Dr. Arnow specializes in psychotherapy for depression. He has practiced for more than 30 years. Dr. Arnow has a special interest in psychotherapy for chronic and treatment-resistant depression.
Professor - Med Center Line, Psychiatry and Behavioral Sciences
Member, Wu Tsai Neurosciences Institute
Associate Chair, Department of Psychiatry & Behavioral Sciences (2010 - Present)
Co-Director of Clinical Training, PGSP/Stanford Psy.D. Consortium, Department of Psychiatry and Behavioral Sciences (2006 - 2012)
Co-Chair, PGSP/Stanford Psy.D. Consortium, Department of Psychiatry and Behavioral Sciences (2001 - 2006)
Chief, Adult Outpatient Clinics, Department of Psychiatry and Behavioral Sciences (2000 - 2006)
Director of Psychology Training, Department of Psychiatry and Behavioral Sciences (1992 - Present)
Chief, Psychology Service, Department of Psychiatry and Behavioral Sciences (1992 - Present)
Director, Psychosocial Treatment Clinic (formerly Behavioral Medicine Clinic), Department of Psychiatry and Behavioral Sciences (1985 - Present)
Boards, Advisory Committees, Professional Organizations
Founding Fellow, Academy of Cognitive Therapy (1996 - Present)
Fellow, American Psychological Association -- Division 12: Society of Clinical Psychology (2013 - Present)
Member, Society for Psychotherapy Research (2014 - Present)
Member, Association for Behavioral and Cognitive Therapies
Fellowship: Stanford University Psychology Postdoctoral Fellowship (1985) CA
PhD Training: Stanford University Psychology (1984) CA
Ph.D, Stanford University, Counseling Psychology (1984)
Current Research and Scholarly Interests
Current research interests include treatment outcome for major depression, particularly treatment refractory and chronic forms of major depression, as well as mediators and moderators of outcome; the epidemiology of chronic pain and depression; relationships between child maltreatment and adult sequelae, including psychiatric, medical and health care utilization.
Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry.
2020; 18 (1): 170
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.
View details for DOI 10.1186/s12916-020-01623-9
View details for PubMedID 32498707
- Assessing the accuracy of automatic speech recognition for psychotherapy NPJ DIGITAL MEDICINE 2020; 3 (1)
Using fMRI connectivity to define a treatment-resistant form of post-traumatic stress disorder.
Science translational medicine
2019; 11 (486)
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.
View details for PubMedID 30944165
Key Considerations for Incorporating Conversational AI in Psychotherapy.
Frontiers in psychiatry
2019; 10: 746
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.
View details for DOI 10.3389/fpsyt.2019.00746
View details for PubMedID 31681047
Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths.
Journal of general internal medicine
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.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.Retrospective cohort study of decedents.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.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.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).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.
View details for DOI 10.1007/s11606-019-05307-w
View details for PubMedID 31667746
- PTSD Psychotherapy Outcome Predicted by Brain Activation During Emotional Reactivity and Regulation AMERICAN JOURNAL OF PSYCHIATRY 2017; 174 (12): 1163–74
PRELIMINARY ANALYSIS OF LIFE EXPECTANCY AND COMMON CAUSES OF DEATH AMONG VETERANS WITH MENTAL ILLNESSES
SPRINGER. 2017: S284
View details for Web of Science ID 000440259000449
Side Effects to Antidepressant Treatment in Patients With Depression and Comorbid Panic Disorder.
journal of clinical psychiatry
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).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.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.Potentially due to heightened 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.ClinicalTrials.gov identifier: NCT00057551.
View details for DOI 10.4088/JCP.15m10370
View details for PubMedID 28068460
- Major Depressive Disorder The SAGE Encyclopedia of Abnormal and Clinical Psychology Sage Publishing. 2017; A.E. Wenzel: 1994–1997
Selective Effects of Psychotherapy on Frontopolar Cortical Function in PTSD.
The American journal of psychiatry
2017; 174 (12): 1175–84
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.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.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.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.
View details for PubMedID 28715907
Change in Patients' Interpersonal Impacts as a Mediator of the Alliance-Outcome Association in Treatment for Chronic Depression
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2016; 84 (12): 1135-1144
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.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.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.Results further support CBASP change theory and suggest a candidate mechanism of the alliance's effect on outcome. (PsycINFO Database Record
View details for DOI 10.1037/ccp0000149
View details for Web of Science ID 000389304500010
View details for PubMedID 27748609
Brain Mechanisms and Predictors of Response to Prolonged Exposure Therapy in PTSD
NATURE PUBLISHING GROUP. 2016: S291–S292
View details for Web of Science ID 000440365600493
Convergence in patient-therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment.
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.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).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.The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.
View details for PubMedID 26829714
Neural Mechanisms of Psychotherapy for PTSD: Emotional Reactivity and Regulation
NATURE PUBLISHING GROUP. 2015: S278–S279
View details for Web of Science ID 000366597700483
Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans.
American journal of public health
2015; 105 (12): 2564-2569
We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI).A total of 4 461 208 veterans were seen in the Veterans Health Administration's patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement.A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes.Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.
View details for DOI 10.2105/AJPH.2015.302836
View details for PubMedID 26474009
Depression Subtypes in Predicting Antidepressant Response: A Report From the iSPOT-D Trial
AMERICAN JOURNAL OF PSYCHIATRY
2015; 172 (8): 743-750
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.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).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.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.
View details for DOI 10.1176/appi.ajp.2015.14020181
View details for Web of Science ID 000359274700014
View details for PubMedID 25815419
- Impairment and distress patterns distinguishing the melancholic depression subtype: An iSPOT-D report. JOURNAL OF AFFECTIVE DISORDERS 2015; 174: 493-502
- Depressive disorders STUDY GUIDE TO DSM-5 edited by Roberts, L. W., Louie, A. K. Washington, DC: American Psychiatric Press. 2015: 113–135
- Harnessing the potential of the therapeutic alliance. World psychiatry 2014; 13 (3): 238-240
- Dysthymia and chronic major depression THE WILEY HANDBOOK OF COGNITIVE BEHAVIORAL THERAPY, VOLUME 3: SPECIFIC DISORDERS edited by Smits, J. A. Hoboken, NJ: Wiley-Blackwell. 2014: 1189–1214
- Review: different psychotherapies have comparable effects on adult depression EVIDENCE-BASED MENTAL HEALTH 2013; 16 (4): 122
Detecting critical decision points in psychotherapy and psychotherapy + medication for chronic depression.
Journal of consulting and clinical psychology
2013; 81 (5): 783-792
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. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
View details for DOI 10.1037/a0033250
View details for PubMedID 23750462
The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.
Journal of consulting and clinical psychology
2013; 81 (4): 627-638
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).
View details for DOI 10.1037/a0031530
View details for PubMedID 23339536
Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression.
JOURNAL OF PSYCHIATRIC RESEARCH
2013; 47: 113-121
View details for DOI 10.1016/j.jpsychires.2012.09.018
- Improving female sexual health: A quantitative evaluation of an educational intervention for healthcare professionals. SEX EDUCATION: SEXUALITY, SOCIETY AND LEARNING 2013; 13: 535-547
PATIENT TREATMENT PREFERENCE AS A PREDICTOR OF RESPONSE AND ATTRITION IN TREATMENT FOR CHRONIC DEPRESSION
DEPRESSION AND ANXIETY
2012; 29 (10): 896-905
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.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).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.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.
View details for DOI 10.1002/da.21977
View details for Web of Science ID 000309394600009
View details for PubMedID 22767424
View details for PubMedCentralID PMC3463778
The Relation Between Changes in Patients' Interpersonal Impact Messages and Outcome in Treatment for Chronic Depression
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2012; 80 (3): 354-364
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.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.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.The findings support CBASP theory, suggesting that interpersonal change is related to depression reduction among chronically depressed patients.
View details for DOI 10.1037/a0028351
View details for Web of Science ID 000304508000004
View details for PubMedID 22545738
- The case formulation approach to cognitive-behavior therapy (Book Review) PSYCHOTHERAPY RESEARCH 2012; 22 (2): 239–40
Does Gender Moderate the Relationship Between Childhood Maltreatment and Adult Depression?
2011; 16 (3): 175-183
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.
View details for DOI 10.1177/1077559511412067
View details for PubMedID 21727161
Social Problem Solving and Depressive Symptoms Over Time: A Randomized Clinical Trial of Cognitive-Behavioral Analysis System of Psychotherapy, Brief Supportive Psychotherapy, and Pharmacotherapy
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2011; 79 (3): 342-352
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).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.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.It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches.
