Publications by authors named "Robin B Jarrett"

72 Publications

Advancing health through research: A scoping review of and model for adjunctive psychosocial interventions to improve outcomes for perinatal women with bipolar disorder.

J Affect Disord 2021 Nov 18;294:586-591. Epub 2021 Jul 18.

Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, United States. Electronic address:

Background: We aimed to identify randomized clinical trials (RCTs) which evaluated the efficacy of adjunctive psychosocial interventions to improve outcomes during the perinatal period for women with bipolar disorder (BD).

Methods: We scanned the literature to identify RCTs evaluating the efficacy of adjunctive psychosocial therapies or interventions provided during the perinatal period to women with BD. We searched from 1946 to July 2020 using Embase, Ovid Medline, PsycINFO, and Scopus. We then searched for future, current, and recently completed RCTs described on www.ClinicalTrials.gov.

Results: This scoping review (1946 - July 2020) revealed no published RCTs for this population. The findings expose an important gap in research and knowledge, as well as a health disparity.

Conclusion: We heuristically tied a mechanistic stress reduction model to relevant findings. The initial hypotheses are informed by effective stress reducing psychosocial interventions for: a) people with BD outside the perinatal period and b) perinatal women with major depressive disorder (MDD may improve the health of perinatal women with BD). We hypothesize that the perinatal trajectory of health for women with BD will improve by adding psychosocial interventions or therapies to treatment as usual. We propose maternal stress reduction as a potential mediator/mechanism.

Limitations: Findings reported are limited to the methods of a scoping review. Reproductive status tends to be a missing variable; we highlight the need for its inclusion. Interdisciplinary, collaborative research to improve the treatment outcome for perinatal women with BD is warranted and ripe for advancement.
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http://dx.doi.org/10.1016/j.jad.2021.07.024DOI Listing
November 2021

Mindful Self-Care for Caregivers: A Proof of Concept Study Investigating a Model for Embedded Caregiver Support in a Pediatric Setting.

J Autism Dev Disord 2021 Jun 9. Epub 2021 Jun 9.

Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 9086, Dallas, TX, 75390, USA.

We conducted an open-trial proof of concept study to determine the safety, acceptability, and feasibility of Mindful Self-Care for Caregivers (MSCC) for parents of children with Autism Spectrum Disorders (ASD) (N = 13). The intervention was offered as a co-located care model in a pediatric specialty center where the participants' children received care. Results demonstrated that the intervention was: highly acceptable to all stakeholders (i.e., participants, the group facilitator, and center administration) and could be conducted safely by a masters-level practitioner with minimal resources. Further, secondary measures support a hypothesized interventional model of MSCC, demonstrating gains in mindfulness skills and sense of competency in the parenting role reduced perceived stress and depression in parents of children with ASD.
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http://dx.doi.org/10.1007/s10803-021-05113-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189552PMC
June 2021

Stability and Change in Relations Between Personality Traits and the Interpersonal Problems Circumplex During Cognitive Therapy for Recurrent Depression.

Assessment 2021 Apr 2:10731911211005183. Epub 2021 Apr 2.

The University of Texas Southwestern Medical Center, Dallas, TX, USA.

Both personality impairment and maladaptive-range traits are necessary for diagnosis in the alternative model of personality disorder. We clarified personality impairment-trait connections using measures of the interpersonal problems circumplex and personality traits among adult outpatients ( = 351) with major depressive disorder receiving cognitive therapy (CT). The trait scales' circumplex projections were summarized by elevation (correlations with general interpersonal problems), amplitude (specific relations to the circumplex dimensions of dominance and affiliation), and angle (predominant orientation in the two-dimensional circumplex). Most trait scales showed hypothesized circumplex relations, including substantive elevation (e.g., negative temperament, mistrust), amplitude (e.g., aggression, detachment), and expected angles (e.g., positive temperament and manipulativeness oriented toward overly nurturant/intrusive or domineering/vindictive problems, respectively), that were stable across time during CT. These results revealed meaningful and consistent impairment-trait connections, even during CT when mean depressive affect decreased substantially.
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http://dx.doi.org/10.1177/10731911211005183DOI Listing
April 2021

Assessment of patient and provider attitudes towards therapeutic drug monitoring to improve medication adherence in low-income patients with hypertension: a qualitative study.

BMJ Open 2020 11 27;10(11):e039940. Epub 2020 Nov 27.

Hypertension Section, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States

Objectives: Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM.

Design: Prospective analysis of responses to a set of questions during semistructured interviews.

Setting: Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population.

Participants: Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics.

Primary And Secondary Outcome Measures: Attitudes towards TDM and the potential impact on physician-patient relationship.

Results: We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician-patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks.

Conclusion: The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient-physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.
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http://dx.doi.org/10.1136/bmjopen-2020-039940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703422PMC
November 2020

Quality of life after response to acute-phase cognitive therapy for recurrent depression.

J Affect Disord 2021 01 15;278:218-225. Epub 2020 Sep 15.

Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA. Electronic address:

Background: Adults with major depressive disorder (MDD) often experience reduced quality of life (QOL). Efficacious acute-phase treatments, including cognitive therapy (CT) or medication, decrease depressive symptoms and, to a lesser degree, increase QOL. We tested longer-term changes in QOL after response to acute-phase CT, including the potential effects of continuation treatment for depression and time-lagged relations between QOL and depressive symptoms.

Methods: Responders to acute-phase CT (N = 290) completed QOL and depressive symptom assessments repeatedly for 32 post-acute months. Higher-risk responders were randomized to 8 months of continuation treatment (CT, fluoxetine, or pill placebo) and then entered a 24-month follow-up. Lower-risk responders were only assessed for 32 months.

Results: On average, large gains in QOL made during acute-phase CT response were maintained for 32 months. Continuation CT or fluoxetine did not improve QOL relative to pill placebo. Controlling for residual depressive symptoms, higher QOL after acute-phase CT response was a protective factor against MDD relapse and recurrence. Higher QOL predicted subsequent reductions in depressive symptom severity, but depressive symptom severity did not predict subsequent changes in QOL.

Limitations: Generalization of results to other patient populations, treatments, and measures is uncertain. The clinical trial was not designed to test relations between QOL and depression. Replication is needed before clinical application of these results.

Conclusions: Gains in QOL made during response to acute-phase CT are relatively stable and may help protect against relapse/recurrence. Continuation CT or fluoxetine may not further improve QOL among acute-phase CT responders.
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http://dx.doi.org/10.1016/j.jad.2020.09.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704560PMC
January 2021

Psychometric properties of the Marital Adjustment Scale during cognitive therapy for depression: New research opportunities.

Psychol Assess 2020 Nov 27;32(11):1028-1036. Epub 2020 Aug 27.

Department of Psychiatry.

Poor dyadic adjustment in marital or similar relationships is common among patients seeking individual cognitive therapy (CT) for major depressive disorder (MDD). Here we examined the psychometric properties of the marital adjustment subscale (MAS) of the Social Adjustment Scale-Self-report (SAS-SR; Weissman & Bothwell, 1976). Among married or cohabiting patients receiving individual CT for recurrent MDD ( = 306) in the context of two randomized controlled trials, the MAS demonstrated moderate internal consistency and test-retest reliability, strong convergence with the Dyadic Adjustment Scale (Spanier, 1976), and moderate relations with interpersonal problems and depressive symptoms. Controlling baseline depressive symptom severity, greater pre-CT relationship discord on the MAS predicted less reduction in depressive symptom severity and lower odds of depression remission during CT. These results support the reliability, validity, and potential utility of the MAS. Using the MAS may help investigators "mine" existing data sets including the SAS-SR to further understanding of dyadic functioning and its potential impact on depression treatment and other health outcomes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352069PMC
November 2020

Do Cognitive Therapy Skills Neutralize Lifetime Stress to Improve Treatment Outcomes in Recurrent Depression?

Behav Ther 2020 09 27;51(5):739-752. Epub 2019 Nov 27.

University of Texas Southwestern Medical Center. Electronic address:

Cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but not all patients respond. Past research suggests that stressful life events (SLE; e.g., childhood maltreatment, emotional and physical abuse, relationship discord, physical illness) sometimes reduce the efficacy of depression treatment, whereas greater acquisition and use of CT skills may improve patient outcomes. In a sample of 276 outpatient participants with recurrent MDD, we tested the hypothesis that patients with more SLE benefit more from CT skills in attaining response and remaining free of relapse/recurrence. Patients with more pretreatment SLE did not develop weaker CT skills, on average, but were significantly less likely to respond to CT. However, SLE predicted non-response only for patients with relatively weak skills, and not for those with stronger CT skills. Similarly, among acute-phase responders, SLE increased risk for MDD relapse/recurrence among patients with weaker CT skills. Thus, the combination of more SLE and weaker CT skills forecasted negative outcomes. These novel findings are discussed in the context of improving CT for depression among patients with greater lifetime history of SLE and require replication before clinical application.
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http://dx.doi.org/10.1016/j.beth.2019.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431681PMC
September 2020

Do patients' cognitive therapy skills predict personality change during treatment of depression?

Behav Res Ther 2020 Jul 20;133:103695. Epub 2020 Jul 20.

Department of Psychiatry, The University of Texas Southwestern Medical Center, USA. Electronic address:

Background: Psychological interventions can change personality, including increasing positive temperament (extraversion) and decreasing negative temperament (neuroticism), but why these changes occur is unclear. The current study tested the extent to which patients' acquisition and use of skills taught in cognitive therapy (CT) correlated with changes in positive and negative temperament during treatment of depression.

Method: Outpatients (N = 351) with recurrent major depressive disorder (MDD) were enrolled in a 12-week CT protocol. Temperament (early and late in CT), patient skills (mid and late in CT), and depressive symptoms (early, mid, and late in CT) were measured repeatedly.

Results: Patients with greater acquisition and use of CT skills showed significantly larger increases in positive temperament and larger decreases in negative temperament in path analyses. Effect sizes were small, median standardized |beta| = 0.13. Models controlled depressive symptom levels and changes.

