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Objective: Although evidence suggests that patients with depression use more medical services than those without depression, few studies have examined whether specific subgroups of patients with depression have higher utilization than others. The study compared costs for general medical care with and without psychiatric care for patients with major depression and disabling chronic pain (reference group) with costs for five other groups: those with depression and nondisabling chronic pain, those with major depressive disorder alone, those with no depression who had disabling chronic pain, those with depression who had chronic pain that was not disabling, and those who had neither pain nor depression. Costs for the group with major depressive disorder alone were compared to costs for the three groups without depression.Methods: A questionnaire assessing major depressive disorder, chronic pain, and pain-related disability was mailed to a random sample of Kaiser Permanente patients who visited a primary care clinic. A total of 5,808 patients responded (54% participation rate). Costs for a two-year period were obtained from Kaiser Permanente's Cost Management Information System. Analyses were adjusted for presence of any of four major chronic medical illnesses.Results: Total costs for patients in the reference group were significantly higher than costs for the other five subgroups. Regression analyses indicated that continuous measures of severity of pain and severity of depression were associated with increased costs, but no statistically significant interaction of depression and pain on total cost was observed.Conclusions: Patients with major depressive disorder and comorbid disabling chronic pain had higher medical service costs than other groups of patients with and without depression. However, findings suggest that the increases in cost from having both pain and depression are additive and not multiplicative. [ABSTRACT FROM AUTHOR]

OBJECTIVE:: Previous research, mostly using retrospective reports, indicated a relation of negative affect and dietary restraint with the occurrence of binge episodes in binge eating disorder (BED). We employed Ecological Momentary Assessment (EMA) to better understand precursors and consequences of binge eating. METHOD:: Thirty-three females with BED carried a handheld computer for 7 days, and were periodically prompted to indicate their current emotions, hunger, and binge status. RESULTS:: Negative mood and hunger were significantly higher at prebinge than at nonbinge times, but negative mood was even higher at postbinge. Participants attributed binge episodes to mood more frequently than to hunger or abstinence violation. CONCLUSION:: The finding that negative mood is actually heightened subsequent to a binge suggests the need to further investigate what is reinforcing about a binge, including possible escape from self-awareness. Strengths of EMA technology are discussed, as well as its broad utility in BED assessment and treatment. (c) 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006. [ABSTRACT FROM AUTHOR]

Although individual psychotherapy is generally effective for a range of mental health conditions, little is known about the moment-to-moment language use of effective therapists. Increased access to computational power, coupled with a rise in computer-mediated communication (telehealth), makes feasible the large-scale analyses of language use during psychotherapy. Transparent methodological approaches are lacking, however. Here we present novel methods to increase the efficiency of efforts to examine language use in psychotherapy. We evaluate three important aspects of therapist language use - timing, responsiveness, and consistency - across five clinically relevant language domains: pronouns, time orientation, emotional polarity, therapist tactics, and paralinguistic style. We find therapist language is dynamic within sessions, responds to patient language, and relates to patient symptom diagnosis but not symptom severity. Our results demonstrate that analyzing therapist language at scale is feasible and may help answer longstanding questions about specific behaviors of effective therapists., (© 2022. The Author(s).)

Background: Exposure-based psychotherapy is a first-line treatment for posttraumatic stress disorder (PTSD), but its mechanisms are poorly understood. Functional brain connectivity is a promising metric for identifying treatment mechanisms and biosignatures of therapeutic response. To this end, we assessed amygdala and insula treatment-related connectivity changes and their relationship to PTSD symptom improvements., Methods: Individuals with a primary PTSD diagnosis (N = 66) participated in a randomized clinical trial of prolonged exposure therapy (n = 36) versus treatment waiting list (n = 30). Task-free functional magnetic resonance imaging was completed prior to randomization and 1 month following cessation of treatment/waiting list. Whole-brain blood oxygenation level-dependent responses were acquired. Intrinsic connectivity was assessed by subregion in the amygdala and insula, limbic structures key to the disorder pathophysiology. Dynamic causal modeling assessed evidence for effective connectivity changes in select nodes informed by intrinsic connectivity findings., Results: The amygdala and insula displayed widespread patterns of primarily subregion-uniform intrinsic connectivity change, including increased connectivity between the amygdala and insula; increased connectivity of both regions with the ventral prefrontal cortex and frontopolar and sensory cortices; and decreased connectivity of both regions with the left frontoparietal nodes of the executive control network. Larger decreases in amygdala-frontal connectivity and insula-parietal connectivity were associated with larger PTSD symptom reductions. Dynamic causal modeling evidence suggested that treatment decreased left frontal inhibition of the left amygdala, and larger decreases were associated with larger symptom reductions., Conclusions: PTSD psychotherapy adaptively attenuates functional interactions between frontoparietal and limbic brain circuitry at rest, which may reflect a potential mechanism or biosignature of recovery., (Copyright © 2020 Society of Biological Psychiatry. All rights reserved.)

Background: Antidepressant medication (ADM) and psychotherapy are effective treatments for major depressive disorder (MDD). It is unclear, however, if treatments differ in their effectiveness at the symptom level and whether symptom information can be utilised to inform treatment allocation. The present study synthesises comparative effectiveness information from randomised controlled trials (RCTs) of ADM versus psychotherapy for MDD at the symptom level and develops and tests the Symptom-Oriented Therapy (SOrT) metric for precision treatment allocation., Methods: First, we conducted systematic review and meta-analyses of RCTs comparing ADM and psychotherapy at the individual symptom level. We searched PubMed Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, a database specific for psychotherapy RCTs, and looked for unpublished RCTs. Random-effects meta-analyses were applied on sum-scores and for individual symptoms for the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) measures. Second, we computed the SOrT metric, which combines meta-analytic effect sizes with patients' symptom profiles. The SOrT metric was evaluated using data from the Munich Antidepressant Response Signature (MARS) study (n = 407) and the Emory Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study (n = 234)., Results: The systematic review identified 38 RCTs for qualitative inclusion, 27 and 19 for quantitative inclusion at the sum-score level, and 9 and 4 for quantitative inclusion on individual symptom level for the HAM-D and BDI, respectively. Neither meta-analytic strategy revealed significant differences in the effectiveness of ADM and psychotherapy across the two depression measures. The SOrT metric did not show meaningful associations with other clinical variables in the MARS sample, and there was no indication of utility of the metric for better treatment allocation from PReDICT data., Conclusions: This registered report showed no differences of ADM and psychotherapy for the treatment of MDD at sum-score and symptom levels. Symptom-based metrics such as the proposed SOrT metric do not inform allocation to these treatments, but predictive value of symptom information requires further testing for other treatment comparisons.