View details for DOI 10.1037/a0023208
View details for Web of Science ID 000291129600008
View details for PubMedID 21500885
View details for PubMedCentralID PMC3109172
Catastrophizing, depression and pain-related disability
GENERAL HOSPITAL PSYCHIATRY
2011; 33 (2): 150-156
The objective of the study was to examine catastrophizing, depression and their interactive effects in predicting disability in patients with chronic pain.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.Both catastrophic thinking and depression were statistically significant predictors of both measures of pain-related disability, with larger effect sizes observed for catastrophic thinking.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.
View details for DOI 10.1016/j.genhosppsych.2010.12.008
View details for PubMedID 21596208
Dyadic discord at baseline is associated with lack of remission in the acute treatment of chronic depression
2010; 40 (3): 415-424
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.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).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].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.
View details for DOI 10.1017/S0033291709990535
View details for Web of Science ID 000275011100007
View details for PubMedID 19607755
Cognitive Behavioral Analysis System of Psychotherapy and Brief Supportive Psychotherapy for Augmentation of Antidepressant Nonresponse in Chronic Depression
ARCHIVES OF GENERAL PSYCHIATRY
2009; 66 (11): 1178-1188
Previous studies have found that few chronically depressed patients remit with antidepressant medications alone.To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial.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.Eight academic sites.Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years.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).Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores.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.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.
View details for Web of Science ID 000271427500004
View details for PubMedID 19884606
View details for PubMedCentralID PMC3512199
Select comorbid personality disorders and the treatment of chronic depression with nefazodone, targeted psychotherapy, or their combination
JOURNAL OF AFFECTIVE DISORDERS
2009; 117 (3): 174-179
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.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.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.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.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.
View details for DOI 10.1016/j.jad.2009.01.010
View details for Web of Science ID 000270245500008
View details for PubMedID 19217168
EARLY ADVERSITY IN CHRONIC DEPRESSION: CLINICAL CORRELATES AND RESPONSE TO PHARMACOTHERAPY
115th Annual Convention of the American-Psychological-Association
WILEY-BLACKWELL. 2009: 701–10
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.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.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.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.
View details for DOI 10.1002/da.20577
View details for Web of Science ID 000268736700002
View details for PubMedID 19434623
View details for PubMedCentralID PMC3528400
Patient Preference as a Moderator of Outcome for Chronic Forms of Major Depressive Disorder Treated With Nefazodone, Cognitive Behavioral Analysis System of Psychotherapy, or Their Combination
JOURNAL OF CLINICAL PSYCHIATRY
2009; 70 (3): 354-361
Little is known about moderators of response to psychotherapy, medication, and combined treatment for chronic forms of major depressive disorder (MDD). We hypothesized that patient preference at baseline would interact with treatment group to differentially affect treatment outcome.We report outcomes for 429 patients who participated in a randomized multicenter trial of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combination therapy for chronic forms of MDD (DSM-IV criteria) and who indicated their preference for type of treatment at study entry. The primary outcome measures were total scores on the 24-item Hamilton Rating Scale for Depression (HAM-D-24) and categorical definitions of remission or partial response. The patients were recruited between June 1996 and December 1997.There was an interactive effect of preference and treatment group on outcome. The treatment effect varied as a function of preference, and was particularly apparent for patients who initially expressed preference for one of the monotherapies. Patients who preferred medication had a higher remission rate (45.5%) and lower mean HAM-D-24 score (11.6) at study exit if they received medication than if they received psychotherapy (remission rate, 22.2%; mean HAM-D-24 score, 21.0). Patients who preferred psychotherapy had a higher remission rate (50.0%) and lower mean HAM-D-24 score (12.1) if they received psychotherapy than if they received medication (remission rate 7.7%, mean HAM-D-24 score 18.3). Nevertheless, treatment preference was not associated with risk of dropout from the study.These results suggest that patient preference is a potent moderator of treatment response for patients with chronic forms of MDD; however, relatively low proportions of the patient sample preferred one of the monotherapies, participants were not blinded to treatment assignment, and there was no placebo group.
View details for Web of Science ID 000264735200007
View details for PubMedID 19192474
Relationships Among Depression, Chronic Pain, Chronic Disabling Pain, and Medical Costs
2009; 60 (3): 344-350
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.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.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.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.
View details for Web of Science ID 000263723600010
View details for PubMedID 19252047
WOMEN WITH HYPOACTIVE SEXUAL DESIRE DISORDER COMPARED TO NORMAL FEMALES: A FUNCTIONAL MAGNETIC RESONANCE IMAGING STUDY
2009; 158 (2): 484-502
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.
View details for DOI 10.1016/j.neuroscience.2008.09.044
View details for Web of Science ID 000262959900012
View details for PubMedID 18976696
- Cognitive-Behavioral therapy for refractory cases: Turning failure to success. Depression. In D. McKay, JS Abromowits, S Taylor (Eds.) American Psychological Association Press. 2009: 183–210
INTERPERSONAL STYLES OF CHRONICALLY DEPRESSED OUTPATIENTS: PROFILES AND THERAPEUTIC CHANGE
2008; 45 (4): 491-506
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).
View details for DOI 10.1037/a0014335
View details for Web of Science ID 000262213000006
View details for PubMedID 22122536
Integrative cognitive therapy for depression: A randomized pilot comparison
2008; 45 (2): 122-134
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).
View details for DOI 10.1037/0033-322.214.171.124
View details for Web of Science ID 000256766200002
View details for PubMedID 22122413
Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2008; 76 (3): 459-467
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.
View details for DOI 10.1037/0022-006X.76.3.459
View details for Web of Science ID 000256326700010
View details for PubMedID 18540739
- Cognitive and behavioral mediators of combined pharmacotherapy and psychotherapy of chronic depression COGNITIVE THERAPY AND RESEARCH 2008; 32 (2): 197-211
- The efficacy of CBT, IPT, and related psychotherapies for depression: A review by treatment phase. Depression: Mind and Body 2008; 4: 15-27
- Empirical Support for a Conceptual Model of Posttraumatic Stress Disorder among survivors of child sexual abuse. In T Richardson, MV Williams (Eds). Child Abuse and Violence. In T Richardson, MV Williams (Eds). Nova Science Publishers. 2008: 43–57
In the mind's eye: Provider and patient attitudes on functional brain imaging
JOURNAL OF PSYCHIATRIC RESEARH
2008; 43: 107-114
View details for DOI 10.1016/j.jpsychires.2008.02.008.
What's driving the binge in binge eating disorder?: A prospective examination of precursors and consequences
International Conference on Eating Disorders
JOHN WILEY & SONS INC. 2007: 195–203
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.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.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.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.
View details for DOI 10.1002/eat.20352
View details for Web of Science ID 000245089100001
View details for PubMedID 17103418
Bipolar disorder: Improving diagnosis and optimizing integrated care
JOURNAL OF CLINICAL PSYCHOLOGY
2007; 63 (1): 73-92
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.
View details for DOI 10.1002/jclp.20333
View details for Web of Science ID 000243044600005
View details for PubMedID 17115430
Patient expectations and therapeutic alliance as predictors of outcome in group cognitive-behavioral therapy for insomnia.
Behavioral sleep medicine
2007; 5 (3): 210-228
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.
View details for PubMedID 17680732
Dropouts versus completers among chronically depressed outpatients
JOURNAL OF AFFECTIVE DISORDERS
2007; 97 (1-3): 197-202
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.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).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.The sample included only individuals with chronic depression.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.
View details for DOI 10.1016/j.jad.2006.06.017
View details for Web of Science ID 000243734600023
View details for PubMedID 16857266
Comorbid depression, chronic pain, and disability in primary care
2006; 68 (2): 262-268
The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together.A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate).Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level.Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.