Conclusions: Skills taught in CT for recurrent depression correlate with personality change during this efficacious treatment. The absence of measures of CT skills at baseline and personality mid-CT allows several interpretations of the current findings. Future research is needed to clarify whether patients' use of CT skills facilitates adaptive changes in personality during CT.
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http://dx.doi.org/10.1016/j.brat.2020.103695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855535PMC
July 2020

Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry.

BMC Med 2020 06 5;18(1):170. Epub 2020 Jun 5.

Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany.

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.
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http://dx.doi.org/10.1186/s12916-020-01623-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273646PMC
June 2020

Development of a Novel Adult Congenital Heart Disease-Specific Patient-Reported Outcome Metric.

J Am Heart Assoc 2020 06 16;9(11):e015730. Epub 2020 May 16.

Department of Cardiology Mid-America Heart Institute Kansas City KS.

Background Patient-reported outcome metrics (PROs) quantify important outcomes in clinical trials and can be sensitive measures of patient experience in clinical practice. Currently, there is no validated disease-specific PRO for adults with congenital heart disease (ACHD). Methods and Results We conducted a preliminary psychometric validation of a novel ACHD PRO. ACHD patients were recruited prospectively from 2 institutions and completed a series of questionnaires, a physician health assessment, and a 6-minute walk test. Participants returned to complete the same questionnaires and assessment 3 months±2 weeks later. We tested the internal consistency and test-retest reliability by comparing responses among clinically stable patients at the 2 study visits. We assessed convergent and divergent validity by comparison of ACHD PRO responses to existing validated questionnaires. We assessed responsiveness by comparison with patient-reported clinical change. One hundred three patients completed 1 study visit and 81 completed both. The ACHD PRO demonstrated good internal consistency in each of its 5 domains (Cronbach's α: 0.87; 0.74; 0.74; 0.90; and 0.89, respectively) and in the overall summary score (0.92). Test-retest reliability was good with an intraclass correlation ≥0.73 for all domains and 0.78 for the Summary Score. The ACHD PRO accurately assessed domain concepts based on comparison with validated standards. Preliminary estimates of responsiveness suggest sensitivity to clinical status. Conclusions These studies provide initial support for the validity and reliability of the ACHD PRO. Further studies are needed to assess its sensitivity to changes in clinical status.
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http://dx.doi.org/10.1161/JAHA.119.015730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428986PMC
June 2020

Can we help more?

Authors:
Robin B Jarrett

World Psychiatry 2020 Jun;19(2):246-247

Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.

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http://dx.doi.org/10.1002/wps.20749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214946PMC
June 2020

Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression?

J Affect Disord 2020 02 31;262:323-332. Epub 2019 Oct 31.

Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, United States. Electronic address:

Background: Pre-treatment sleep disturbance has been shown to predict antidepressant treatment outcomes. How changes in sleep disturbance during acute treatment affect longitudinal outcomes, or whether continuation-phase treatment further improves sleep disturbance, is unclear.

Methods: We assessed sleep disturbance repeatedly in: a) 523 adults with recurrent MDD who consented to 12-14 weeks of acute-phase cognitive therapy (A-CT) and b) 241 A-CT responders at elevated risk for depression relapse/recurrence who were randomized to 8 months of continuation-phase treatment (CCT vs. fluoxetine vs. matched pill placebo) and followed protocol-treatment-free for 24 months. Trajectories of change in sleep and depression during and after A-CT were evaluated with multilevel models; individual intercepts and slopes were retained and input into Cox regression models to predict remission, recovery, relapse, and recurrence of MDD.

Results: Sleep disturbance improved over the course of A-CT, but most patients continued to report clinically significant sleep complaints. Response and remission were more likely in patients with less overall sleep disturbance and those with greater reduction in sleep disturbance during A-CT; these patients also achieved post-A-CT remission and recovery sooner. Sleep improvements endured throughout follow-up but were not enhanced by continuation-phase treatment. Sleep disturbance did not predict relapse or recurrence consistently.

Limitations: Objective sleep disturbance was not assessed. Analyses were not specifically powered to use sleep changes to predict outcomes.

Conclusions: Improvements in sleep disturbance during A-CT are linked to shorter times to remission and recovery, supporting consideration of monitoring and targeting sleep disturbance in adults with depression.
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http://dx.doi.org/10.1016/j.jad.2019.10.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919563PMC
February 2020

The Role of Dyadic Discord in Outcomes in Acute Phase Cognitive Therapy for Adults With Recurrent Major Depressive Disorder.

Behav Ther 2019 07 6;50(4):778-790. Epub 2018 Dec 6.

