phobia, (2) reducing negative social cognitions, (3) increasing positive cognitions, and (4) enhancing the effects of subsequent EXP. People with generalized social phobia (N= 60) were randomly assigned to CR followed by EXP or to a control intervention followed by EXP. Support was found for predictions 1 to 3, but not 4.

CBT for OCD: The rationale, protocol, and challenges

Behavior therapy, specifically exposure plus response prevention (ERP) has been firmly established as the treatment of choice for obsessive-compulsive disorder (OCD). However, the dropout rates plus the percentage of people who do not benefit from ERP require reconsideration. For those people who do receive benefit, a considerable portion of the presenting OC symptoms remain, often necessitating further treatment. Newer cognitive-behavioral approaches that focus on challenging OCD appraisals and beliefs have been proposed as alternatives to ERP. The CBT conceptualization, rationale, and treatment strategies are described, as are the challenges. The pros and cons of conducting treatment in groups are also discussed.

Comorbid panic disorder and major depression: implications for cognitive-behavioral therapy.

Panic disorder and major depression frequently coexist, yet the implications of comorbidity for psychological treatments have rarely been studied. The objective of this study was to evaluate whether pretreatment comorbidity of major depression affects the outcome of cognitive-behavioral treatment (CBT) of panic disorder. Thirty-seven clients who met diagnostic criteria for both panic and major depression participated in 10 sessions of individual CBT for panic. Treatment outcome was contrasted with the outcome of 53 clients having only panic disorder who received the same treatment. The co-occurrence of depression did not adversely affect CBT for panic. These results have implications for clinical practice and theoretical implications for the nature of the relationship between panic and depression.

Conscientiousness in Depression: Tendencies, Predictive Utility, and Longitudinal Stability

This study examined the association between conscientiousness and psychiatric symptomatology in a clinical sample, the stability of conscientiousness over a 6-month period, and the incremental utility of conscientiousness scores in accounting for variance in psychiatric symptomatology. Sixty-three depressed patients were assessed following inpatient discharge and at 6-month follow-up. Our sample scored 1 standard deviation below the normative mean on conscientiousness at discharge and at 6-month follow-up, with evidence of significant stability over time. However, substantial volatility in conscientiousness scores at 6-month follow-up was noted among patients with high conscientiousness scores at discharge. Conscientiousness had incremental utility in predicting depression scores at 6-month follow-up beyond the effects of social support, life stressors, and general psychiatric symptomatology. The integration of conscientiousness with current conceptualizations of depression is presented.

Mechanisms of Symptom Reduction in Treatment for Obsessions.

OBJECTIVE We explored the dynamic relationship between cognition and obsession severity during 2 different treatments for primary obsessions, examining evidence for the hypothesis that symptom reduction would be mediated by appraisals about the meaning of unwanted intrusive thoughts. METHOD Data from a recent randomized controlled trial were analyzed with traditional mediation analyses and latent difference scores. The trial had compared cognitive behavioral therapy and stress management training among 73 patients with primary obsessions. Mediation analyses were conducted with pre-, post-, and follow-up scores on the Obsessions subscale of the Yale-Brown Obsessive Compulsive Scale and 2 self-report measures of cognitions related to obsessive-compulsive disorder. Bivariate dual change score (BDCS) analyses were conducted with weekly assessments of obsession severity and appraisals of personal significance. RESULTS Change in most cognitions related to obsessive-compulsive disorder accounted for reduction in obsession severity during the course of treatment and follow-up. BDCS analyses of the longitudinal data, however, indicated prior obsession severity is a leading indicator of subsequent change in appraisals, rather than the reverse. Analyses also suggested cognitive behavioral therapy is more effective than stress management training when symptoms are severe and that stress management training is more advantageous in the context of mild-to-moderate obsessions. CONCLUSIONS The traditional mediation analysis indicated that appraisal change is a tenable mediator of obsession reduction, but the BDCS results raise doubts about the causal direction. The results highlight the importance of examining the dynamic relationship between putative mediators and outcome variables, and they suggest interesting hypotheses about mechanisms in treatment of obsessions.

Severity of unipolar depression and choice of treatment

The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (Elkin et al., Archives of General Psychiatry, 46, 971-982; 1989) reported treatment-by-severity interactions favouring pharmacotherapy for more depressed outpatients, on a minority of relevant comparisons. The present study reports secondary analyses from a similar, preexisting data set in which treatment-by-severity interactions are systematically investigated with depressed outpatients treated either with nondirective psychotherapy, behaviour therapy, pharmacotherapy, or relaxation/placebo. Despite multiple severity measures and variable severity cut scores, no treatment was differentially effective in improving more severely depressed patients. Also, there was little difference across symptom severity levels in the proportions of recovered patients between treatment groups. Finally, dynamic cluster analysis demonstrated that the proportion of pharmacotherapy nonresponders (20%) did not differ from the proportion of nonresponders in behaviour therapy or placebo groups. It is concluded that this failure to replicate the NIMH trial findings can not be attributed to treatment differences, populations or statistical power. The suggestion that pharmacotherapy be the treatment of choice for more severely depressed outpatients appears to be unjustified on the basis of available evidence.

Cognitive Specificity in Panic and Depression: Implications for Comorbidity

Previous studies of cognitive specificity indepression and anxiety disorders have establishedreliable profiles of depressive cognitions, and to asomewhat lesser extent, panic-related cognitions. The present study examines cognitive specificity inpure diagnostic groups of patients with panic disorderor major depression and compares cognitive profiles inthese single diagnosis groups to those observed in a group of individuals with comorbid panicand depression. In addition to Becks CognitionChecklist, we introduce a cognition inventory thatincludes subscales for panic and depression along withsomatic preoccupation, social fears, and worry. Goodspecificity was found for panic and depressioncognitions in the pure diagnostic groups, and thecomorbid group was equivalent to the pure groups onthese measures. However, the comorbid group was alsosignificantly more troubled by less prototypicalcognitions concerning social-evaluative fears andsomatic preoccupation. These results suggest thatindividuals with comorbid depression and panic may holdadditional maladaptive beliefs beyond specificcognitions typically associated with each disorderalone.