View details for DOI 10.1097/01.psy.0000204851.15499.fc
View details for Web of Science ID 000236591400013
View details for PubMedID 16554392
The abuse-related beliefs questionnaire for survivors of childhood sexual abuse
CHILD ABUSE AND NEGLECT
2006; 30: 929-943
View details for DOI 10.1016/j.chiabu.2006.01.004
- Adult Depression: Characteristics, burden, models, and interventions Abnormal Psychology in the 21st Century. In T Plant, (Ed.) Greenwood Express: Westport, CT. 2006: 139–166
- The therapeutic alliance and CBASP-specific skill acquisition in the treatment of chronic depression COGNITIVE THERAPY AND RESEARCH 2005; 29 (6): 803-817
The efficacy of divalproex sodium in the treatment of agitation associated with major depression
JOURNAL OF CLINICAL PSYCHOPHARMACOLOGY
2005; 25 (5): 476-479
Agitation is both a feature of major depression and a common side effect of antidepressant treatment. Depressive agitation correlates with overall severity of illness and suicide risk, whereas treatment-emergent agitation may contribute to early discontinuation of pharmacotherapy. Thus, agitation merits investigation as a treatment target in clinical depression.In this study, adults with major depression were evaluated for change in agitation and other mood symptoms during adjunctive treatment with divalproex sodium. Twelve patients on antidepressants, who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression, were given low doses of divalproex sodium and evaluated repeatedly for symptoms of depression, anxiety, and agitation. Agitation severity was evaluated using the Overt Agitation Severity Scale and the Stanford Scale for Agitation Symptoms. Mood symptoms were assessed with the Hamilton Anxiety and the Hamilton Depression Rating Scales.Nine of 12 patients completed 4 weeks of treatment. All agitation scores decreased sharply, whereas depression (Hamilton Depression Rating Scale) and anxiety (Hamilton Anxiety Rating Scale) symptoms decreased only modestly. Decreased agitation was not merely a function of decreases on the Hamilton Depression or Hamilton Anxiety Rating Scales. Relatively low doses of divalproex sodium appear to be useful in the treatment of agitation associated with major depression.The observation that decreases in agitation were not simply an artifact of overall change in depressive or anxiety symptoms is in keeping with the previous clinical impression that divalproex sodium has a specific effect on depressive agitation. Controlled clinical trials are needed to fully evaluate the utility and symptom specificity of divalproex sodium in depression.
View details for DOI 10.1097/01.jcp.0000177552.21338.b0
View details for Web of Science ID 000232287500015
View details for PubMedID 16160625
Assessing insomnia severity in depression: comparison of depression rating scales and sleep diaries
JOURNAL OF PSYCHIATRIC RESEARCH
2005; 39 (5): 481-488
Depression and sleep researchers typically assess insomnia severity differently. Whereas depression researchers usually assess insomnia with items on depression symptom inventories, sleep researchers usually assess the subjective experience of insomnia with sleep diaries. The present manuscript utilizes baseline data from 397 participants in a large multi-site chronic depression study to assess agreement between these two methodologies. The results indicate that the early, middle, and late insomnia items of the Hamilton Rating Scale for Depression (HRSD(24)) and the Inventory of Depression Symptoms - Self Report (IDS-SR(30)) are highly correlated with the weekly mean values of time to sleep onset, time awake after sleep onset, and time awake prior to the planned wake-up obtained from prospective sleep diaries. Results also reveal significant correspondence between the weekly-mean of daily sleep efficiency, an accepted measure of sleep continuity (the ratio between reported time asleep and time in bed), and the insomnia scale scores of the HRSD(24) and the IDS-SR(30) (the mean score on the three insomnia items of each depression measure). Unit increments in HRSD(24) scores for early, middle and late insomnia were associated with significant increases in unwanted minutes awake for corresponding periods on sleep diaries. Similar relationships were found for early insomnia on the IDS-SR(30) but not for middle and late insomnia. Overall, with few exceptions, findings revealed substantial agreement between the HRSD(24), IDS-SR(30) and prospective sleep diary data. The study supports the validity of the sleep items and sleep subscales of the HRSD(24) and the IDS-SR(30) as global measures of insomnia severity in depression. Conventional sleep assessment procedures can complement depression scales by providing additional information about specific aspects of sleep in depression.
View details for DOI 10.1016/j.jpsychires.2004.12.003
View details for Web of Science ID 000231579300005
View details for PubMedID 15992557
Chronic depression - Medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not
ARCHIVES OF GENERAL PSYCHIATRY
2005; 62 (5): 513-520
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.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).Crossover trial.Twelve academic outpatient psychiatric centers.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.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.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.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%).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.
View details for Web of Science ID 000228905600007
View details for PubMedID 15867104
The association between patient characteristics and the therapeutic alliance in cognitive-behavioral and interpersonal therapy for bulimia nervosa
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2005; 73 (2): 203-211
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.
View details for DOI 10.1037/0022-006X.73.2.203
View details for Web of Science ID 000227924100002
View details for PubMedID 15796627
Self-reported depressive symptom measures: Sensitivity to detecting change in a randomized, controlled trial of chronically depressed, nonpsychotic outpatients
2005; 30 (2): 405-416
This study evaluated and compared the performance of three self-report measures: (1) 30-item Inventory of Depressive Symptomatology-Self-Report (IDS-SR30); (2) 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16); and (3) Patient Global Impression-Improvement (PGI-I) in assessing clinical outcomes in depressed patients during a 12-week, acute phase, randomized, controlled trial comparing nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), and the combination in the treatment of chronic depression. The IDS-SR30, QIDS-SR16, PGI-I, and the 24-item Hamilton Depression Rating Scale (HDRS24) ratings were collected at baseline and at weeks 1-4, 6, 8, 10, and 12. Response was defined a priori as a > or =50% reduction in baseline total score for the IDS-SR30 or for the QIDS-SR16 or as a PGI-I score of 1 or 2 at exit. Overall response rates (LOCF) to nefazodone were 41% (IDS-SR30), 45% (QIDS-SR16), 53% (PCI-I), and 47% (HDRS17). For CBASP, response rates were 41% (IDS-SR30), 45% (QIDS-SR16), 48% (PGI-I), and 46% (HDRS17). For the combination, response rates were 68% (IDS-SR30 and QIDS-SR16), 73% (PGI-I), and 76% (HDRS17). Similarly, remission rates were comparable for nefazodone (IDS-SR30=32%, QIDS-SR16=28%, PGI-I=22%, HDRS17=30%), for CBASP (IDS-SR30=32%, QIDS-SR16=30%, PGI-I=21%, HDRS17=32%), and for the combination (IDS-SR30=52%, QIDS-SR16=50%, PGI-I=25%, HDRS17=49%). Both the IDS-SR30 and QIDS-SR16 closely mirrored and confirmed findings based on the HDRS24. These findings raise the possibility that these two self-reports could provide cost- and time-efficient substitutes for clinician ratings in treatment trials of outpatients with nonpsychotic MDD without cognitive impairment. Global patient ratings such as the PGI-I, as opposed to specific item-based ratings, provide less valid findings.
View details for DOI 10.1038/sj.npp.1300614
View details for Web of Science ID 000226569900020
View details for PubMedID 15578008
Childhood sexual and physical abuse and the 1-year prevalence of medical problems in the national comorbidity survey
2005; 24 (1): 32-40
In a population sample (N=5,877; ages 15 to 54), the authors found childhood sexual and physical abuse to be associated with the 1-year prevalence of serious health problems for both men and women. The authors also found that participants' psychiatric disorders partially mediated the effects of physical and sexual abuse on adult health. However, childhood abuse continued to independently influence health status after the authors controlled for psychiatric disorders. Contrary to expectations, individuals who experienced a combination of sexual and physical abuse did not have a higher frequency of health problems than those who experienced either type of abuse alone. Implications for these findings are discussed, including possible mechanisms that may account for the association between childhood abuse and adult health problems.
View details for DOI 10.1037/0278-6126.96.36.199
View details for Web of Science ID 000226224900004
View details for PubMedID 15631560
Therapeutic alliance and patient expectations as predictors of outcome in group CBT for insomnia
AMER ACADEMY SLEEP MEDICINE. 2005: A227–A228
View details for Web of Science ID 000228906101186
- Cognitive behavioral analysis system of psychotherapy for chronic depression. COGNITIVE AND BEHAVIORAL PRACTICE 2005; 12: 6-16
- Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients PSYCHOTHERAPY 2004; 41 (3): 255-265
Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2004; 72 (4): 681-688
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.
View details for DOI 10.1037/0022-006X.72.4.681
View details for Web of Science ID 000222924600015
View details for PubMedID 15301653
Coherence and specificity of information-processing biases in depression and social phobia
JOURNAL OF ABNORMAL PSYCHOLOGY
2004; 113 (3): 386-398
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.