The University of Texas Southwestern Medical Center. Electronic address:

Major depressive disorder (MDD) and relationship discord between cohabiting partners frequently co-occur, with bidirectional effects established. As relationship quality influences understanding and treatment of MDD, the current analyses clarified the relations of pretreatment dyadic discord with outcomes during and at the end of acute phase cognitive therapy (CT) for adults with recurrent MDD. Married or cohabiting patients (n = 219) completed the Dyadic Adjustment Scale (DYS) before and after a 16-20 session, 12-14 week CT protocol. Lower levels of dyadic adjustment indicated higher levels of dyadic discord. Response to CT was defined as the absence of a major depressive episode and ≤ 12 on the 17-item Hamilton Rating Scale for Depression. Pretreatment dyadic discord, whether defined as a continuous or categorical variable (using DYS cutoff score of 97), was not associated with treatment completion or response but was positively associated with levels of depressive symptoms at the end of acute phase CT. Furthermore, CT was associated with declines in dyadic discord, with 23.3% of initially discordant couples moving to nondiscordant status at the end of CT. Depressive symptoms did not significantly mediate changes in dyadic discord. Finally, pre- (but not mid-) treatment dyadic discord was associated with subsequent changes in depressive symptoms, suggesting limited mediation. These findings replicate prior research indicating that individual CT is associated with reductions in depressive symptoms and dyadic discord while clarifying that lower pre-treatment dyadic discord may predict initial improvement in depressive symptoms.
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http://dx.doi.org/10.1016/j.beth.2018.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582984PMC
July 2019

Could Treatment Matching Patients' Beliefs About Depression Improve Outcomes?

Behav Ther 2019 07 8;50(4):765-777. Epub 2018 Dec 8.

The University of Texas Southwestern Medical Center. Electronic address:

Patients' beliefs about depression and expectations for treatment can influence outcomes of major depressive disorder (MDD) treatments. We hypothesized that patients with weaker biological beliefs (less endorsement of [a] biochemical causes and [b] need for medication) and more optimistic treatment expectations (greater improvement and shorter time to improvement), have better outcomes in cognitive therapy (CT). Outpatients with recurrent MDD who received acute-phase CT (N = 152), and a subset of partial or unstable responders (N = 51) randomized to 8 months of continuation CT or fluoxetine with clinical management, completed repeated measures of beliefs, expectations, and depression. As hypothesized, patients with weaker biological beliefs about depression, and patients who expected a shorter time to improvement, experienced greater change in depressive symptoms and more frequent response to acute-phase CT. Moreover, responders who received continuation treatment better matched to their biological beliefs (i.e., responders with weaker biological beliefs about depression who received continuation CT, or responders with stronger biological beliefs about depression who received continuation fluoxetine) had fewer depressive symptoms and less relapse/recurrence by 32 months after acute-phase CT than did responders who received mismatched continuation treatment. Specific screening and/or intervention targeting patients' biological beliefs about depression could increase CT efficacy.
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http://dx.doi.org/10.1016/j.beth.2018.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582988PMC
July 2019

The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis.

World Psychiatry 2019 Jun;18(2):183-191

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

A recent individual patient data meta-analysis showed that antidepressant medication is slightly more efficacious than cognitive behavioral therapy (CBT) in reducing overall depression severity in patients with a DSM-defined depressive disorder. We used an update of that dataset, based on seventeen randomized clinical trials, to examine the comparative efficacy of antidepressant medication vs. CBT in more detail by focusing on individual depressive symptoms as assessed with the 17-item Hamilton Rating Scale for Depression. Five symptoms (i.e., "depressed mood" , "feelings of guilt" , "suicidal thoughts" , "psychic anxiety" and "general somatic symptoms") showed larger improvements in the medication compared to the CBT condition (effect sizes ranging from .13 to .16), whereas no differences were found for the twelve other symptoms. In addition, network estimation techniques revealed that all effects, except that on "depressed mood" , were direct and could not be explained by any of the other direct or indirect treatment effects. Exploratory analyses showed that information about the symptom-specific efficacy could help in identifying those patients who, based on their pre-treatment symptomatology, are likely to benefit more from antidepressant medication than from CBT (effect size of .30) versus those for whom both treatments are likely to be equally efficacious. Overall, our symptom-oriented approach results in a more thorough evaluation of the efficacy of antidepressant medication over CBT and shows potential in "precision psychiatry" .
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http://dx.doi.org/10.1002/wps.20630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502416PMC
June 2019

Estimating outcome probabilities from early symptom changes in cognitive therapy for recurrent depression.

J Consult Clin Psychol 2019 Jun 22;87(6):510-520. Epub 2019 Apr 22.

Department of Psychiatry, The University of Texas Southwestern Medical Center.

Objective: Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) producing benefits comparable to pharmacotherapy, but not all patients respond or remit. The purpose of the current analyses was to estimate CT patients' probability of nonresponse and remission from symptom improvement early in treatment.

Method: Data from 2 clinical trials of acute-phase CT for recurrent depression were pooled for analysis (N = 679). Adult outpatients received 16- or 20-session CT protocols. Symptoms were measured repeatedly with the clinician-report Hamilton Rating Scale for Depression (HRSD) and Inventory of Depressive Symptomatology-Self-Report (IDS-SR). Outcomes at exit from CT were nonresponse (<50% reduction in HRSD scores) and remission (no MDD and HRSD score ≤6).