Accurate transcription of audio recordings in psychotherapy would improve therapy effectiveness, clinician training, and safety monitoring. Although automatic speech recognition software is commercially available, its accuracy in mental health settings has not been well described. It is unclear which metrics and thresholds are appropriate for different clinical use cases, which may range from population descriptions to individual safety monitoring. Here we show that automatic speech recognition is feasible in psychotherapy, but further improvements in accuracy are needed before widespread use. Our HIPAA-compliant automatic speech recognition system demonstrated a transcription word error rate of 25%. For depression-related utterances, sensitivity was 80% and positive predictive value was 83%. For clinician-identified harm-related sentences, the word error rate was 34%. These results suggest that automatic speech recognition may support understanding of language patterns and subgroup variation in existing treatments but may not be ready for individual-level safety surveillance., Competing Interests: Competing interestsL.F-F. served as Chief Scientist at Google Cloud from 2017 to 2018. The remaining authors declare no competing interests., (© The Author(s) 2020.)

Background: Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses., Objective: To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses., Design: Retrospective cohort study of decedents., Setting/participants: Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index., Main Measures: Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses., Key Results: Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001)., Conclusions: Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness.

Conversational artificial intelligence (AI) is changing the way mental health care is delivered. By gathering diagnostic information, facilitating treatment, and reviewing clinician behavior, conversational AI is poised to impact traditional approaches to delivering psychotherapy. While this transition is not disconnected from existing professional services, specific formulations of clinician-AI collaboration and migration paths between forms remain vague. In this viewpoint, we introduce four approaches to AI-human integration in mental health service delivery. To inform future research and policy, these four approaches are addressed through four dimensions of impact: access to care, quality, clinician-patient relationship, and patient self-disclosure and sharing. Although many research questions are yet to be investigated, we view safety, trust, and oversight as crucial first steps. If conversational AI isn't safe it should not be used, and if it isn't trusted, it won't be. In order to assess safety, trust, interfaces, procedures, and system level workflows, oversight and collaboration is needed between AI systems, patients, clinicians, and administrators., (Copyright © 2019 Miner, Shah, Bullock, Arnow, Bailenson and Hancock.)

A mechanistic understanding of the pathology of psychiatric disorders has been hampered by extensive heterogeneity in biology, symptoms, and behavior within diagnostic categories that are defined subjectively. We investigated whether leveraging individual differences in information-processing impairments in patients with post-traumatic stress disorder (PTSD) could reveal phenotypes within the disorder. We found that a subgroup of patients with PTSD from two independent cohorts displayed both aberrant functional connectivity within the ventral attention network (VAN) as revealed by functional magnetic resonance imaging (fMRI) neuroimaging and impaired verbal memory on a word list learning task. This combined phenotype was not associated with differences in symptoms or comorbidities, but nonetheless could be used to predict a poor response to psychotherapy, the best-validated treatment for PTSD. Using concurrent focal noninvasive transcranial magnetic stimulation and electroencephalography, we then identified alterations in neural signal flow in the VAN that were evoked by direct stimulation of that network. These alterations were associated with individual differences in functional fMRI connectivity within the VAN. Our findings define specific neurobiological mechanisms in a subgroup of patients with PTSD that could contribute to the poor response to psychotherapy., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Objective: Exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD), but many patients do not respond. Brain functions governing treatment outcome are not well characterized. The authors examined brain systems relevant to emotional reactivity and regulation, constructs that are thought to be central to PTSD and exposure therapy effects, to identify the functional traits of individuals most likely to benefit from treatment., Method: Individuals with PTSD underwent functional MRI (fMRI) while completing three tasks assessing emotional reactivity and regulation. Participants were then randomly assigned to immediate prolonged exposure treatment (N=36) or a waiting list condition (N=30). A random subset of the prolonged exposure group (N=17) underwent single-pulse transcranial magnetic stimulation (TMS) concurrent with fMRI to examine whether predictive activation patterns reflect causal influence within circuits. Linear mixed-effects modeling in line with the intent-to-treat principle was used to examine how baseline brain function moderated the effect of treatment on PTSD symptoms., Results: At baseline, individuals with larger treatment-related symptom reductions (compared with the waiting list condition) demonstrated 1) greater dorsal prefrontal activation and 2) less left amygdala activation, both during emotion reactivity; 3) better inhibition of the left amygdala induced by single TMS pulses to the right dorsolateral prefrontal cortex; and 4) greater ventromedial prefrontal/ventral striatal activation during emotional conflict regulation. Reappraisal-related activation was not a significant moderator of the treatment effect., Conclusions: Capacity to benefit from prolonged exposure in PTSD is gated by the degree to which prefrontal resources are spontaneously engaged when superficially processing threat and adaptively mitigating emotional interference, but not when deliberately reducing negative emotionality.

Objective: Exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD), but a comprehensive, emotion-focused perspective on how psychotherapy affects brain function is lacking. The authors assessed changes in brain function after prolonged exposure therapy across three emotional reactivity and regulation paradigms., Method: Individuals with PTSD underwent functional MRI (fMRI) at rest and while completing three tasks assessing emotional reactivity and regulation. Individuals were then randomly assigned to immediate prolonged exposure treatment (N=36) or a waiting list condition (N=30) and underwent a second scan approximately 4 weeks after the last treatment session or a comparable waiting period, respectively., Results: Treatment-specific changes were observed only during cognitive reappraisal of negative images. Psychotherapy increased lateral frontopolar cortex activity and connectivity with the ventromedial prefrontal cortex/ventral striatum. Greater increases in frontopolar activation were associated with improvement in hyperarousal symptoms and psychological well-being. The frontopolar cortex also displayed a greater variety of temporal resting-state signal pattern changes after treatment. Concurrent transcranial magnetic stimulation and fMRI in healthy participants demonstrated that the lateral frontopolar cortex exerts downstream influence on the ventromedial prefrontal cortex/ventral striatum., Conclusions: Changes in frontopolar function during deliberate regulation of negative affect is one key mechanism of adaptive psychotherapeutic change in PTSD. Given that frontopolar connectivity with ventromedial regions during emotion regulation is enhanced by psychotherapy and that the frontopolar cortex exerts downstream influence on ventromedial regions in healthy individuals, these findings inform a novel conceptualization of how psychotherapy works, and they identify a promising target for stimulation-based therapeutics.