View details for DOI 10.1037/0021-843x.113.3.386
View details for Web of Science ID 000223137900003
View details for PubMedID 15311984
Major depressive disorder and co-morbid chronic pain, a costly condition
24th CINP Congress
CAMBRIDGE UNIV PRESS. 2004: S336–S336
View details for Web of Science ID 000224663002054
Rumination and distraction among chronic depressives in treatment: a structural equation analysis.
COGNITIVE THERAPY AND RESEARCH
2004; 28 (1): 67-83
View details for DOI 10.1023/B:COTR.0000016931.37807.ab
Relationships between childhood maltreatment, adult health and psychiatric outcomes, and medical utilization
JOURNAL OF CLINICAL PSYCHIATRY
2004; 65: 10-15
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.
View details for Web of Science ID 000223784500003
View details for PubMedID 15315472
- Chronic pain and depression: the mind, brain and body connection. CURRENT PSYCHIATRY 2004; Nov. Supp.: 3-20
- Bulimia nervosa: Treatment. In N Anderson (Ed). Encyclopedia of Behavioral Medicine. Newbury Park, CA: Sage Publications 2004: 115-117
Female sexual arousal: a behavioral analysis
FERTILITY AND STERILITY
2003; 80 (6): 1480-1487
This study was designed to assess female sexual arousal by using a combination of physiologic measures and self-reported level of arousal.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.An academic teaching hospital.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.Randomly ordered sequences of erotic and relaxation tapes with and without sound.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.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.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.
View details for DOI 10.1016/S0015-0282(03)02210-6
View details for Web of Science ID 000187284200029
View details for PubMedID 14667887
Therapeutic reactance as a predictor of outcome in the treatment of chronic depression
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2003; 71 (6): 1025-1035
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.
View details for DOI 10.1037/0022-006X.71.6.1025
View details for Web of Science ID 000186693600008
View details for PubMedID 14622078
Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2003; 71 (6): 997-1006
Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.
View details for DOI 10.1037/0022-006X.71.6.997
View details for Web of Science ID 000186693600005
View details for PubMedID 14622075
Randomized, placebo-controlled trial of nefazodone maintenance treatment in preventing recurrence in chronic depression
2003; 54 (8): 806-817
Maintenance treatment to prevent recurrences is recommended for chronic forms of major depressive disorder (MDD), but few studies have examined maintenance efficacy of antidepressants with chronic MDD. This randomized, placebo-controlled study of the efficacy and safety of nefazodone in preventing recurrence was conducted for patients with chronic MDD.A total of 165 outpatients with chronic, nonpsychotic MDD, MDD plus dysthymic disorder ("double-depression"), or recurrent MDD with incomplete inter-episode recovery, who achieved and maintained a clinical response during acute and continuation treatment with either nefazodone alone or nefazodone combined with psychotherapy, were randomized to 52 weeks of double-blind nefazodone (maximum dose 600 mg/day) or placebo. The occurrence of major depressive episodes during maintenance treatment was assessed with the 24-item Hamilton Rating Scale for Depression, a DSM-IV MDD checklist, and a blinded review of symptom exacerbations by a consensus committee of research clinicians.Application of a competing-risk model that estimated the conditional probability of recurrence among those patients remaining on active therapy revealed a significant (p =.043) difference between nefazodone (n = 76) and placebo (n = 74) when the latter part of the 1-year maintenance period was emphasized. At the end of 1 year, the conditional probability of recurrence was 30.3% for nefazodone-treated patients, compared with 47.5% for placebo-treated patients. Prior concomitant psychotherapy during acute/continuation treatment, although enhancing the initial response, was not associated with lower recurrence rates. Discontinuations due to adverse events were relatively low for both nefazodone (5.3%) and placebo (4.8%). Somnolence was significantly greater among the patients taking active medication (15.4%), compared with placebo (4.6%).Nefazodone is well-tolerated and is an effective maintenance therapy for chronic forms of MDD.
View details for DOI 10.1016/S0006-3223(02)01971-6
View details for Web of Science ID 000185750100005
View details for PubMedID 14550680
The 16-item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression
2003; 54 (5): 573-583
The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbach's alpha =.86), the IDS-SR(30) (Cronbach's alpha =.92), and the HAM-D(24) (Cronbach's alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.
View details for DOI 10.1016/S0006-3223(03)01866-8
View details for Web of Science ID 000184906100009
View details for PubMedID 12946886
Effectiveness of psychotherapy and combination treatment for chronic depression
JOURNAL OF CLINICAL PSYCHOLOGY
2003; 59 (8): 893-905
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.
View details for DOI 10.1002/jclp.10181
View details for Web of Science ID 000184361500008
View details for PubMedID 12858430
Patient's therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication
2003; 33 (4): 693-702
We tested the hypotheses that the addition of medication to psychotherapy enhances participation in the latter by: (1) speeding the acquisition of the psychotherapy's targeted skill; and (2) facilitating higher skill level acquisition.Participants were 431 chronically depressed patients who received Cognitive Behavioral Analysis System of Psychotherapy (CBASP), alone (N=214) or in combination with nefazodone (N=217), as part of a randomized chronic depression study (Keller et al. 2000). CBASP, developed specifically to treat chronic depression, uses a specific procedure, 'situational analysis' to help patients engage in more effective goal-oriented interpersonal behaviours. At the end of each session, therapists rated patients on their performance of situational analysis. Outcome on depressive symptoms was assessed with the 24-item Hamilton Rating Scale for Depression.Although reductions in depression were significantly greater in combined treatment compared to CBASP alone, there were no between-group differences in either the rate of skill acquisition or overall skill level at the end of treatment. Proficiency in the use of the main skill taught in psychotherapy at treatment midpoint predicted outcome independently of medication status and of baseline depressive severity.Effective participation in CBASP, as reflected by proficiency in the compensatory skill taught in psychotherapy, is not enhanced by the addition of medication and does not mediate the between-group difference in depression outcome.
View details for DOI 10.1017/S0033291703007608
View details for Web of Science ID 000183495600013
View details for PubMedID 12785471
Individualized measurement of irrational beliefs in remitted depressives
JOURNAL OF CLINICAL PSYCHOLOGY
2003; 59 (4): 439-455
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.
View details for DOI 10.1002/jclp.10081
View details for Web of Science ID 000181750000004
View details for PubMedID 12652636
The effects of psychotherapy, nefazodone, and their combination on subjective assessment of disturbed sleep in chronic depression
2003; 26 (2): 130-136
The purpose of the study was to compare the effects of psychotherapy, nefazodone, and their combination on subjective measures of sleep in patients with chronic forms of major depression.Participants were randomized to receive 12 weeks of treatment with one of the three interventions.The study was conducted in parallel at 12 academic institutions and was approved by the Human Subjects Committee at each site.484 adult outpatients (65.29% female) who met DSM-IV criteria for one of three chronic forms of major depression.Psychotherapy (16-20 sessions) was provided by certified therapists following a standardized treatment manual for Cognitive Behavioral Analysis System of Psychotherapy (CBASP), a variant of cognitive psychotherapy developed for chronic depression. Pharmacotherapy consisted of open-label nefazodone, 300-600 mg per day in two divided doses prescribed by psychiatrists. The clinical management visits were limited to 15-20 minutes and followed a standardized protocol. Combination treatment consisted of both therapies.Depression outcome was determined by the 24-item Hamilton Rating Scale for Depression and the 30-item Inventory of Depressive Symptomatology-Self Rating. Sleep outcome was measured prospectively with daily sleep diaries that were completed a week prior to HRSD assessments at baseline and after 1, 2, 3, 4, 8, and 12 weeks of treatment. Although nefazodone alone and CBASP alone had comparable impact on global measures of depression outcome, only monotherapy with nefazodone improved early morning awakening and total sleep time. Significant improvements in sleep quality, time awake after sleep onset, latency to sleep onset, and sleep efficiency were present in each of the three treatment groups. These improvements, however, occurred earlier in the course of treatment for participants receiving nefazodone, alone or in combination with CBASP.Nefazodone therapy may have a direct impact on disturbed sleep associated with depression beyond what would be expected if the improvements were all a consequence of improved depression.
View details for Web of Science ID 000181541300003
View details for PubMedID 12683470
Continuation treatment of chronic depression: a comparison of nefazodone, cognitive behavioral analysis system of psychotherapy, and their combination.