Results: The nonresponse rate was 45.7%, and the remission rate was 33.4%. In logistic regression models, improvements on the HRSD or IDS-SR from intake to CT Sessions 3, 5, 7, 9, or 11 significantly predicted both outcomes, with prediction gaining in accuracy in later sessions. Clinician and self-report assessments yielded similar results. Prediction of outcomes replicated across data sets. Patients with no symptom improvement by CT Session 9 (Week 5) had ≤10% probability of remission and >75% probability of nonresponse.

Conclusions: Outcomes of CT for depression are predictable from early symptom changes. Clinicians may find nonresponse and remission probability estimates useful in the informed consent process and in choosing whether to continue, augment, or switch treatments for CT patients with recurrent MDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853186PMC
June 2019

Translating the BDI and BDI-II into the HAMD and vice versa with equipercentile linking.

Epidemiol Psychiatr Sci 2019 Mar 14;29:e24. Epub 2019 Mar 14.

Department of Clinical, Neuro-, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands.

Aims: The Hamilton Depression Rating Scale (HAMD) and the Beck Depression Inventory (BDI) are the most frequently used observer-rated and self-report scales of depression, respectively. It is important to know what a given total score or a change score from baseline on one scale means in relation to the other scale.

Methods: We obtained individual participant data from the randomised controlled trials of psychological and pharmacological treatments for major depressive disorders. We then identified corresponding scores of the HAMD and the BDI (369 patients from seven trials) or the BDI-II (683 patients from another seven trials) using the equipercentile linking method.

Results: The HAMD total scores of 10, 20 and 30 corresponded approximately with the BDI scores of 10, 27 and 42 or with the BDI-II scores of 13, 32 and 50. The HAMD change scores of -20 and -10 with the BDI of -29 and -15 and with the BDI-II of -35 and -16.

Conclusions: The results can help clinicians interpret the HAMD or BDI scores of their patients in a more versatile manner and also help clinicians and researchers evaluate such scores reported in the literature or the database, when scores on only one of these scales are provided. We present a conversion table for future research.
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http://dx.doi.org/10.1017/S2045796019000088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061209PMC
March 2019

Partner criticism during acute-phase cognitive therapy for recurrent major depressive disorder.

Behav Res Ther 2019 02 21;113:48-56. Epub 2018 Dec 21.

Department of Psychiatry, The University of Texas Southwestern Medical Center, USA. Electronic address:

Many patients with major depressive disorder (MDD) are married or in marriage-like relationships that could influence treatment process and outcomes. We clarified relations of patient-reported criticism from partners (perceived criticism) and criticism of partners with psychosocial functioning and changes in cognitive therapy (CT) for depression. Partnered outpatients (N = 219) received a 12-week CT protocol and completed measures repeatedly. As hypothesized, perceived criticism and criticism of partners correlated with personality (e.g., perceived criticism: trait mistrust, self-harm; criticism of partners: negative temperament, aggression), social-interpersonal problems (perceived criticism: cold and overly nurturant behavior; criticism of partners: vindictive and domineering behavior; both measures: poor adjustment in partnered and family relationships), cognitive content (both measures: negative failure attributions, dysfunctional attitudes), and depressive symptom intensity (both measures), although effect sizes were small-moderate. Both criticism measures decreased little during CT and remained elevated compared to community norms, despite the fact that relations between the criticism measures and depressive symptoms included both stable trait and more transient state components. From these findings, we speculate that some patients with MDD elicit or amplify criticism in ways that harm their relationships and psychosocial functioning and may benefit from additional or strategic treatment.
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http://dx.doi.org/10.1016/j.brat.2018.12.010DOI Listing
February 2019

Do comorbid social and other anxiety disorders predict outcomes during and after cognitive therapy for depression?

J Affect Disord 2019 01 25;242:150-158. Epub 2018 Aug 25.

Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Background: Cognitive therapy (CT) improves symptoms in adults with major depressive disorder (MDD) plus comorbid anxiety disorder, but the specific type of anxiety may influence outcomes. This study compared CT outcomes among adults with MDD plus social, other, or no comorbid anxiety disorders.

Methods: Outpatients with recurrent MDD (N = 523, including 87 with social and 110 with other comorbid anxiety disorders) received acute-phase CT. Higher risk responders (n = 241 with partial or unstable response) were randomized to 8 months of continuation treatment (CT or clinical management plus fluoxetine or pill placebo), followed by 24 months of assessment. Lower risk responders (n = 49) were assessed for 32 months without additional research treatment. Depression, anxiety symptoms, and social avoidance were measured repeatedly.

Results: Other (non-social), but not social, anxiety disorders predicted elevated depression and anxiety symptoms throughout and after acute-phase CT. Social, but not other, anxiety disorder predicted greater reduction in depressive symptoms during acute-phase CT and elevated social avoidance during and after acute-phase CT.

Limitations: Anxiety disorders were assessed only before acute-phase treatment. The anxiety symptom measure was brief. Generalization to other patient populations and treatments is unknown.