Objective: This study tested whether discrepancy between patients' and therapists' ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment., Method: Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N = 357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD)., Results: Patients' and therapists' alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up., Conclusions: The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.

Objective: Side effects to antidepressant medication can affect the efficacy of treatment, but few predictors foretell who experiences side effects and which side effects they experience. This secondary data analysis examined whether depressed patients with comorbid panic disorder were more likely to experience side effects than those without panic disorder. The study also examined whether greater burden of side effects predicted a poorer treatment course for patients with panic disorder than those without panic disorder. To examine the specificity of these effects, analyses also examined 2 other anxiety disorders-social phobia and generalized anxiety disorder (GAD)., Methods: Between 2002 and 2006, a large sample (N = 808) of chronically depressed individuals (assessed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders [SCID-IV]) received antidepressants according to a predetermined algorithm for 12 weeks. Every 2 weeks, depressive symptoms (per the Hamilton Depression Rating Scale) and side effects (specific side effects as well as several indicators of side effect burden) were assessed., Results: Lifetime diagnosis of panic disorder (assessed using the SCID-IV) at baseline was associated with higher likelihood of gastrointestinal (OR = 1.6 [95% CI, 1.0-2.6]), cardiac (OR = 1.8 [95% CI, 1.1-3.1]), neurologic (OR = 2.6 [95% CI, 1.6-4.2]), and genitourinary side effects (OR = 3.0 [95% CI, 1.7-5.3]) during treatment. Increases in side effect frequency, intensity, and impairment over time were more strongly associated with increases in depressive symptoms for patients with panic disorder compared to those without panic disorder. Neither social phobia nor GAD was associated with these effects., Conclusions: Potentially due to heighte​ned interoceptive awareness of changes in their body, chronically depressed individuals with panic disorder may be at greater risk than those without panic disorder for antidepressant side effects and to experience a worsening of depressive symptoms as a result of these side effects over time., Trial Registration: ClinicalTrials.gov identifier: NCT00057551​., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

Objective: Theories posit that chronically depressed individuals have hostile and submissive interpersonal styles that undermine their interpersonal effectiveness and contribute to the cause and maintenance of their depression. Recent findings support this theory and demonstrate that chronically depressed patients' interpersonal impacts on their therapist become more adaptive (i.e., less hostile and submissive, and more friendly and assertive) during a targeted chronic depression treatment: cognitive-behavioral analysis system of psychotherapy (CBASP). In this study, the authors examined whether such changes in interpersonal impacts (as rated by clinicians' experiences of interacting with their patients) mediated the association between early patient-rated alliance quality and final session depression., Method: Data derived from a large trial for chronic depression that compared the efficacy of CBASP, nefazodone, and their combination. The current subsample (N = 220) included patients in the CBASP and combined conditions who completed at least 1 depression assessment and the alliance measure, and whose therapists completed at least 1 interpersonal impacts assessment. Mediation models were fit using a bootstrapping procedure for assessing indirect effects., Results: As hypothesized, results supported a mediating effect; higher early alliance predicted decreases in patient hostile-submissiveness during therapy, which in turn related to lower final session depression (indirect effect B = -.02, 95% confidence interval: -.07, -.001). This indirect effect accounted for 13% of the total effect of alliance on depression. There was no moderating effect of treatment condition on the indirect effect., Conclusions: Results further support CBASP change theory and suggest a candidate mechanism of the alliance's effect on outcome. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Objective: The study aims were 1) to describe the proportions of individuals who met criteria for melancholic, atypical, and anxious depressive subtypes, as well as subtype combinations, in a large sample of depressed outpatients, and 2) to compare subtype profiles on remission and change in depressive symptoms after acute treatment with one of three antidepressant medications., Method: Participants 18-65 years of age (N=1,008) who met criteria for major depressive disorder were randomly assigned to 8 weeks of treatment with escitalopram, sertraline, or extended-release venlafaxine. Participants were classified by subtype. Those who met criteria for no subtype or multiple subtypes were classified separately, resulting in eight mutually exclusive groups. A mixed-effects model using the intent-to-treat sample compared the groups' symptom score trajectories, and logistic regression compared likelihood of remission (defined as a score ≤5 on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report)., Results: Thirty-nine percent of participants exhibited a pure-form subtype, 36% met criteria for more than one subtype, and 25% did not meet criteria for any subtype. All subtype groups exhibited a similar significant trajectory of symptom reduction across the trial. Likelihood of remission did not differ significantly between subtype groups, and depression subtype was not a moderator of treatment effect., Conclusions: There was substantial overlap of the three depressive subtypes, and individuals in all subtype groups responded similarly to the three antidepressants. The consistency of these findings with those of the Sequenced Treatment Alternatives to Relieve Depression trial suggests that subtypes may be of minimal value in antidepressant selection.