2003; 37 (4): 73-87
Little is known about the relative benefits of psychotherapy, medication, and combined treatment as continuation therapies for chronic forms of major depressive disorder (MDD) after a positive response to acute treatment. We hypothesize that combined treatment would demonstrate superior continuation phase outcomes compared to either monotherapy, as evidenced by lower relapse rates and greater rates of improvement from partial to full remission. We report 16-week continuation phase outcomes for 324 patients who had participated in either the acute phase of a randomized multicenter trial of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combination therapy (COMB) for chronic forms of MDD. Patients entering the continuation phase had either fully or partially remitted after 12 weeks of acute phase treatment. The primary efficacy measure was the 24-item Hamilton Rating Scale for Depression. For patients in remission at acute phase exit, 73.3% (107/146) maintained their remitted status at endpoint of the continuation phase. Of those having a partial remission at acute phase exit, 52.9% (92/174) achieved full remission by end of continuation. A greater proportion of patients maintained a partial or full remission status on COMB (90%) compared to nefazodone (80%, p=0.011) or to CBASP (82%, p=0.042). These differences reflected greater symptom re-emergence in the partial remission groups on CBASP and nefazodone monotherapy compared to COMB. Continuation treatment assignment was not randomized or blinded. There was no placebo group. Most patients with chronic forms of MDD sustained their acute phase response and more than 50% of partial remitters achieved full remission while continuing treatment with nefazodone, CBASP, or COMB. COMB was associated with less symptom re-emergence during the continuation phase than either monotherapy, particularly for partial remitters.
View details for PubMedID 15131518
Behavioral activation and inhibition systems and the severity and course of depression
JOURNAL OF ABNORMAL PSYCHOLOGY
2002; 111 (4): 589-597
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.
View details for DOI 10.1037//0021-843X.111.4.589
View details for Web of Science ID 000178941600006
View details for PubMedID 12428772
Sexual function and satisfaction in the treatment of chronic major depression with nefazodone, psychotherapy, and their combination
JOURNAL OF CLINICAL PSYCHIATRY
2002; 63 (8): 709-716
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.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.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.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.
View details for Web of Science ID 000177510300009
View details for PubMedID 12197452
Brain activation and sexual arousal in healthy, heterosexual males
2002; 125: 1014-1023
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.
View details for Web of Science ID 000175626900010
View details for PubMedID 11960892
Pretreatment correlates of the therapeutic alliance in the chronically depressed.
JOURNAL OF CONTEMPORARY PSYCHOTHERAPY
2002; 32 (4): 281-290
View details for DOI 10.1023/A:1020524910971
Is clinical depression distinct from subthreshold depressive symptoms? A review of the continuity issue in depression research
JOURNAL OF NERVOUS AND MENTAL DISEASE
2001; 189 (8): 498-506
Resolving whether subthreshold depressive symptoms exist on a continuum with unipolar clinical depression is important for progress on both theoretical and applied issues. To date, most studies have found that individuals with subthreshold depressive symptoms resemble cases of major depressive disorder along many important dimensions (e.g., in terms of patterns of functional impairment, psychiatric and physical comorbidity, familiality, sleeping EEG, and risk of future major depression). However, such manifest similarities do not rule out the possibility of a latent qualitative difference between subthreshold and diagnosable depression. Formal taxonomic analyses, intended to resolve the possibility of a latent qualitative distinction, have so far yielded contradictory findings. Several large-sample latent class analyses (LCA) have identified latent clinical and nonclinical classes of unipolar depression, but LCA is vulnerable to identification of spurious classes. Paul Meehl's taxometric methods provide a potentially conservative alternative way to identify latent classes. The one comprehensive taxometric analysis reported to date suggests that self-report depression symptoms occur along a latent continuum but exclusive reliance on self-report depression measures and incomplete information regarding sample base rates of depression makes it difficult to draw strong inferences from that report. We conclude that although most of the evidence at this time appears to favor both a manifest and latent continuum of unipolar depression symptomatology, several important issues remain unresolved. Complete resolution of the continuity question would be speeded by the application of both taxometric techniques and LCA to a single large sample with a known base rate of lifetime diagnosed depressives.
View details for Web of Science ID 000170618200002
View details for PubMedID 11531201
Emotional experiencing: To facilitate or regulate?
JOURNAL OF CLINICAL PSYCHOLOGY
2001; 57 (2): 157-168
In the preceding several decades, both empirical research and advances in the theoretical literatures of diverse schools of thought suggest that greater client in-session emotional experiencing is related to therapeutic change. What has yet to be explored and explicated are the variables that indicate when, and with whom, facilitating emotional experiencing may be most and least helpful. This article offers an exploration of the clinical and empirical literatures that bear on this issue. It also suggests preliminary client and therapist variables that point either toward or away from the therapeutic facilitation of client emotional experiencing.
View details for Web of Science ID 000166758700003
View details for PubMedID 11180144
- Private high school students are at risk for bulimic pathology. EATING DISORDERS: THE JOURNAL OF TREATMENT AND PREVENTION 2001; 9: 125-139
Severity of child maltreatment, pain complaints and medical utilization among women
JOURNAL OF PSYCHIATRIC RESEARCH
2000; 34 (6): 413-421
High medical utilization in adults has been linked to both reported history of childhood abuse and mental health problems. However, few studies have explored relationships between abuse severity and psychological distress to identify subgroups with unique utilization patterns and medical complaints. This study compared two groups of psychologically distressed, high utilizers. One group (DS) was comprised of those with psychological distress, who reported a history of child sexual abuse (CSA); the other group (DSP) consisted of those with psychological distress, who reported CSA plus a history of childhood physical abuse. The groups were compared on severity of sexual and nonsexual child maltreatment, medical complaints and medical utilization. From a convenience sample of 206 females age 20-63, recruited while waiting for a physician appointment in a primary care clinic, we compared 25 DSPs to 33 DSs. Compared with DSs, DSPs reported significantly more severe: (1) sexual abuse including completed intercourse; (2) emotional abuse; (3) emotional neglect; and (4) psychological distress. DSPs also showed a nonsignificant trend towards more severe physical neglect. In addition to being significantly higher on emergency room visits, DSPs were marginally higher than DSs on nonpsychiatric outpatient visits. DSPs had significantly more frequent chronic and acute pain complaints at emergency room (ER) visits. Headaches were the most frequently coded diagnosis at ER visits in this sample. DSPs accounted for 89% of these ER visits attributable to headaches. The interaction of psychological distress and reported severity of child maltreatment reveals subgroups with unique utilization patterns and medical complaints. Physicians should screen patients for child maltreatment severity and psychological distress and should be involved in mental health referral where necessary.
View details for Web of Science ID 000167473400006
View details for PubMedID 11165309
The relationship of childhood sexual abuse and depression with somatic symptoms and medical utilization
2000; 30 (5): 1063-1077
Previous research suggests that childhood sexual abuse is associated with high rates of retrospectively reported medical utilization and medical problems as an adult. The goal of this study was to determine if abused females have higher rates of medical utilization using self-report and objective measures, compared with non-abused females. A further goal was to determine whether findings of prior research would be replicated when childhood physical abuse level was controlled. This study also examined the moderating impact of depressed mood on current health measures in this population.Six hundred and eight women recruited from a health maintenance organization completed self-report measures of health symptoms for the previous month and doctor visits for the previous year. Objective doctor records over a 2 year period were examined for a subset of 136 of these women.Results showed significantly more self-reported health symptoms and more self-reported doctor visits in abused participants compared with those who reported no childhood history of sexual abuse. Objective doctor visits demonstrated the same pattern with abused participants exhibiting more visits related to out-patient surgery and out-patient internal medicine. In addition, persons who were both sexually abused and depressed tended to visit the emergency room more frequently and to have more in-patient internal medicine and ophthalmology visits than sexually abused participants who reported low depressed mood and non-abused controls.These results replicate prior studies and suggest that current depression may moderate the relationship between sexual abuse and medical problems in adulthood.