Conclusions: Non-social comorbid anxiety disorders may reduce the efficacy of acute-phase CT for MDD by diminishing both short- and longer term outcomes relative to depressed patients without comorbid anxiety disorders. Comorbid social anxiety disorder may increase relative reductions in depressive symptoms during acute-phase CT for MDD, but patients with comorbid social anxiety disorder may require specialized focus on social avoidance during CT.
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http://dx.doi.org/10.1016/j.jad.2018.08.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151272PMC
January 2019

Methodological Recommendations for Trials of Psychological Interventions.

Psychother Psychosom 2018 13;87(5):276-284. Epub 2018 Jul 13.

Department of Psychology, University of Bologna, Bologna, Italy.

Recent years have seen major developments in psychotherapy research that suggest the need to address critical methodological issues. These recommendations, developed by an international group of researchers, do not replace those for randomized controlled trials, but rather supplement strategies that need to be taken into account when considering psychological treatments. The limitations of traditional taxonomy and assessment methods are outlined, with suggestions for consideration of staging methods. Active psychotherapy control groups are recommended, and adaptive and dismantling study designs offer important opportunities. The treatments that are used, and particularly their specific ingredients, need to be described in detail for both the experimental and the control groups. Assessment should be performed blind before and after treatment and at long-term follow-up. A combination of observer- and self-rated measures is recommended. Side effects of psychotherapy should be evaluated using appropriate methods. Finally, the number of participants who deteriorate after treatment should be noted according to the methods that were used to define response or remission.
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http://dx.doi.org/10.1159/000490574DOI Listing
November 2018

Patients' comprehension and skill usage as a putative mediator of change or an engaged target in cognitive therapy: Preliminary findings.

J Affect Disord 2018 01 27;226:163-168. Epub 2017 Sep 27.

Departments of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia Veterans Affairs Medical Center, United States.

Background: The skills that patients learn in cognitive therapy (CT) and use thereafter may mediate improvement in depression during and after intervention.

Method: We used a sequential, three-stage design: acute phase (523 outpatients received 12-14 weeks of CT); 8-month experimental phase (responders at higher risk were randomized to continuation phases: C-CT, C-fluoxetine or C-pill placebo); and 24 months of longitudinal, post-treatment follow-up. Path analyses estimated mediation by skill measured by the Skills of Cognitive Therapy (SoCT: Patient and Observer [Therapist] versions).

Results: Better SoCT scores predicted lower depressive symptoms both in CT and C-CT. In CT depressive symptoms did not predict subsequent changes in skills. During CT and C-CT, when averaged across patients and therapists, skills predicted subsequent decreases in depressive symptoms.

Limitations: Generalization of findings may be limited by the trial's methodology.

Conclusion: Further rigorous investigation of the role of patient CT skills stands to increase understanding of mediators of change or engaged targets in psychosocial intervention.
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http://dx.doi.org/10.1016/j.jad.2017.09.045DOI Listing
January 2018

Relations of Shared and Unique Components of Personality and Psychosocial Functioning to Depressive Symptoms.

J Pers Disord 2018 10 13;32(5):577-602. Epub 2017 Sep 13.

Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas.

Consistent with theories of depression, several personality (e.g., high neuroticism, low extraversion) and psychosocial (e.g., interpersonal problems, cognitive content) variables predict depressive symptoms substantively. In this extended replication, we clarified whether 13 theoretically relevant personality and psychosocial variables were unique versus overlapping predictors of symptoms among 351 adult outpatients with recurrent major depressive disorder who received acute-phase cognitive therapy (CT). Using factor analysis and regression methods, we partitioned the measures' variance into general components common across the two types of measures (psychosocial and personality), within-type components shared only with other measures of the same type, and scale-specific components. From early to late in CT, and from late in CT through 8 months after response, the general components were the strongest (median r = .23)-and scale-specific components the weakest (median r = .01)-forward predictors of symptoms. We discuss implications for measurement and treatment of depression.
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http://dx.doi.org/10.1521/pedi_2017_31_313DOI Listing
October 2018

Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder.

Psychiatry Res 2017 07 22;253:174-181. Epub 2017 Mar 22.

Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments' effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients' pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16-21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.
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http://dx.doi.org/10.1016/j.psychres.2017.03.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481171PMC
July 2017

Initial severity of depression and efficacy of cognitive-behavioural therapy: individual-participant data meta-analysis of pill-placebo-controlled trials.

Br J Psychiatry 2017 03 19;210(3):190-196. Epub 2017 Jan 19.

Toshi A. Furukawa, MD, PhD, Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan; Erica S. Weitz, MA, Department of Clinical Psychology and EMGO Institute for Health and Care Research, VU University Amsterdam, The Netherlands; Shiro Tanaka, PhD, Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan; Steven D. Hollon, PhD, Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA; Stefan G. Hofmann, PhD, Department of Psychological and Brain Science, Boston University, Massachusetts, USA; Gerhard Andersson, PhD, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden and Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stokholm, Sweden; Jos Twisk, PhD, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Amsterdam, The Netherlands; Robert J. DeRubeis, PhD, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Sona Dimidjian, PhD, Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, USA; Ulrich Hegerl, MD, PhD, Roland Mergl, PhD, Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany; Robin B. Jarrett, PhD, Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; Jeffrey R. Vittengl, PhD, Department of Psychology, Truman State University, Kirksville, Missouri, USA; Norio Watanabe, MD, PhD, Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan; Pim Cuijpers, PhD, Department of Clinical Psychology and EMGO Institute for Health and Care Research, VU University Amsterdam, The Netherlands.