Background: This study seeks to provide a comprehensive and systematic evaluation of baseline clinical and psychological features and treatment response characteristics that differentiate Major Depressive Disorder (MDD) outpatients with and without melancholic features. Reflecting the emphasis in DSM-5, we also include impairment and distress., Methods: Participants were assessed pre-treatment on clinical features (severity, risk factors, comorbid conditions, illness course), psychological profile (personality, emotion regulation), functional capacity (social and occupational function, quality of life) and distress/coping (negativity bias, emotional resilience, social skills, satisfaction with life). Participants were randomized to sertraline, escitalopram or venlafaxine extended-release and re-assessed post-treatment at 8 weeks regarding remission, response, and change in impairment and distress., Results: Patients with melancholic features (n=339; 33.7%) were distinguished clinically from non-melancholics by more severe depressive symptoms and greater exposure to abuse in childhood. Psychologically, melancholic patients were defined by introversion, and a greater use of suppression to regulate negative emotion. Melancholics also had poorer capacity for social and occupational function, and physical and psychological quality of life, along with poorer coping, reflected in less emotional resilience and capacity for social skills. Post-treatment, melancholic patients had lower remission and response, but some of this effect was due to the more severe symptoms pre-treatment. The distress/coping outcome measure of capacity for social skills remained significantly lower for melancholic participants., Limitations: Due to the cross-sectional nature of this study, causal pathways cannot be concluded., Conclusions: Findings provide new insights into a melancholic profile of reduced ability to function interpersonally or effectively deal with one׳s emotions. This distinctly poorer capacity for social skills remained post-treatment. The pre-treatment profile may account for some of the difficulty in achieving remission or response with treatment., (Copyright © 2014. Published by Elsevier B.V.)

Objective: We sought to quantify clinical decision points for identifying depression treatment nonremitters prior to end-of-treatment., Method: Data came from the psychotherapy arms of a randomized clinical trial for chronic depression. Participants (n = 352; 65.6% female; 92.3% White; mean age = 44.3 years) received 12 weeks of cognitive behavioral analysis system of psychotherapy (CBASP) or CBASP plus an antidepressant medication. In half of the sample, receiver operating curve analyses were used to identify efficient percentage of symptom reduction cut points on the Inventory of Depressive Symptoms-Self-Report (IDS-SR) for predicting end-of-treatment nonremission based on the Hamilton Rating Scale for Depression (HRSD). Sensitivity, specificity, predictive values, and Cohen's kappa for identified cut points were calculated using the remaining half of the sample., Results: Percentage of IDS-SR symptom reduction at Weeks 6 and 8 predicted end-of-treatment HRSD remission status in both the combined treatment (Week 6 cut point = 50.0%, Cohen's κ = .42; Week 8 cut point = 54.3%, Cohen's κ = .45) and psychotherapy only (Week 6 cut point = 60.7%, Cohen's κ = .41; Week 8 cut point = 48.7%, Cohen's κ = .49). Status at Week 8 was more reliable for identifying nonremitters in psychotherapy-only treatment., Conclusions: Those with chronic depression who will not remit in structured, time-limited psychotherapy for depression, either with therapy alone or in combination with antidepressant medication, are identifiable prior to end of treatment. Findings provide an operationalized strategy for designing adaptive psychotherapy interventions.

Objective: This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP)., Method: 395 adults (57% female; Mage = 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16-20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change., Results: A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) = 62.48, p < .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) = 8.31, p = .004., Conclusions: The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies., (PsycINFO Database Record (c) 2013 APA, all rights reserved.)

Objective: Individuals with chronic depression exhibit heterogeneous responses to treatment. Important individual differences may therefore exist within this particularly difficult to treat population that act as moderators of treatment response., Method: The present study examined whether pretreatment levels of dysfunctional attitudes (DA) moderated treatment response in a large sample of chronically depressed individuals. Data were taken from the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) treatment study--a multi-site treatment and augmentation study of 808 chronically depressed individuals. REVAMP comprised two phases: 1) a 12-week open-label antidepressant trial and 2), a subsequent phase, in which phase 1 non-remitters (N = 491) were randomized to either receive an ongoing medication algorithm alone, medication plus cognitive behavioral analysis system of psychotherapy, or medication plus brief supportive psychotherapy., Result: In phase 1, compared to the pharmacotherapy response of patients with lower DA scores, the response for patients with higher DA scores was steeper, but leveled off toward the end of the phase. In phase 2, DA predicted a differential response in the medication only arm, but not in the two psychotherapy + medication conditions. Specifically, in the phase 2 medication only condition, patients with higher DA improved while those with lower DA scores did not., Conclusion: These results indicate that the relation between DA and treatment response in chronic depression is complex, but suggest that greater DA may be associated with a steeper reduction and/or better response to pharmacotherapy., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Findings regarding the relationship between patient treatment preference and treatment outcome are mixed. This is a secondary data analysis investigating the relationship between treatment preference, and symptom outcome and attrition in a large two-phase depression treatment trial., Methods: Patients met DSM-IV criteria for chronic forms of depression. Phase I was a 12-week, nonrandomized, open-label trial in which all participants (n = 785) received antidepressant medication(s) (ADM). Phase I nonremitters were randomized to Phase II, in which they received 12 weeks of either cognitive-behavioral system of psychotherapy (CBASP) + ADM (n = 193), brief supportive psychotherapy (BSP) + ADM (n = 187), or ADM only (n = 93). Participants indicated their treatment preference (medication only, combined treatment or no preference) at study entry. Symptoms were measured at 2-week intervals with the 24-item Hamilton Rating Scale for Depression (HAM-D)., Results: A large majority of patients reported a preference for combined treatment. Patients who preferred medication only were more likely to endorse a chemical imbalance explanation for depression, whereas those desiring combined treatment were more likely to attribute their depression to stressful experiences. In Phase I, patients who expressed no treatment preference showed greater rates of HAM-D symptom reduction than those with any preference, and patients with a preference for medication showed higher attrition than those preferring combined treatment. In Phase II, baseline treatment preference was not associated with symptom reduction or attrition., Conclusions: Treatment preferences may moderate treatment response and attrition in unexpected ways. Research identifying factors associated with differing preferences may enable improved treatment retention and response., (© 2012 Wiley Periodicals, Inc.)