View details for Web of Science ID 000089305800007
View details for PubMedID 12027043
- Psychologists' beliefs and clinical characteristics: Judging the veracity of childhood sexual abuse memories PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2000; 31 (4): 372-377
- A brief screening instrument to detect psychological distress in primary care settings. MEDICINE AND PSYCHIATRY 2000; 3: 17-22
Childhood sexual abuse, psychological distress, and medical use among women
1999; 61 (6): 762-770
This study examined the relationships between reported history of childhood sexual abuse (CSA), psychological distress, and medical utilization among women in a health maintenance organization (HMO) setting.Participants were 206 women aged 20 to 63 years who were recruited from an HMO primary care clinic waiting area. Participants were classified, using screening questionnaires and the revised Symptom Checklist 90, as 1) CSA-distressed, 2) distressed only, 3) CSA only, or 4) control participants. Medical utilization rates were generated from the computerized database of the HMO for 1) nonpsychiatric outpatient, 2) psychiatric outpatient, 3) emergency room (ER), and 4) inpatient admissions.CSA-distressed and distressed only groups both used significantly more nonpsychiatric outpatient visits than CSA only and control participants but were not different from one another. CSA only and control participants did not differ on nonpsychiatric outpatient utilization. CSA-distressed participants used significantly more ER visits and were more likely to visit the ER for pain-related complaints than other participants. Among CSA-distressed participants, those who met criteria for physical abuse had significantly more ER visits than those who did not. There were no differences among the four groups in inpatient utilization rates.Psychological distress is associated with higher outpatient medical utilization, independent of CSA history. History of CSA with concomitant psychological distress is associated with significantly higher ER visits, particularly for those with a history of physical abuse. History of CSA without distress is not associated with elevated rates of medical utilization. Screening for psychological distress, CSA, and physical abuse may help to identify distinct subgroups with unique utilization patterns.
View details for Web of Science ID 000083881700007
View details for PubMedID 10593627
Psychotherapy for depression: Current and future directions in research, theory, practice and public policy
JOURNAL OF CLINICAL PSYCHOLOGY
1999; 55 (11): 1347-1370
This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.
View details for Web of Science ID 000083492500003
View details for PubMedID 10599825
Psychologists' beliefs about the prevalence of childhood sexual abuse: The influence of sexual abuse history, gender, and theoretical orientation
CHILD ABUSE & NEGLECT
1999; 23 (8): 803-811
This study examined the influence of sexual abuse history, gender, theoretical orientation, and age on beliefs about the prevalence of childhood sexual abuse among clinical and counseling psychologists.A mail survey design was used in this study. Participants were randomly selected from the American Psychological Association membership database. There were 615 psychologists who completed self-report measures on beliefs about the prevalence of childhood sexual abuse and demographic characteristics.Overall, clinicians' scores on the prevalence of childhood sexual abuse were moderate. There were significant gender differences on beliefs, suggesting that women were more likely believe that childhood sexual abuse is a common occurrence compared to men. Multiple regression analysis indicated that clinician characteristics (history of sexual abuse, gender, and theoretical orientation) were significantly related to beliefs about the prevalence of childhood sexual abuse. However, these characteristics only accounted for a small amount of the overall variance predicting beliefs.These results suggest that clinicians do not hold extreme beliefs regarding the prevalence of childhood sexual abuse. Moreover, certain clinician characteristics are associated with their beliefs, which in turn, may impact their clinical judgment and treatment decisions. Furthermore, much of the variance was unaccounted for in the model indicating that psychologists' beliefs are complex and are not unduly influenced by their personal characteristics. Implications for clinical practice and future research are discussed.
View details for Web of Science ID 000081643300008
View details for PubMedID 10477240
- Eating disorders - Introduction JOURNAL OF CLINICAL PSYCHOLOGY 1999; 55 (6): 669-674
Why are empirically supported treatments for bulimia nervosa underutilized and what can we do about it?
JOURNAL OF CLINICAL PSYCHOLOGY
1999; 55 (6): 769-779
Empirically supported therapies for bulimia nervosa, as well as for other disorders, are rarely utilized. Underutilization is frequently attributed to doubts among psychotherapists about the value of randomized controlled trials and professional resistance to the perceived constraints of manualized therapy. However, controversies about the usefulness of empirically supported therapies have been shaped by lack of access to adequate training and inexperience in delivering these treatments. A proposal for expanding training opportunities is presented along with discussion about how more intensive training for the practicing therapist would affect current controversies regarding the value and relevance of empirically supported therapies for bulimia nervosa and other disorders.
View details for Web of Science ID 000080671000009
View details for PubMedID 10445866
- Premanarcheal versus postmanarcheal anorexia nervosa: a comparative study. CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 1999; 4: 403-414
The effects of extending cognitive-behavioral therapy for binge eating disorder among initial treatment nonresponders
INTERNATIONAL JOURNAL OF EATING DISORDERS
1997; 21 (4): 347-352
The study was designed with the aim of determining whether extending group cognitive-behavioral therapy (CBT) would enhance outcome among individuals with binge eating disorder (BED) who failed to stop binge eating after an initial 12-week CBT intervention.Forty-six participants who met diagnostic criteria for BED were randomly allocated to either a 12-week group CBT intervention or a waiting list control condition. At the end of 12 weeks, treated participants who met clinical criteria for improvement subsequently received 12 sessions of behavioral weight loss. Remaining participants received 12 additional sessions of CBT for binge eating.Fifty percent of treated participants improved with the initial 12-week course of CBT. There was a strong trend for the extension of CBT to affect improvement in binge eating among initial nonresponders (6 of 14 subjects no longer met diagnostic criteria for BED). Overall, extending CBT led to clinical improvement in 66.7% of all treated participants, with treatment gains occurring through session 20.The results suggest that an extended course of CBT (i.e., longer than 12 weeks) will likely maximize the number of potential responders to treatment.
View details for Web of Science ID A1997WV96800007
View details for PubMedID 9138046
One-year follow-up of cognitive-behavioral therapy for obese individuals with binge eating disorder
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1997; 65 (2): 343-347
The results of a 1-year posttreatment follow-up of 93 obese women diagnosed as having binge eating disorder (BED) and treated with group cognitive-behavioral therapy (CBT) followed by weight loss treatment are described. The group as a whole maintained both reductions in binge eating and abstinence rates fairly well. However, they regained the weight lost during treatment. Those who stopped binge eating during CBT maintained a weight loss of 4.0 kg over the follow-up period. In contrast, those who continued to binge gained 3.6 kg. Twenty-six percent of those abstinent after CBT met criteria for BED at follow-up and had gained weight, whereas the remaining 74% had lost weight. Stopping binge eating appears critical to sustained weight loss in BED.
View details for Web of Science ID A1997WP24900019
View details for PubMedID 9086701
- Psychotherapy of anorexia and bulimia nervosa Bailliere's Clinical Psychiatry: Eating disorders. In D Jimmerson, W Kay (Eds). London: W.B. Saunders. 1997: 235–257
The aversiveness of specific emotional states associated with binge-eating in obese subjects
AUSTRALIAN AND NEW ZEALAND JOURNAL OF PSYCHIATRY
1996; 30 (6): 839-844
The aim of this study was to examine the hypothesis that non-purge-related binge-eating in obesity is maintained by a 'trade-off' in which a highly aversive emotional state is exchanged for a less aversive state.Ninety-eight obese binge-eaters meeting the DSM-IV criteria for binge-eating disorder were contrasted with 65 non-binge-eating controls on their perceived distress associated with negative mood states usually experienced before and after binges.Binge-eaters reported significantly greater distress and lower tolerance of negative mood compared to controls. Furthermore, when compared with controls, binge-eaters reported that emotions typically reported before binges (e.g. anger) were more aversive than those reported after (e.g. guilt).These results were interpreted as supporting the 'trade-off' theory and have implications for the treatment of binge-eating disorder.
View details for Web of Science ID A1996WC06500020
View details for PubMedID 9034475
Maintenance following a very-low-calorie diet
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1996; 64 (3): 610-613
The authors posed 2 questions in this randomized study of maintenance procedures in which participants were followed for 15 months after completion of a very-low-calorie diet: Would stimulus narrowing during the reintroduction of solid food, achieved by the use of prepackaged foods, improve weight losses and the maintenance of those losses as compared with the use of regular food? Would reintroduction of foods dependent on progress in losing or maintaining weight be superior to reintroduction on a time-dependent basis? Neither the stimulus narrowing condition nor the reintroduction procedure enhanced either maximum weight loss or maintenance of those losses. The stimulus narrowing condition appeared to be poorly tolerated; compliance and attendance were poorer in this condition than in the regular food condition.