The influence of baseline severity has been examined for antidepressant medications but has not been studied properly for cognitive-behavioural therapy (CBT) in comparison with pill placebo.To synthesise evidence regarding the influence of initial severity on efficacy of CBT from all randomised controlled trials (RCTs) in which CBT, in face-to-face individual or group format, was compared with pill-placebo control in adults with major depression.A systematic review and an individual-participant data meta-analysis using mixed models that included trial effects as random effects. We used multiple imputation to handle missing data.We identified five RCTs, and we were given access to individual-level data ( = 509) for all five. The analyses revealed that the difference in changes in Hamilton Rating Scale for Depression between CBT and pill placebo was not influenced by baseline severity (interaction = 0.43). Removing the non-significant interaction term from the model, the difference between CBT and pill placebo was a standardised mean difference of -0.22 (95% CI -0.42 to -0.02, = 0.03, = 0%).Patients suffering from major depression can expect as much benefit from CBT across the wide range of baseline severity. This finding can help inform individualised treatment decisions by patients and their clinicians.
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http://dx.doi.org/10.1192/bjp.bp.116.187773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331187PMC
March 2017

Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression.

Depress Anxiety 2017 03 6;34(3):246-256. Epub 2016 Dec 6.

Department of Psychology, Vanderbilt University, Nashville, TN, USA.

Background: Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis.

Methods: We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses.

Results: In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10).

Conclusions: We found no indication that melancholic or atypical depressions are significant or relevant moderators or predictors of outcome of CBT and ADM.
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http://dx.doi.org/10.1002/da.22580DOI Listing
March 2017

Defined symptom-change trajectories during acute-phase cognitive therapy for depression predict better longitudinal outcomes.

Behav Res Ther 2016 12 18;87:48-57. Epub 2016 Aug 18.

Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA. Electronic address:

Background: Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but responders experience varying post-acute outcomes (e.g., relapse vs. recovery). Responders' symptom-change trajectories during response to acute-phase CT may predict longer term outcomes.

Method: We studied adult outpatients (N = 220) with recurrent MDD who responded to CT but had residual symptoms. Responders with linear (steady improvement), log-linear (quicker improvement earlier and slower later), one-step (a single, relatively large, stable improvement between adjacent assessments), or undefined (not linear, log-linear, or one-step) symptom trajectories were assessed every 4 months for 32 additional months.

Results: Defined (linear, log-linear, one-step) versus undefined acute-phase trajectories predicted lower depressive symptoms (d = 0.36), lower weekly probability of being in a major depressive episode (OR = 0.46), higher weekly probabilities of remission (OR = 1.93) and recovery (OR = 2.35), less hopelessness (d = 0.41), fewer dysfunctional attitudes (d = 0.31), and better social adjustment (d = 0.32) for 32 months after acute-phase CT. Differences among defined trajectory groups were nonsignificant.

Conclusions: Responding to acute-phase CT with a defined trajectory (orderly pattern) of symptom reduction predicts better longer term outcomes, but which defined trajectory (linear, log-linear, or one-step) appears unimportant. Frequent measurement of depressive symptoms to identify un/defined CT response trajectories may clarify need for continued clinical monitoring and treatment.
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http://dx.doi.org/10.1016/j.brat.2016.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127736PMC
December 2016

Longitudinal social-interpersonal functioning among higher-risk responders to acute-phase cognitive therapy for recurrent major depressive disorder.

J Affect Disord 2016 Jul 13;199:148-56. Epub 2016 Apr 13.

Department of Psychiatry, The University of Texas Southwestern Medical Center, United States. Electronic address:

Background: Social-interpersonal dysfunction increases disability in major depressive disorder (MDD). Here we clarified the durability of improvements in social-interpersonal functioning made during acute-phase cognitive therapy (CT), whether continuation CT (C-CT) or fluoxetine (FLX) further improved functioning, and relations of functioning with depressive symptoms and relapse/recurrence.

Method: Adult outpatients (N=241) with recurrent MDD who responded to acute-phase CT with higher risk of relapse (due to unstable or partial remission) were randomized to 8 months of C-CT, FLX, or pill placebo plus clinical management (PBO) and followed 24 additional months. We analyzed repeated measures of patients' social adjustment, interpersonal problems, dyadic adjustment, depressive symptoms, and major depressive relapse/recurrence.

Results: Large improvements in social-interpersonal functioning occurring during acute-phase CT (median d=1.4) were maintained, with many patients (median=66%) scoring in normal ranges for 32 months. Social-interpersonal functioning did not differ significantly among C-CT, FLX, and PBO arms. Beyond concurrently measured residual symptoms, deterioration in social-interpersonal functioning preceded and predicted upticks in depressive symptoms and major depressive relapse/recurrence.