Objective: Interpersonal theories posit that chronically depressed individuals have hostile and submissive styles in their social interactions, which may undermine their interpersonal effectiveness and maintain their depression. Recent findings support this theory and also show that patients' interpersonal impact messages, as perceived by their psychotherapists, change in theoretically predicted ways following cognitive-behavioral analysis system of psychotherapy (CBASP) alone or with medication. This study extended these previous findings by examining whether such changes were associated with their depression change and response status., Method: Data derived from a large clinical trial for chronic depression compared the efficacy of CBASP, nefazodone, and their combination. To assess patients' impact messages, CBASP clinicians completed the Impact Message Inventory (IMI; Kiesler & Schmidt, 1993) following an early and late session. Our subsample (N = 259) consisted of patients in the CBASP and combined conditions who had depression severity data for at least 1 post-randomization visit and whose clinicians completed at least 1 IMI rating. We used hierarchical linear modeling (HLM) to calculate IMI change scores and to model depression change. We used HLM and logistic regression to test our predictor questions., Results: As hypothesized, decreases in patients' hostile-submissive impact messages were significantly associated with depression reduction (γ = 0.27, 95% CI [0.11, 0.43], p < .01) and favorable treatment response (B = -0.05, 95% CI [-0.09, -0.01], p = .03), regardless of treatment condition., Conclusions: The findings support CBASP theory, suggesting that interpersonal change is related to depression reduction among chronically depressed patients.

Although considerable evidence demonstrates that adults who report childhood maltreatment are at increased risk of depression in adulthood, little is known about whether gender moderates risk. In a sample of 5,673 adult Health Maintenance Organization (HMO) patients, the authors employed the Patient Health Questionnaire-8 (PHQ-8) to assess major depressive disorder (MDD) and the Childhood Trauma Questionnaire (CTQ) to assess five different types of childhood maltreatment: emotional, physical, and sexual abuse, as well as emotional and physical neglect. Logistic regression models tested the main and interactive effects of gender and childhood maltreatment. Consistent with previous studies, men and women with histories of each type of childhood adversity were significantly more likely to meet criteria for MDD. However, the authors found no evidence that gender moderates the risk of depression. These findings suggest that men and women reporting history of childhood maltreatment are equally likely to suffer major depression in adulthood.

Objective: Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009)., Method: Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks., Results: CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions., Conclusions: It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches., ((PsycINFO Database Record (c) 2011 APA, all rights reserved).)

Objective: The objective of the study was to examine catastrophizing, depression and their interactive effects in predicting disability in patients with chronic pain., Method: A battery of questionnaires was mailed to primary care patients in a large integrated health care delivery system. The Patient Health Questionnaire was used to assess major depression, the Coping Strategies Questionnaire assessed catastrophizing and the Graded Chronic Pain Scale was used to assess pain intensity and two measures of disability, including self-report of pain interference and days missed from usual activities. Patient medical records were used to assess severe medical illness. Of the 5808 respondents, 2618 met criteria for chronic pain. Multiple regression analyses, covarying for age, gender, severe medical illness and pain intensity, estimated the main and interactive effects of catastrophic thinking and depression on two measures of pain-related disability., Results: Both catastrophic thinking and depression were statistically significant predictors of both measures of pain-related disability, with larger effect sizes observed for catastrophic thinking., Conclusions: Routine assessment of both catastrophic thinking and depression is important in the treatment of chronic pain patients, and modification of these factors may reduce disability and increase the ability of chronic pain patients to participate in daily life activity., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Dyadic discord, while common in depression, has not been specifically evaluated as an outcome predictor in chronic major depressive disorder. This study investigated pretreatment dyadic discord as a predictor of non-remission and its relationship to depressive symptom change during acute treatment for chronic depression., Method: Out-patients with chronic depression were randomized to 12 weeks of treatment with nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy or their combination. Measures included the Marital Adjustment Scale (MAS) and the Inventory of Depressive Symptomatology - Self Report (IDS-SR30). Of 681 original patients, 316 were partnered and 171 of these completed a baseline and exit MAS, and at least one post-baseline IDS-SR30. MAS scores were analysed as continuous and categorical variables ('dyadic discord' v. 'no dyadic discord' defined as an MAS score >2.36. Remission was defined as an IDS-SR30 of 14 at exit (equivalent to a 17-item Hamilton Rating Scale for Depression of 7)., Results: Patients with dyadic discord at baseline had lower remission rates (34.1%) than those without dyadic discord (61.2%) (all three treatment groups) (chi2=12.6, df=1, p=0.0004). MAS scores improved significantly with each of the treatments, although the change was reduced by controlling for improvement in depression. Depression remission at exit was associated with less dyadic discord at exit than non-remission for all three groups [for total sample, 1.8 v. 2.4, t(169)=7.3, p<0.0001]., Conclusions: Dyadic discord in chronically depressed patients is predictive of a lower likelihood of remission of depression. Couple therapy for those with dyadic discord may increase remission rates.

Context: Previous studies have found that few chronically depressed patients remit with antidepressant medications alone., Objective: To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial., Design: This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone., Setting: Eight academic sites., Participants: Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years., Interventions: Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs)., Main Outcome Measures: Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores., Results: In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores., Conclusions: Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing.

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.

Lack of sexual interest is the most common sexual complaint among women. However, factors affecting sexual desire in women have rarely been studied. While the role of the brain in integrating the sensory, attentional, motivational, and motor aspects of sexual response is commonly acknowledged as important, little is known about specific patterns of brain activation and sexual interest or response, particularly among women. We compared 20 females with no history of sexual dysfunction (NHSD) to 16 women with hypoactive sexual desire disorder (HSDD) in a functional magnetic resonance imaging (fMRI) study that included assessment of subjective sexual arousal, peripheral sexual response using a vaginal photoplethysmograph (VPP), as well as brain activation across three time points. Video stimuli included erotic, sports, and relaxing segments. Subjective arousal to erotic stimuli was significantly greater in NHSD participants compared with HSDD. In the erotic-sports contrast, NHSD women showed significantly greater activation in the bilateral entorhinal cortex than HSDD women. In the same contrast, HSDD females demonstrated higher activation than NHSD females in the medial frontal gyrus (Brodmann area (BA) 10), right inferior frontal gyrus (BA 47) and bilateral putamen. There were no between group differences in VPP-correlated brain activation and peripheral sexual response was not significantly associated with either subjective sexual response or brain activation patterns. Findings were consistent across the three experimental sessions. The results suggest differences between women with NHSD and HSDD in encoding arousing stimuli, retrieval of past erotic experiences, or both. The findings of greater activation in BA 10 and BA 47 among women with HSDD suggest that this group allocated significantly more attention to monitoring and/or evaluating their responses than NHSD participants, which may interfere with normal sexual response.

