Do depressed men and women respond similarly to cognitive behavior therapy?

OBJECTIVE

A great majority of the evidence pertaining to the effectiveness of the time-limited psychotherapies as treatments of major depression are derived from studies of either predominantly or entirely female subject groups. Depressed men and women differ in a number of important respects that may alter the course of affective disorder, and as a result, they may also differ in their responses to psychotherapy. In this study the outcomes of 40 men and 44 women treated with cognitive behavior therapy were compared.

METHOD

The patients were interviewed with the Schedule for Affective Disorders and Schizophrenia and diagnosed according to the Research Diagnostic Criteria and DSM-III-R criteria. Subsequently, they were assessed every other week (with the Hamilton Depression Rating Scale, Beck Depression Inventory, and Global Assessment Scale) during a standardized, time-limited cognitive behavior therapy protocol. The outcomes of the men and women were compared by means of a series of analyses of variance and covariance and survival analyses.

RESULTS

There were several significant pretreatment differences, and the men attended significantly fewer therapy sessions than the women. Although the men and women generally had comparable responses, patients with higher pretreatment levels of depressive symptoms, particularly women, had poorer outcomes.

CONCLUSIONS

This study provides further evidence of gender-specific differences in depressed patients' symptoms and treatment utilization. Cognitive behavior therapy appears to be a comparably useful outpatient treatment for men and women. However, either more intensive cognitive behavior therapy or alternative methods of treatment may be warranted for patients with more severe syndromes.

Affect intensity and phasic REM sleep in depressed men before and after treatment with cognitive-behavioral therapy

This article explored the relationship between daytime affect and REM sleep in 45 depressed men before and after treatment with cognitive-behavioral therapy and in a control group of 43 healthy subjects. The intensity of daytime affect (as measured by the sum of positive and negative affects) in depressed men correlated significantly and positively with phasic REM sleep measures at both pre- and posttreatment. This relationship was not found in healthy control subjects. In depressed men, both affect intensity and phasic REM sleep measures decreased over the course of treatment. The results suggest a relationship between phasic REM sleep and intensity of affect reported by depressed men. On the basis of this preliminary observation, it was hypothesized that abnormalities in phasic REM sleep in depressed patients are related, in part, to fundamental alterations in the intensity of their affective experience.

Inpatient applications of cognitive-behavioral therapy : a review of recent developments

The authors review empirical research of the past decade on cognitive-behavioral therapy (CBT) in the treatment of depressed inpatients and offer suggestions for future investigations. CBT appears to offer additive benefits in combination with pharmacotherapy, particularly after the transition from inpatient to outpatient treatment. CBT also holds promise as a primary treatment for inpatients but has not been clearly shown to be as effective as antidepressants. There is as yet no evidence that inpatient CBT is superior to other psychotherapies of comparable intensity or that short-term inpatient CBT has enduring value if not followed by outpatient therapy. Further research is needed to clarify the specific effects of CBT for inpatients and to establish its cost-effectiveness.

The effects of fenfluramine on sleep and prolactin in depressed inpatients: a comparison of potential indices of brain serotonergic responsivity

The effects of fenfluramine, an indirect serotonergic agonist, on electroencephalographic sleep and prolactin secretion were assessed in 12 unmedicated inpatients with a primary diagnosis of major depressive episode. Compared to prefenfluramine profiles, sleep studies performed following fenfluramine administration showed a statistically significant reduction of slow-wave sleep (SWS) (p < 0.001) and a corresponding increase in percentage of stage-2 sleep (p < 0.007). Automated delta wave counts per min decreased significantly during the first nonrapid eye movement (NREM) period (p = 0.04), and automated rapid-eye movement (REM) counts were also decreased in the second REM period (p = 0.02). These effects on sleep electroencephalogram (EEG) did not correlate significantly with another measure of serotonergic responsivity, namely peak prolactin level following fenfluramine, nor with the severity of depression. The reductions in SWS and REM counts are proposed to be the result of time-dependent changes in serotonergic neurotransmission following the administration of fenfluramine. These findings are consistent with earlier work suggesting a role for serotonin in initiation and regulation of SWS and REM sleep.