Limitations: Results may not generalize to other patient populations, treatment protocols, or measures of social-interpersonal functioning. Mechanisms of risk connecting poorer social-interpersonal functioning with depression were not studied.

Conclusions: Average improvements in social-interpersonal functioning among higher-risk responders to acute phase CT are durable for 32 months. After acute-phase CT, C-CT or FLX may not further improve social-interpersonal functioning. Among acute-phase CT responders, deteriorating social-interpersonal functioning provides a clear, measurable signal of risk for impending major depressive relapse/recurrence and opportunity for preemptive intervention.
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http://dx.doi.org/10.1016/j.jad.2016.04.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4862892PMC
July 2016

Divergent Outcomes in Cognitive-Behavioral Therapy and Pharmacotherapy for Adult Depression.

Am J Psychiatry 2016 May 12;173(5):481-90. Epub 2016 Feb 12.

From the Department of Psychology, Truman State University, Kirksville, Mo.; the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas; the Department of Clinical Psychology and the EMGO Institute for Health and Care Research, VU University Amsterdam, the Netherlands; the Department of Psychology, Vanderbilt University, Nashville, Tenn.; the Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj, Romania; the Department of Psychology, University of Pennsylvania, Philadelphia; the Department of Psychology and Neuroscience, University of Colorado, Boulder; the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta; the Fatemeh Zahra Infertility and Reproductive Health Research Center and the Department of Psychiatry, Babol University of Medical Sciences, Babol, Iran; the Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany; the Department of Psychiatry, Faculty of Medicine, University of Toronto; the Department of Psychology, University of Toronto-Scarborough; the Health Services Research Center, Neuropsychiatric Institute, University of California, Los Angeles; the Department of Preventive Medicine and the Center for Behavioral Intervention Technologies, Feinberg School of Medicine, Northwestern University, Chicago; the Duke-National University of Singapore Graduate Medical School, Singapore; and the Department of Psychology, University of Notre Dame, Notre Dame, Ind.

Objective: Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes.

Method: Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models.

Results: About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels.

Conclusions: Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
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http://dx.doi.org/10.1176/appi.ajp.2015.15040492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934129PMC
May 2016

Quantifying and qualifying the preventive effects of acute-phase cognitive therapy: Pathways to personalizing care.

J Consult Clin Psychol 2016 Apr 14;84(4):365-76. Epub 2015 Dec 14.

Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania.

Objective: To determine the extent to which prospectively identified responders to cognitive therapy (CT) for recurrent major depressive disorder (MDD) hypothesized to be lower risk show significantly less relapse or recurrence than treated higher risk counterparts across 32 months.

Method: Outpatients (N = 523), aged 18-70, with recurrent MDD received 12-14 weeks of CT. The last 7 consecutive scores from the Hamilton Rating Scale for Depression (HRSD-17) were used to stratify or define responders (n = 290) into lower (7 HRSD-17 scores of less than or equal to 6; n = 49; 17%) and higher risk (n = 241; 83%). The lower risk patients entered the 32-month follow-up. Higher risk patients were randomized to 8 months of continuation-phase CT or clinical management plus double-blind fluoxetine or pill placebo, with a 24-month follow-up.

Results: Lower risk patients were significantly less likely to relapse over the first 8 months compared to higher risk patients (Kaplan-Meier [KM] estimates; i.e., 4.9% = lower risk; 22.1% = higher risk; log-rank χ2 = 6.83, p = .009). This increased risk was attenuated, but not completely neutralized, by active continuation-phase therapy. Over the subsequent 24 months, the lower and higher risk groups did not differ in relapse or recurrence risk.

Conclusions: Rapid and sustained acute-phase CT remission identifies responders who do not require continuation-phase treatment to prevent relapse (i.e., return of an index episode). To prevent recurrence (i.e., new episodes), however, strategic allocation and more frequent "dosing" of CT and/or targeted maintenance-phase treatments may be required. Longitudinal follow-up is recommended.
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http://dx.doi.org/10.1037/ccp0000069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807431PMC
April 2016

Detecting Sudden Gains during Treatment of Major Depressive Disorder: Cautions from a Monte Carlo Analysis.

Curr Psychiatry Rev 2015 Feb;11(1):19-31

Department of Psychiatry, The University of Texas Southwestern Medical Center.

Sudden gains are relatively large, quick, stable drops in symptom scores during treatment of depression that may (or may not) signal important therapeutic events. We review what is known and unknown currently about the prevalence, causes, and outcomes of sudden gains. We argue that valid identification of sudden gains (vs. random fluctuations in symptoms and gradual gains) is prerequisite to their understanding. In Monte Carlo simulations, three popular criterion sets showed inadequate power to detect sudden gains and many false positives due to (a) testing multiple intervals for sudden gains, (b) finite retest reliability of symptom measures, and (c) failure to account for gradual gains. Sudden gains in published clinical datasets appear similar in form and frequency to false positives in the simulations. We discuss the need to develop psychometrically sound methods to detect sudden gains and to differentiate sudden from random and gradual gains.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606893PMC
http://dx.doi.org/10.2174/1573400510666140929195441DOI Listing
February 2015
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