Background: There is growing evidence suggesting that early adversity may be a marker for a distinct pathway to major depressive disorder (MDD). We examined associations between childhood adversity and a broad variety of clinical characteristics and response to pharmacotherapy in a large sample of patients with chronic forms of MDD., Methods: Subjects included 808 patients with chronic forms of MDD (chronic MDD, double depression, or recurrent MDD with incomplete recovery between episodes and a total continuous duration of >2 years) who were enrolled in a 12-week open-label trial of algorithm-guided pharmacotherapy. Baseline assessments included a semi-structured diagnostic interview, and clinician- and self-rated measures of depressive symptoms, social functioning, depressotypic cognitions, and personality traits, and childhood adversity. Patients were re-evaluated every 2 weeks., Results: A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self-rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self-criticism were each associated with multiple forms of childhood adversity. A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing the 12-week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission., Conclusions: These findings indicate that a history of childhood adversity is associated with an especially chronic form of MDD that is less responsive to antidepressant pharmacotherapy., ((c) 2009 Wiley-Liss, Inc.)

Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

The main aim of the present novel reanalysis of archival data was to compare the time to remission during 12 weeks of treatment of chronic depression following antidepressant medication (n = 218), psychotherapy (n = 216), and their combination (n = 222). Cox regression survival analyses revealed that the combination of medication and psychotherapy produced full remission from chronic depression more rapidly than either of the single modality treatments, which did not differ from each other. Receiver operating characteristic curve analysis was used to explore predictors (treatment group, demographic, clinical, and psychosocial) of remission. For those receiving the combination treatment, the most likely to succeed were those with low baseline depression (24-item Hamilton Rating Scale for Depression [HRSD; M. Hamilton, 1967] score < 26) and those with high depression scores but low anxiety (HRSD = 26 and Hamilton Anxiety Rating Scale [M. Hamilton, 1959] < 14). Both profiles were associated with at least 40% chance of attaining full remission. The model did not identify predictors for those receiving medication or psychotherapy alone, and it did not distinguish between the 2 monotherapies. The authors conclude that combined antidepressant medications and psychotherapy result in faster full remission of chronic forms of major depressive disorder., ((c) 2008 APA, all rights reserved)

This pilot study examined the efficacy of an integrative form of cognitive therapy (ICT) for depression that incorporates specific strategies for addressing alliance ruptures. Although a previous study on depression found that ICT was superior to a wait-list condition (L. G. Castonguay et al., 2004), the current study provides the 1st direct comparison between ICT and traditional cognitive therapy (CT). Twenty-two depressed adults were randomly assigned to ICT or CT (11 patients per condition), which were delivered by clinicians in training. Outcome was assessed with a specific depression measure and a global symptomatology measure. The groups were also compared on patient-perceived alliance quality and therapist empathy. Effect size estimates revealed that ICT patients evidenced greater posttreatment improvement on both outcome measures (with small to medium effects) and more clinically significant change than did CT patients. ICT patients also had higher alliance and empathy scores across treatment (with medium to large effects). The findings, albeit very preliminary, support the potential viability of ICT and the potential causal influence of the rupture-repair interventions on treatment process and outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Bipolar disorder is a chronic, severe condition commonly causing substantial mortality and psychosocial morbidity. Challenges in recognition can delay the institution of appropriate management, whereas misdiagnosis may initiate pharmacologic interventions that adversely affect the condition's course. Pharmacotherapy remains the foundation of treatment. In addition to efficacy, tolerability is an important consideration in medication choice, particularly for long-term maintenance because of its impact on adherence. Mood stabilizers are the classic treatments for bipolar disorder. Newer agents such as atypical antipsychotics may offer efficacy and/or tolerability advantages compared with other medications. The role of antidepressants in bipolar disorder remains controversial. Growing evidence indicates that adjunctive psychosocial interventions improve long-term functioning; consequently, psychologists are becoming increasingly involved in the long-term care of patients with bipolar disorder. This review seeks to update psychologists and related healthcare professionals on recent advances and the current limitations in the diagnosis and treatment of bipolar disorder., ((c) 2006 Wiley Periodicals, Inc.)

Despite growing evidence for the efficacy of cognitive-behavioral therapy for insomnia (CBT-I), few data exist on the relation between process and outcome for this treatment. Drawing on interpersonal theory and the broader psychotherapy literature, this study examined the contribution of patient expectations and the therapeutic alliance to outcomes in group CBT-I. For patients with low early treatment expectations for improvement, those perceiving the therapist as higher in affiliation had greater reduction in sleep problems. Perceiving the therapist as critically confrontive was generally associated with less treatment satisfaction, and particularly so for those individuals who came to treatment with high expectations for improvement. Critical confrontation also differentiated dropouts from continuers, with dropouts experiencing their therapist as more critically confrontive.

Background: Premature termination is common among patients treated for depression with either pharmacotherapy or psychotherapy. Yet little is known about factors associated with premature treatment termination among depressed patients., Methods: This study examines predictors of, time to, and reasons for dropout from the 12-week acute phase treatment of nonpsychotic adult outpatients, age 18-75, with chronic major depression who were randomly assigned to nefazadone alone (MED), cognitive behavioral analysis system of psychotherapy alone (CBASP) or both treatments (COMB)., Results: Of 681 randomized study participants, 156 were defined as dropouts. Dropout rates were equivalent across the three treatments. Among dropouts, those in COMB remained in treatment (Mean=40 days) significantly longer than those in either MED (Mean=27 days) or CBASP (Mean=28 days). Dropouts attributed to medication side-effects were significantly lower in COMB than in MED, suggesting that the relationship with the psychotherapist may increase patient willingness to tolerate side-effects associated with antidepressant medications. Ethnic or racial minority status, younger age, lower income, and co-morbid anxiety disorders significantly predicted dropout in the full sample. Within treatments, differences between completers and dropouts in minority status and the prevalence of anxiety disorders were most pronounced in MED. Among those receiving CBASP, dropouts had significantly lower therapeutic alliance scores than completers., Limitations: The sample included only individuals with chronic depression., Conclusions: Predictors of dropout included baseline patient characteristics, but not early response to treatment. Ethnic and racial minorities and those with comorbid anxiety are at higher risk of premature termination, particularly in pharmacotherapy, and may require modified treatment strategies.