View details for PubMedID 8698956
- Treatment goals and strategies of cognitive-behavioral and psychodynamic therapists: a naturalistic investigation. JOURNAL OF PSYCHOTHERAPY INTEGRATION 1996; 6: 333-347
- Cognitive-behavioral therapy for bulimia nervosa. Treating Eating Disorders. In J Werne, (Ed) San Francisco, CA: Jossey-Bass. 1996: 101–141
COMPARING THE COST-EFFECTIVENESS OF PSYCHIATRIC TREATMENTS - BULIMIA-NERVOSA
1995; 58 (1): 13-21
We conducted an exploratory post hoc study that compared the cost effectiveness of five treatments for bulimia nervosa: 15 weeks of cognitive behavioral therapy (CB) followed by three monthly sessions, 16 weeks (Med16) and 24 weeks (Med24) of desipramine (< or = 300 mg/day), and CB combined with desipramine for those durations (Combo16 and Combo24). We illustrate how a treatment's cost effectiveness varies according to when evaluation is done and how effectiveness and cost are defined. At 32 weeks, Med16 appears the most cost-effective treatment, and Combo16 appears the least. At 1 year, Med24 appears the most cost-effective treatment, and Combo16 appears the least. Using this post hoc analysis as an example, we discuss the pitfalls and limitations of cost-effectiveness analysis of psychiatric treatments.
View details for Web of Science ID A1995RW58200002
View details for PubMedID 8539308
THE EMOTIONAL EATING SCALE - THE DEVELOPMENT OF A MEASURE TO ASSESS COPING WITH NEGATIVE AFFECT BY EATING
INTERNATIONAL JOURNAL OF EATING DISORDERS
1995; 18 (1): 79-90
The development of the Emotional Eating Scale (EES) is described. The factor solution replicated the scale's construction, revealing Anger/Frustration, Anxiety, and Depression subscales. All three subscales correlated highly with measures of binge eating, providing evidence of construct validity. None of the EES subscales correlated significantly with general measures of psychopathology. With few exceptions, changes in EES subscales correlated with treatment-related changes in binge eating. In support of the measure's discriminant efficiency, when compared with obese binge eaters, subscale scores of a sample of anxiety-disordered patients were significantly lower. Lack of correlation between a measure of cognitive restraint and EES subscales suggests that emotional eating may precipitate binge episodes among the obese independent of the level of restraint.
View details for Web of Science ID A1995RE82800008
View details for PubMedID 7670446
DOES INTERPERSONAL THERAPY HELP PATIENTS WITH BINGE-EATING DISORDER WHO FAIL TO RESPOND TO COGNITIVE-BEHAVIORAL THERAPY
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1995; 63 (3): 356-360
The aim of this quasi-experimental study was to examine the effectiveness of group interpersonal therapy (IPT) in treating overweight patients with binge eating disorder who did not stop binge eating after 12 weeks of group cognitive-behavioral therapy (CBT). Participants in this study were randomly allocated to either group CBT or to an assessment-only control group. After 12 weeks of treatment with CBT, 55% of participants met criteria for improvement and began 12 weeks of weight loss therapy, whereas the nonresponders began 12 weeks of group IPT. Over the 24-week period, participants who received treatment reduced binge eating and weight significantly more than the waiting-list control group. However, IPT led to no further improvement for those who did not improve with CBT. Predictors of poor outcome were early onset of, and more severe, binge eating.
View details for PubMedID 7608347
- When weight becomes an obsession. HEALTHLINE - SAINT LOUIS - 1995; 14: 6-7
THE LAST-SUPPER - EMOTIONAL DETERMINANTS OF PRETREATMENT WEIGHT FLUCTUATION OBESE BINGE EATERS
INTERNATIONAL JOURNAL OF EATING DISORDERS
1994; 16 (1): 83-88
The tendency of some dieters to overeat and gain weight prior to beginning a diet is well known. We examined whether emotional variables might account for this phenomenon among a group of 86 obese individuals preparing to begin a treatment program for binge eating and weight loss. Whereas subjects' baseline mood state (anger, anxiety, and depression) did not influence pretreatment weight variability, the self-reported tendency to overeat in response to specific negative emotions had a significant influence. Specifically, subjects who characteristically overeat in response to anger and depression gained weight pretreatment, whereas subjects who overeat in response to anxiety lost weight. The findings are discussed in relation to the influence of specific cognitive and emotional responses to the prospect of dieting.
View details for Web of Science ID A1994NU24300008
View details for PubMedID 7920585
ONE-YEAR FOLLOW-UP OF PSYCHOSOCIAL AND PHARMACOLOGICAL TREATMENTS FOR BULIMIA-NERVOSA
JOURNAL OF CLINICAL PSYCHIATRY
1994; 55 (5): 179-183
This study examined the outcome 1-year posttreatment of the use of desipramine, cognitive-behavioral therapy (CBT), and their combination in the treatment of bulimia nervosa.Sixty-one patients meeting DSM-III-R criteria for bulimia nervosa were randomly assigned to one of five groups--desipramine (withdrawn at 16 or 24 weeks), CBT (18 sessions), or the combined treatment (18 sessions of CBT plus desipramine withdrawn at 16 or 24 weeks)--and were followed to 1-year posttreatment.At 1-year follow-up, both the combined 24-week treatment and CBT alone were significantly superior in reducing binge eating to desipramine given for 16 weeks. The combined treatment was also superior to 16 weeks of desipramine in reducing emotionally driven eating and dietary restraint. Only 18% (2 of 11) of those receiving 16 weeks of desipramine were free of binge eating and purging at follow-up compared with 78% (7 of 9) of those receiving the combined 24-week treatment. The other groups fell between these two extremes.With the exception of the group treated for 16 weeks with desipramine alone, maintenance of improvement appeared satisfactory with all the treatments. Since the poorest results were found with 16 weeks of desipramine treatment, this study suggests that desipramine should be continued for at least 24 weeks either alone or combined with CBT. The broadest gain in reducing the psychopathology associated with bulimia nervosa was found with the combined 24-week treatment.
View details for Web of Science ID A1994NQ97600001
View details for PubMedID 8071266
WEIGHT-LOSS, COGNITIVE-BEHAVIORAL, AND DESIPRAMINE TREATMENTS IN BINGE-EATING DISORDER - AN ADDITIVE DESIGN
1994; 25 (2): 225-238
View details for Web of Science ID A1994NQ42700005
BINGE EATING AMONG THE OBESE - A DESCRIPTIVE STUDY
JOURNAL OF BEHAVIORAL MEDICINE
1992; 15 (2): 155-170
Nineteen obese females applying for treatment for binge eating were administered a semistructured interview assessing the presence or absence of food restrictions, thoughts, feelings and physical sensations associated with binges, typical precipitants to binges, and factors identified as useful in avoiding binge eating. Both negative mood and abstinence violations emerged as important precipitants. The results also suggested that these precipitants constitute separate, independent pathways to binge eating. Implications of these findings with respect to restraint theory are discussed.
View details for Web of Science ID A1992HR49400004
View details for PubMedID 1583679
PHARMACOLOGICAL AND COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA-NERVOSA - A CONTROLLED COMPARISON
AMERICAN JOURNAL OF PSYCHIATRY
1992; 149 (1): 82-87
This study examined the relative effectiveness of desipramine, cognitive-behavioral therapy, and their combination in the treatment of bulimia nervosa, together with the effects of withdrawing medication after two different lengths of treatment.Seventy-one patients meeting DSM-III-R criteria for bulimia nervosa, recruited from an eating disorders clinic or by advertisements, were assigned at random to one of five groups: desipramine (withdrawn at 16 or 24 weeks), combined treatment (medication withdrawn at 16 or 24 weeks), and cognitive-behavioral therapy (15 sessions). All treatments were conducted individually in an outpatient clinic. The primary outcome measures were binge eating and purging rates assessed at pretreatment, 16, 24, and 32 weeks. The results were analyzed as three groups (medication, cognitive-behavioral therapy, and combined treatment) at 16 weeks and as five groups at subsequent assessments.At 16 weeks, both cognitive-behavioral therapy and the combined treatment were superior to medication given for 16 weeks in reducing binge eating and purging. At 32 weeks, however, only the combined 24-week treatment was superior to medication given for 16 weeks. The combined treatment was also more effective in reducing dietary preoccupation and hunger. Continuing cognitive-behavioral therapy appeared to prevent relapse in patients withdrawn from medication at 16 weeks.Overall, the results favor the use of a combination of medication and cognitive-behavioral therapy in the treatment of bulimia nervosa, with medication continued for at least 24 weeks.