Evaluating the hopelessness model of depression: diathesis-stress and symptom components

The hopelessness model of depression posits that latent attributional diatheses combine with stressors to produce a specific subtype of depression characterized by a specific set of symptoms. Associations between attributional diathesis, stress, and symptoms were examined to test the prediction that hopelessness depressions are characterized by a specific symptom profile. Fifty-seven depressed outpatients were categorized into subgroups on the basis of whether or not they met the criteria of L. Y. Abramson, L. B. Alloy, and G. I. Metalsky's (1988) hopelessness depression, defined as a match in content domain between attributional diathesis and negative stressor. Support for hopelessness depression was mixed. The hopelessness subtype differed from other major depressions with respect to symptom profile. However, the differences in symptomatology were not wholly consistent with the predictions of the hopelessness model.

Cognition and life stress in depression: cognitive factors and the definition, rating, and generation of negative life events

The relationship between cognitive factors and different conceptualizations and measures of life stress poses important questions for contemporary theories of depression. We examined whether cognitive factors (dysfunctional attitudes and attributional style) are related to the definition, rating, and generation of negative life events. Life events were assessed with both subjective self-report and more objective interview-based methods in endogenously depressed outpatients. The results partially support the hypothesis that cognitive factors are related to definition and severity ratings of self-report measures of particular types of life events. These relationships held primarily for achievement, as compared with interpersonal, events. The results also support the hypothesis that elevated scores on measures of cognition are associated with the number of objectively defined events occurring prior to the onset of depression, suggesting that some patients may generate the life events that in turn may initiate a depressive episode.

Correlation of nocturnal penile tumescence and daytime affect intensity in depressed men

Although depressed patients have been shown to have diminished nocturnal penile tumescence (NPT), there remains considerable variability of NPT in depression. We hypothesized that affective experience during the day accounts for some of this variability. Forty-five depressed men had assessments of affect intensity and affect balance, NPT, and daytime sexual function, both before and after treatment with Beck's cognitive behavior therapy (CBT). Forty-three normal control subjects were studied for comparison. Daytime affect intensity in depressed men, but not in control subjects, correlated significantly and positively with measures of NPT duration and rigidity both before and after treatment, regardless of the adequacy of daytime sexual function. When the effect of daytime affect on REM activity was controlled, the observed correlations became nonsignificant at pretreatment, but remained significant at posttreatment. Neuropharmacologically mediated changes in arousal responsivity associated with depression may underlie the observed relation between daytime affect intensity, rapid eye movement activity, and NPT.

A comprehensive review of cyclothymic disorder

Chronic affective disorders have generated much interest during the past decade due to increasing recognition of their clinical importance and because of controversy about their appropriate classification and treatment. The purpose of this paper was to review cyclothymic disorder. This review will include historical concepts, clinical phenomenology, family history, biological studies, and treatment of cyclothymia. In addition, the relationship of cyclothymia to other psychiatric disorders, such as bipolar, dysthymic, and personality disorders, is examined. The results suggest that some forms of cyclothymia are strongly associated with bipolar disorder, but that the condition is clinically heterogeneous. The problems of existing research in this area and future directions for research are also discussed.

Comparison of full-dose versus half-dose pharmacotherapy in the maintenance treatment of recurrent depression

Recent evidence points to the prophylactic efficacy of maintaining recurrent unipolar patients on the same dose of antidepressant medication that was used to treat the acute episode (Frank et al., 1990; Kupfer et al., 1992). Therefore, the question of whether such patients should be tapered to a lower maintenance dose after successful resolution of an acute episode is clearly important. In this report we describe a small randomized clinical trial in which patients were assigned to either full-dose or half-dose maintenance treatment for a period of 3 years. Survival analysis suggests that superior prophylaxis can be achieved with a full-dose as compared to a half-dose maintenance treatment strategy (p < 0.07). Mean survival time for the full-dose subjects was 135.17 (SE 19.75) weeks as compared to 74.94 (SE 19.78) weeks (median of 43.1 weeks) for the half-dose subjects. We conclude that for patients who have suffered several recurrences, full-dose maintenance treatment is the more effective prophylactic strategy.