Context: Although various strategies are available to manage nonresponders to an initial treatment for depression, no controlled trials address the utility of switching from an antidepressant medication to psychotherapy or vice versa., Objective: To compare the responses of chronically depressed nonresponders to 12 weeks of treatment with either nefazodone or cognitive behavioral analysis system of psychotherapy (CBASP) who were crossed over to the alternate treatment (nefazodone, n = 79; CBASP, n = 61)., Design: Crossover trial., Setting: Twelve academic outpatient psychiatric centers., Patients: There were 140 outpatients with chronic major depressive disorder; 92 (65.7%) were female, 126 (90.0%) were white, and the mean age was 43.1 years. Thirty participants dropped out of the study prematurely, 22 in the nefazodone group and 8 in the CBASP group., Interventions: Treatment lasted 12 weeks. The dosage of nefazodone was 100 to 600 mg/d; CBASP was provided twice weekly during weeks 1 through 4 and weekly thereafter., Main Outcome Measures: The 24-item Hamilton Rating Scale for Depression, administered by raters blinded to treatment, the Clinician Global Impressions-Severity scale, and the 30-item Inventory for Depressive Symptomatology-Self-Report., Results: Analysis of the intent-to-treat sample revealed that both the switch from nefazodone to CBASP and the switch from from CBASP to nefazodone resulted in clinically and statistically significant improvements in symptoms. Neither the rates of response nor the rates of remission were significantly different when the groups of completers were compared. However, the switch to CBASP following nefazodone therapy was associated with significantly less attrition due to adverse events, which may explain the higher intent-to-treat response rate among those crossed over to CBASP (57% vs 42%)., Conclusions: Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders. A switch from an antidepressant medication to psychotherapy or vice versa appears to be useful for nonresponders to the initial treatment.

The therapeutic alliance is an established predictor of psychotherapy outcome. However, alliance research in the treatment of eating disorders has been scant, with even less attention paid to correlates of alliance development. The goal of this study was to examine the relation between specific patient characteristics and the development of the alliance in 2 different treatments for bulimia nervosa (BN). Data derive from a large, randomized clinical trial comparing cognitive- behavioral therapy (CBT) and interpersonal therapy (IPT) for BN. Across both treatments, patient expectation of improvement was positively associated with early- and middle-treatment alliance quality. In CBT, baseline symptom severity was negatively related to middle alliance. In IPT, more baseline interpersonal problems were associated with poorer alliance quality at midtreatment., (Copyright (c) 2005 APA, all rights reserved)

Research has not resolved whether depression is associated with a distinct information-processing bias, whether the content of the information-processing bias in depression is specific to themes of loss and sadness, or whether biases are consistent across the tasks most commonly used to assess attention and memory processing. In the present study, participants diagnosed with major depression, social phobia, or no Axis I disorder, completed several information-processing tasks assessing attention and memory for sad, socially threatening, physically threatening, and positive stimuli. As predicted, depressed participants exhibited specific biases for stimuli connoting sadness; social phobic participants did not evidence such specificity for threat stimuli. It is important to note that the different measures of bias in memory and attention were not systematically intercorrelated. Implications for the study of cognitive bias in depression, and for cognitive theory more broadly, are discussed.

Although the efficacy of maintenance pharmacotherapy for the prevention of recurrence in major depressive disorder (MDD) is well documented, few studies have tested the efficacy of psychotherapy as a maintenance treatment. The authors examined the efficacy of the cognitive-behavioral analysis system of psychotherapy (CBASP) as a maintenance treatment for chronic forms of MDD. Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assessment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time. These findings support the use of CBASP as a maintenance treatment for chronic forms of MDD.

Childhood maltreatment strongly predicts poor psychiatric and physical health outcomes in adulthood. This overview of the literature shows that individuals who suffer abuse, neglect, or serious family dysfunction as children are more likely to be depressed, to experience other types of psychiatric illness, to have more physical symptoms (both medically explained and unexplained), and to engage in more health-risk behaviors than their nonabused counterparts. The more severe the abuse, the stronger the association with poor outcomes in adulthood. Childhood sexual abuse in particular has been repeatedly associated, in adulthood, with physical complaints such as chronic pain that are likewise associated with depression. Individuals with a history of childhood abuse, particularly sexual abuse, are more likely than individuals with no history of abuse to become high utilizers of medical care and emergency services. Childhood maltreatment is highly prevalent among both men and women, especially in specialty settings such as emergency psychiatric care.

Objective: This study was designed to assess female sexual arousal by using a combination of physiologic measures and self-reported level of arousal., Design: Twenty subjects viewed a 23-minute sequence of randomly ordered relaxation and erotic tapes, both with and without auditory stimulus. The physiologic parameters of vaginal blood flow, galvanic skin resistance, respiration, pulse, and blood pressure, as well as self-reported level of arousal, were simultaneously recorded and correlated with video segments., Setting: An academic teaching hospital., Patient(s): The 20 subjects (mean age +/- SD: 24.9 +/- 3.0 years) included Caucasian (10), Hispanic (2), Asian-American (4), and African-American (4) women. All women were screened for normal sexual function with the Female Sexual Function Index (FSFI) and with the Beck Anxiety Inventory and Beck Depression Inventory., Intervention(s): Randomly ordered sequences of erotic and relaxation tapes with and without sound., Main Outcome Measure(s): Physiologic and behavioral data, as well as subjective arousal rating, were acquired. The resulting set of multichannel data was correlated with erotic segments and analyzed for sound vs. no sound and time to maximal physiologic arousal., Result(s): Four independent variables were found to have beta values that were significantly different from 0: respiration (mean = -0.239, SD = 0.177, range = -0.55-0.09, t = -6.04), VPP (mean = 0.158, SD = 0.37, range = -0.48-0.80, t = 1.91), rVPP (mean = 0.161, SD = 0.35, range = -0.537-0.686, t = 2.075), and erotic marker (mean = 0.582, SD = 0.191, range = 0.16-0.85, t = 13.6). Neither heart rate nor galvanic skin resistance beta values approached significance. Respiration period was correlated negatively with arousal rating, indicating that subjects breathed faster when aroused. Auditory stimuli during erotic segments did not increase subjective arousal, and for both subjective arousal rating as well as VPP measurement, maximal response occurred within 2 minutes., Conclusion(s): Simultaneous measurement of vaginal blood flow, respiration, pulse, and a variable accounting for the onset and offset of erotic video segments accounts for approximately 50% of the variance in predicting subjective female arousal. Regardless of the presence or absence of audio input, 2 minutes was the average minimum time required to reach maximal arousal in young, sexually functional women.