View details for Web of Science ID A1992GX04000012
View details for PubMedID 1728190
GUTTMAN SCALING IN AGORAPHOBIA - CROSS-CULTURAL REPLICATION AND PREDICTION OF TREATMENT RESPONSE PATTERNS
BRITISH JOURNAL OF CLINICAL PSYCHOLOGY
1990; 29: 37-41
The Fear and Avoidance Scales (FAS) is an 11-item questionnaire consisting of two subscales that measure features of agoraphobia and claustrophobia and that were demonstrated to be valid Guttman scales in a British clinical population. The purposes of the study reported here were to replicate the scale characteristics in the United States and to determine if improvement during treatment would follow the sequence predicted by the hierarchy implied in the scales. The FAS was given to 25 female agoraphobics before and after behavioural treatment. A principal components analysis replicated the agoraphobia and claustrophobia factors established in the British sample. Scalogram analyses showed that the Claustrophobia subscale of the FAS was a valid Guttman scale in the US sample whereas the Agoraphobia subscale yielded a high coefficient of reproducibility but a low coefficient of scalability. Treatment reduced the patients' fears and avoidances in the predicted sequence since for both scales the hierarchy of items remained unchanged following treatment.
View details for Web of Science ID A1990CP17400004
View details for PubMedID 2310869
- Psychological treatment of binge eating. HEALTHLINE - SAINT LOUIS- 1990; 9: 2-4
COGNITIVE BEHAVIORAL TREATMENT WITH AND WITHOUT EXPOSURE PLUS RESPONSE PREVENTION IN THE TREATMENT OF BULIMIA NERVOSA - A REPLY
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1989; 57 (6): 778-779
In this reply to Leitenberg and Rosen (1989), we conclude that the evidence that response prevention of vomiting adds significantly to the efficacy of cognitive-behavioral treatment of bulimia nervosa is not strong. In this context and given the finding in our previous study (Agras, Schneider, Arnow, Raeburn, & Telch, 1989) that the addition of response prevention did not increase the efficacy of cognitive-behavioral treatment and may have reduced it, we believe that our cautionary note concerning the addition of response prevention to cognitive-behavioral treatment should stand.
View details for Web of Science ID A1989CE89900016
View details for PubMedID 2600251
COGNITIVE-BEHAVIORAL AND RESPONSE-PREVENTION TREATMENTS FOR BULIMIA NERVOSA
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
1989; 57 (2): 215-221
This study was designed to assess the additive effects of major components of cognitive-behavioral treatment for bulimia nervosa. Seventy-seven female patients with bulimia nervosa were allocated at random to one of four conditions: wait-list control, self-monitoring of caloric intake and purging behaviors, cognitive-behavioral treatment, and cognitive-behavioral treatment combined with response prevention of vomiting. In the treatment conditions, participants were seen individually for fourteen 1-hr sessions over a 4-month period. All the treatment groups showed significant improvement, whereas the wait-list control group did not. Cognitive-behavioral treatment was, however, the most successful in reducing purging and in promoting positive psychological changes. Fifty-six percent of participants in this condition ceased binge eating and purging by the end of treatment, and the frequency of purging declined by 77.2% during the same period. Of the three treatment conditions, only cognitive-behavioral treatment was superior to the wait-list control. At the 6-month follow-up, 59% of the cognitive-behavioral group were abstinent, and purging had declined by 80%. Cognitive-behavioral treatment was significantly superior to the other treatment groups at this time. Thus, the addition of response prevention of vomiting did not enhance the efficacy of cognitive-behavioral treatment, and the evidence suggests that it may have had a deleterious effect.
View details for Web of Science ID A1989T859000004
View details for PubMedID 2708607
- Psychological treatment of social phobia. THE PSYCHIATRIC TIMES 1989; 6 (7): 6-7
- The nature and treatment of anxiety disorders New York: The Free Press. 1989
EMOTIONAL AND TEMPERAMENTAL CORRELATES OF TYPE-A IN CHILDREN AND ADOLESCENTS
JOURNAL OF YOUTH AND ADOLESCENCE
1988; 17 (6): 461-475
Emotional and behavioral correlates of Type A behavior in children and adolescents were examined in 184 fifth-, seventh-, and ninth-grade students, classified as high or low Type A, using self-report, teacher ratings (fifth grade only), and structured interview procedures. Measures included the Hunter-Wolf A-B Rating Scale, Behavioral Symptoms of Stress Inventory, Dimensions of Temperament Survey, Desire for Control Scale, Eysenck Personality Inventory, and the Multiple Affect Adjective Checklist. High Type A children reported significantly more stressed-related behaviors, higher levels of depression, anger, anxiety, and cognitive disorganization, and greater reactivity than Low Type A. No differences were found on measures of temperament (activity level, attention span, adaptibility, and rhythmicity), desire for control, or introversion-extroversion. Females, in general, reported significantly more behavioral stress symptoms. However, no other gender differences were found. Possible reasons for reported differences between Type A children and adults are discussed, along with gender differences in behavioral symptoms. Need for multiple measures of Type A across situation is considered along with need for controlled longitudinal studies of Type A components and the influence of contexts.
View details for Web of Science ID A1988R653700001
- Behavioral treatment of obesity Handbook of studies on obesity. In GD Burrows, PJV Beaumont, R Casper (Eds.) Amsterdam: Elsevier Science Publishers. 1988
DEVELOPING MEASURES OF TYPE-A BEHAVIOR IN CHILDREN AND ADOLESCENTS
JOURNAL OF HUMAN STRESS
1987; 13 (1): 5-15
Development of measures of Type A behavior in children and adolescents is described and the results of two studies to validate these measures are given. Children in the fifth, seventh, and ninth grades (n = 120 in Study I; n = 652 in Study II) were given five measures of the Type A Behavior Pattern (TABP): the Student Type A Behavior Scale (STABS); Student Structured Interviews (SSI), scored separately for content and behavior; Matthews Youth Test for Health (MYTH); and Parent Observation Checklist, as well as measures of state anxiety, trait anxiety, and depression. Descriptive statistics from the two samples were very similar and indicated that boys scored significantly higher than girls on the MYTH, while seventh and ninth grade girls scored significantly higher than fifth grade girls or boys of any grade on Structured Interview Behavior (SSI-Behavior). Correlations suggested separate self-reported perceptual and behavioral components of Type A behavior in children. In both studies, STABS and SSI-Content correlated moderately well (.48 to .49) but had little relationship with SI-Behavior and the MYTH. Measures of anxiety and depression included to assess discriminant validity were correlated with the self-report measures of TABP (.22 to .56), but showed little relationship with the behavioral measures, especially in the larger cross-validation study. Parallels between these results and those of adult studies are discussed, and the use of multiple measures in classifying subjects is suggested.
View details for Web of Science ID A1987H108200001
View details for PubMedID 3584960
Imipramine in the treatment of bulimia: a double-blind controlled study.
INTERNATIONAL JOURNAL OF EATING DISORDERS
1987; 6 (1): 29-38
View details for DOI 10.1002/1098-108X(198701)6:1<29::AID-EAT2260060105>3.0.CO;2-2
PHYSICAL HEALTH CORRELATES OF TYPE-A BEHAVIOR IN CHILDREN AND ADOLESCENTS
JOURNAL OF BEHAVIORAL MEDICINE
1986; 9 (4): 341-362
A physical examination including resting blood pressure, heart rate, Tanner scales, height, and weight was administered to 184 students in the fifth, seventh, and ninth grades. They completed the Physical Symptoms of Stress Inventory, Health Habits Inventory, and two self-monitoring logs of physical symptoms. School absenteeism, medical records, physician ratings, and family health history data were collected. No significant differences between high- and low-Type A behavior pattern (TABP) subjects were found on any of the physical measurements. However, retrospective and prospective reports of physical symptoms revealed a consistent pattern: high TABP subjects reported significantly more physical symptoms than low-TABP subjects. Self-ratings of stress and tension were significantly higher for high-TABP subjects. High-TABP subjects, however, neither missed more school because of illness nor used physician services more often than low subjects. Further, expected relationships between physical symptoms and illness behavior, including school absence, were evident only for low subjects.
View details for Web of Science ID A1986D851300002
View details for PubMedID 3746902
ADULT PSYCHOPATHOLOGY AND DIAGNOSIS - TURNER,SM, HERSEN,M (Book Review)
1986; 8 (1): 108-109
View details for Web of Science ID A1986AVV5300008
- Enhancing agoraphobia treatment outcome by changing couple communication patterns. BEHAVIOR THERAPY 1985; 16: 452-467