Are buckling force measurements reliable in nocturnal penile tumescence studies?

The study of nocturnal penile tumescence (NPT) is frequently used to evaluate male erectile dysfunction. Buckling force, a measure of rigidity, is an important part of this evaluation, but its reliability is unknown. Accordingly, we studied the reliability of buckling force measurement and the stability of "maximum buckling force" between consecutive NPT series repeated in the same subject. For individual subjects, we correlated buckling forces for separate episodes of sleep-related tumescence that were of comparable fullness (0-100%) as rated by a technician's visual estimates. For healthy control subjects, test-retest correlations were > 0.8 both within-night and across study series separated by an average of 70 weeks. In depressed men, correlations within nights were > 0.9, but fell to 0.64 across study series separated by an average of 21 weeks. Despite the high reliability of buckling force measurement, we found little stability of "maximum buckling force" between NPT series for individual subjects. Considerable variability in the maximum degree of penile rigidity was seen over time despite a constant level of reported daytime erectile function. We conclude that although penile rigidity is one of the more important variables in the assessment of male erectile dysfunction and can be measured reliably, the instability of maximum rigidity during sleep-related erections suggests that it is, at best, an imprecise correlate of daytime erectile function.

Sexual function in depressed men. Assessment by self-report, behavioral, and nocturnal penile tumescence measures before and after treatment with cognitive behavior therapy

Clinicians have long associated depression with alterations in sexual function, predominantly loss of sexual interest. In a longitudinal study measuring self-report, behavioral, and nocturnal penile tumescence variables before and after treatment with cognitive behavior therapy in an unmedicated sample of 40 outpatient depressed men, we found, contrary to expectation, that sexual activity per se was not reduced during the depressed state. Rather, loss of sexual interest appeared to be related to the cognitive set of depression, ie, loss of sexual satisfaction that then improved with remission from depression. Depressed men were heterogeneous, however, with respect to sexual behavior, eg, an anxious and more chronically depressed subgroup of men who did not have remissions with cognitive behavior therapy reported increased sexual interest and sexual activity. Also, contrary to expectation, nocturnal penile tumescence abnormalities in depressed men did not reverse when measured in early remission, nor did nocturnal penile tumescence measures correlate significantly with behavioral measures of sexual function. Nocturnal penile tumescence alterations in depression may thus be similar to other persistent electroencephalographic sleep abnormalities seen in depressed patients in remission, in being more trait-like than statelike.

Five-year outcome for maintenance therapies in recurrent depression

After conducting a randomized, 3-year maintenance trial in 128 patients with recurrent depression who had responded to combined short-term and continuation treatment with imipramine hydrochloride and interpersonal psychotherapy, we asked those individuals who survived the 3-year trial receiving active medication (with or without psychotherapy) to continue in a 2-year additional randomized trial of active medication vs placebo. The question was whether maintaining antidepressant medication at the dosage used to treat the acute episode beyond 3 years would continue to provide a significant prophylactic effect compared with medication discontinuation after the 3 years of effective maintenance treatment. Survival analysis demonstrated a highly significant continued prophylactic effect for active imipramine hydrochloride treatment maintained at an average dose of 200 mg. We conclude that active imipramine treatment is an effective means of preventing recurrence beyond 3 years and that patients with previous episodes less than 2 1/2 years apart, therefore, merit continued prophylaxis for at least 5 years.