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., ((c) 2003 APA)

Although considerable research has been conducted on the efficacy of psychotherapy for depression, with and without medication, relatively few studies have focused on chronic forms of depression. Approximately 20% of individuals with depression experience episodes that last for two years or longer. We review the controlled research on the effectiveness of treatments separately for dysthymia and chronic major depression, focusing on the practical implications of the research for clinicians. In trials conducted with dysthymics, medication has been superior to psychotherapy, with limited evidence that combined treatment has advantages over medication or psychotherapy alone. In chronic major depression, combined treatment has demonstrated significant superiority over medication or psychotherapy alone. Possible explanations for the discrepant findings among dysthymics and those with chronic major depression are discussed., (Copyright 2003 Wiley Periodicals, Inc. J Clin Psychol/In Session.)

Recent reviews of cognitive theories of depression have noted that individualized assessment strategies might help to resolve mixed findings regarding the stability of depressotypic beliefs and attitudes. We describe encouraging results for an individualized measure of one such cognitive construct, irrational beliefs. Twenty depression-prone women (recurrent major depressives in full remission) and twenty closely matched never-depressed controls completed leading forced-choice measures of irrational beliefs (the Belief Scale; BS) and sociotropy-autonomy (The Revised Personal Style Inventory), as well as the Specific Demands on Self Scale (SDS). The BS requires participants to rate their agreement with twenty preselected statements of irrational beliefs, while the SDS focuses on whether participants harbor any strongly held irrational beliefs, even if uncommon or idiosyncratic. Consistent with previous research, there were no group differences on the traditional measure of irrational beliefs. In contrast, depression-prone participants strongly exceeded controls on the SDS, and this difference persisted after controlling for residual depression, anxiety symptoms, anxiety diagnoses, sociotropy, and autonomy. These findings provide some initial support for a key assumption of the rational-emotive model of depression, and, more broadly, suggest that individualized assessment strategies may help researchers capture the core negative beliefs of asymptomatic individuals, even in the absence of mood or cognitive priming., (Copyright 2003 Wiley Periodicals, Inc. J Clin Psychol 59: 439-455, 2003.)

Theorists have proposed that depression is associated with abnormalities in the behavioral activation (BAS) and behavioral inhibition (BIS) systems. In particular, depressed individuals are hypothesized to exhibit deficient BAS and overactive BIS functioning. Self-reported levels of BAS and BIS were examined in 62 depressed participants and 27 nondepressed controls. Clinical functioning was assessed at intake and at 8-month follow-up. Relative to nondepressed controls, depressed participants reported lower BAS levels and higher BIS levels. Within the depressed group, lower BAS levels were associated with greater concurrent depression severity and predicted worse 8-month outcome. Levels of both BIS and BAS showed considerable stability over time and clinical state. Overall, results suggest that BAS dysregulation exacerbates the presentation and course of depressive illness.

Background: Changes in sexual interest/satisfaction and function are frequently associated with major depression and the use of some antidepressant treatments. This study compares the effects of antidepressant medication, psychotherapy, and combined treatment on sexual interest/satisfaction and function in patients with chronic major depression., Method: Outpatients with chronic forms of DSM-IV major depressive disorder (N = 681) were randomly assigned to 12 weeks of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combined nefazodone/CBASP. The Modified Rush Sexual Inventory was used to assess sexual functioning, and the 24-item Hamilton Rating Scale for Depression was used to assess depressive symptoms., Results: At baseline, 65% of men and 48% of women reported some sexual dysfunction. Statistically significant linear improvement in sexual interest/satisfaction was noted across all 3 treatment groups (p < .001). Additionally, significant improvement in sexual function was observed across all 3 treatment groups on a composite measure of female sexual function (p < .001). Controlling for depressive symptoms and gender, combined treatment produced greater improvement in total sexual interest/satisfaction than CBASP alone (p = .007), but was not significantly different from nefazodone alone. Improvement in depressive symptoms was associated with improved sexual interest/satisfaction for men and women and, for men, improved sexual functioning., Conclusion: Chronic depression is associated with high rates of sexual dysfunction. Treatment with nefazodone, CBASP, and combined treatment improved sexual interest/satisfaction, with greatest improvement observed with combined treatment.

Despite the brain's central role in sexual function, little is known about relationships between brain activation and sexual response. In this study, we employed functional MRI (fMRI) to examine relationships between brain activation and sexual arousal in a group of young, healthy, heterosexual males. Each subject was exposed to two sequences of video material consisting of explicitly erotic (E), relaxing (R) and sports (S) segments in an unpredictable order. Data on penile turgidity was collected using a custom-built pneumatic pressure cuff. Both traditional block analyses using contrasts between sexually arousing and non-arousing video clips and a regression using penile turgidity as the covariate of interest were performed. In both types of analyses, contrast images were computed for each subject and these images were subsequently used in a random effects analysis. Strong activations specifically associated with penile turgidity were observed in the right subinsular region including the claustrum, left caudate and putamen, right middle occipital/ middle temporal gyri, bilateral cingulate gyrus and right sensorimotor and pre-motor regions. Smaller, but significant activation was observed in the right hypothalamus. Few significant activations were found in the block analyses. Implications of the findings are discussed. Our study demonstrates the feasibility of examining brain activation/sexual response relationships in an fMRI environment and reveals a number of brain structures whose activation is time-locked to sexual arousal.