Long-term treatments of recurrent depressive disorders

Many, if not most, depressive disorders become recurrent conditions. It is now clear that virtually all recently remitted patients should receive 4 to 6 months of continuation therapy. Moreover, this phase of treatment should continue until the patient has achieved a clear-cut, durable period of recovery. Further, an extended course of maintenance pharmacotherapy is recommended for those patients at risk for subsequent recurrent episodes. In this paper, the rationale for long-term treatment is presented and common strategies are reviewed. Depressive disorders appear to become more autonomous, severe, and potentially refractory with each new episode. Thus, prevention of recurrent depression remains the best available strategy to ensure an optimal long-term outcome for patients with recurrent affective disorders.

Relapse after cognitive behavior therapy of depression: potential implications for longer courses of treatment

OBJECTIVE

The authors studied the risk of relapse among depressed patients after cognitive behavior therapy in order to document the need and potential indications for longer-term models of treatment.

METHOD

Forty-eight patients with major depression who responded during a 16-week course of cognitive behavior therapy entered a 1-year prospective follow-up study, as did two patients who received 20 weeks of therapy. Standardized, independent clinical assessments were completed 1, 3, 6, 9, and 12 months after treatment. Relapse was defined as, at minimum, a 2-week period in which the subject met the DSM-III-R criteria for major depression and had a Hamilton depression scale score of 15 or more.

RESULTS

Sixteen patients (32%) relapsed during the 1-year follow-up. Correlates of relapse included a history of depressive episodes, higher levels of depressive symptoms and dysfunctional attitudes, slower response to therapy, and being unmarried. Patients who fully recovered during therapy (Hamilton depression score of 6 or less for 8 weeks or more) were at significantly lower risk for relapse than those who partially recovered (9% and 52%, respectively). Slower response to therapy, unmarried status, and high residual scores on the Dysfunctional Attitudes Scale were independently and additively related to increased risk of relapse.

CONCLUSIONS

These findings provide further evidence of a relation between residual symptoms and relapse after cessation of active treatment. The authors strongly recommend that models of longer-term psychotherapy be developed for depressed patients who do not recover fully during time-limited cognitive behavior therapy.

Social factors and the psychobiology of depression: relations between life stress and rapid eye movement sleep latency

We examined psychosocial factors (i.e., life stress) and biological factors (i.e., REM sleep latency) that are hypothesized to be of complementary importance for defining depressive subtypes in a sample of 61 nonpsychotic, endogenous major depressives. Subjects were evaluated on several diagnostic scales for life stress, on electroencephalographic sleep data, and on 2 symptom measures for depression. As predicted, persons with severe stress that occurred shortly before depression onset had essentially normal REM latency values; patients without such stress had reduced REM latency values. Both stress and REM latency were also associated with greater severity of self-reported depressive symptoms. Alternative explanations of these findings are discussed, with particular emphasis on different roles of pre-onset and post-onset stressors.

Biological markers, treatment outcome, and 1-year follow-up in endogenous depression: electroencephalographic sleep studies and response to cognitive therapy

Although there are now considerable data attesting to the efficacy of several forms of treatment for depression, there is surprisingly little information to guide the selection of the treatment most likely to benefit a given patient. Biologic markers of depression have received much attention for their potential to provide theoretically and clinically meaningful subgroups for specific treatments. The relationship between electroencephalographic (EEG) sleep disturbances, treatment outcome, and 1-year follow-up was examined for a sample of 53 patients with endogenous major depression receiving cognitive-behavioral therapy. Overall, there was little support for the prediction of a difference in short- or long-term outcome between patients with and without EEG sleep disturbances.

Diminished nocturnal penile tumescence in depression: a replication study

A descriptive study was conducted in a new sample of 51 men with DSM-III-R research diagnostic criteria (RDC) major depression in order to replicate earlier observations that measures of nocturnal penile tumescence (NPT) and penile rigidity are disturbed in depressive states. When compared to both the age-equated patient (n = 34) and normal control (n = 28) groups reported in our 1988 study, the new sample manifested significant abnormalities of NPT and diminished penile rigidity. Such disturbances were not, however, significantly correlated with psychobiological indicators of severe or endogenous depression.

Shifts in affective balance during cognitive therapy of major depression

Thirty-two outpatient depressives were treated by experienced therapists during a 16- to 20-week, 20- to 24-session cognitive-behavioral therapy (CBT) protocol. Patients were classified as CBT responders (n = 22) or nonresponders (n = 10) on the basis of independent clinical ratings of Hamilton (1960) depression severity. Point and confidence interval estimation procedures yielded results consistent with hypotheses derived from the states-of-mind (SOM; Schwartz & Garamoni, 1986) model. At posttreatment, CBT responders shifted the balance of positivity and negativity to the optimal range, whereas nonresponders remained in a predominantly negative SOM. Response status was related more strongly to change in positivity than in negativity. Findings support the view that clinical response to CBT depends on reducing negativity and increasing positivity until an optimal balance is achieved.

Are personality assessments valid in acute major depression?

A number of recent studies indicate that identification of Axis II comorbidity in depressed patients may influence both the initial treatment plan and subsequent prognosis. Nevertheless, the validity of personality disorder diagnoses may be compromised by the effects of the patients' depression on historical recall, which distort presentation of their premorbid strengths and liabilities. These problems are illustrated in this study of 53 acutely depressed unipolar outpatients, with (N = 14) or without (N = 39) personality disorder diagnoses as defined by the Personality Disorder Examination (PDE). We found that: 1) pretreatment PDE diagnoses had no significant associations with any measure of demography, symptomatic status, illness course, or treatment response; and 2) pretreatment PDE diagnoses typically were not confirmed when patients were reassessed following effective treatment with cognitive behavior therapy. These findings provide strong empirical support for the wisdom of deferring definitive assessment of Axis II until an acute depressive disorder has been optimally treated.

Treatment of imipramine-resistant recurrent depression, IV: A double-blind crossover study of tranylcypromine for anergic bipolar depression

OBJECTIVE

Few trials of monoamine oxidase inhibitors (MAOIs) in tricyclic-resistant depression have had double-blind conditions. In the authors' previous double-blind comparison of tranylcypromine and imipramine in anergic bipolar depression, tranylcypromine was significantly more effective. This investigation was a crossover study of nonresponders in the initial study.

METHOD

The subjects were 16 outpatients with anergic bipolar depression. Fourteen had not responded to 4 weeks of treatment with at least 30 mg/day of tranylcypromine or 150 mg/day of imipramine, and two patients were crossed over because of intolerable side effects from the initial drug. The crossover medication was prescribed as in the initial double-blind study.

RESULTS

Twelve patients were crossed over from imipramine to tranylcypromine; nine of them responded to tranylcypromine. Highly significant improvements were documented on the Hamilton, Beck, and Pittsburgh Reversed Vegetative Symptom Scales. Four patients were switched from tranylcypromine to imipramine, but only one responded.

CONCLUSIONS

The high rates of response to tranylcypromine in both the initial and crossover double-blind studies document the efficacy of MAOI treatment for anergic bipolar depression. Moreover, the results further illustrate the utility of MAOIs in tricyclic-resistant depressions.

Early return to REM sleep after nocturnal awakening in depression

Sixteen male outpatients with major depression and 20 age-equated healthy controls were awakened from rapid eye movement (REM) sleep between 1:30 and 3:30 AM, and the rapidity of return to REM sleep was determined. The time it took to return to REM sleep was reduced in depressives compared with controls: 61.6 (17.9 SD) min versus 80.6 (24.9 SD) min, respectively (p = 0.01). The time elapsed until the return to REM sleep was significantly correlated with baseline REM latency in controls (but not depressives). In contrast, return to REM time was significantly correlated with depression severity scores in depressives (but not controls). There was no evidence to support the hypothesis that the more rapid return to REM sleep in depression was caused by a slow wave sleep deficit. The mechanism underlying the rapid return of REM sleep in depression thus may be related to a severity-linked disturbance, such as a proposed increase in REM "pressure."