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Lee R, McMillan D, Delgadillo J, Alexander R, Lucock M. Cognitive change before sudden gains in cognitive behavioural therapy for panic disorder. Behav Cogn Psychother 2024; 52:107-118. [PMID: 37821240 DOI: 10.1017/s1352465823000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Sudden gains occur in a range of disorders and treatments and are of clinical and theoretical significance if they can shed light on therapeutic change processes. This study investigated the relationship between sudden gains in panic symptoms and preceding cognitive change during cognitive behavioural therapy (CBT) for panic disorder. METHOD Participants with panic disorder completed in session measures of panic symptoms and catastrophic cognitions. Independent samples t-tests were used to compare the post-treatment score of those who met criteria for one or more sudden gain during treatment with those who did not, and to compare within-session cognitive change between pre-sudden gain sessions and the previous (control) session. RESULTS Twenty-two (42%) of 53 participants experienced a sudden gain during treatment. Participants demonstrating a sudden gain showed more improvement in panic symptoms from pre- to post-treatment than those without a sudden gain. The within-session cognitive change score in the pre-gain session was significantly greater than in the control session. CONCLUSIONS Sudden gains occurred in individual CBT for panic disorder and within-session cognitive change was associated with sudden gains. This is consistent with the cognitive model of panic disorder and highlights how sudden gains can help to identify key change processes.
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Affiliation(s)
- Rachel Lee
- South West Yorkshire Partnership NHS Foundation Trust, Fieldhead, Wakefield, UK
| | - Dean McMillan
- Hull York Medical School and Department of Health Sciences, Mental Health and Addiction Research Group, University of York, Heslington, York, UK
| | - Jaime Delgadillo
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Rachael Alexander
- South West Yorkshire Partnership NHS Foundation Trust, Fieldhead, Wakefield, UK
| | - Mike Lucock
- University of Huddersfield, Huddersfield, UK
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2
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An examination of sudden gain prevalence across cognitive-behavioural therapy for anxiety and depressive disorders: A quantitative analysis and meta-analytic review. J Anxiety Disord 2023; 95:102697. [PMID: 36921511 DOI: 10.1016/j.janxdis.2023.102697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
Sudden gains, incidences of unexpectedly large and stable session to session symptom reductions during psychotherapy, have been shown in samples of individuals receiving treatment for both anxiety and depressive disorders, although seemingly more frequently in sample receiving treatment for depressive disorders. This may suggest that sudden gains are a function of depression, but the high comorbidity between anxiety and depressive disorders makes this difficult to assess. Study One utilised a sample of 117 adults undergoing CBT for a principal anxiety disorder to explore the effect of comorbid depression on sudden gain prevalence. Results indicated that sudden gains were not more prevalent in the comorbid depression group; however, the frequency of sudden gains was significantly related to comorbid depressive disorder severity. Study Two involved a meta-analysis of 48 studies to compare sudden gain prevalence between trials of CBT for depressive disorders versus anxiety-related disorders. The results of the meta-analysis indicated significantly higher rates of sudden gains in samples with a principal depressive disorder diagnosis, compared to a principal anxiety disorder diagnosis. Sudden gains may therefore be driven by depression, but only at the more severe level.
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Arroll B, Frischtak H, Roskvist R, Mount V, Sundram F, Fletcher S, Kingsford DW, Buttrick L, Bricker J, van der Werf B. FACT effectiveness in primary care; a single visit RCT for depressive symptoms. Int J Psychiatry Med 2022; 57:91-102. [PMID: 33892599 DOI: 10.1177/00912174211010536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with depressive symptoms are common in primary care. Brief, simple therapies are needed. AIM Is a focussed acceptance and commitment therapy (FACT) intervention more effective than the control group for patients with depressive symptoms in primary care at one week follow up?Design and setting: A randomised, blinded controlled trial at a single primary care clinic in Auckland, New Zealand. METHODS Patients presenting to their primary care practice for any reason were recruited from the clinic waiting room. Eligible patients who scored ≥2 on the PHQ-2 indicating potential depressive symptoms were randomised using a remote computer to intervention or control groups. Both groups received a psychosocial assessment using the "work-love-play" questionnaire. The intervention group received additional FACT-based behavioural activation activities. The primary outcome was the mean PHQ-8 score at one week. RESULTS 57 participants entered the trial and 52 had complete outcome data after one week. Baseline PHQ-8 scores were similar for intervention (11.0) and control (11.7). After one week, the mean PHQ-8 score was significantly lower in the intervention group (7.4 vs 10.1 for control; p<0.039 one sided and 0.078 two sided). The number needed to treat to achieve a PHQ-8 score ≤6 was 4.0 on intention to treat analysis (p = 0.043 two sided). There were no significant differences observed on the secondary outcomes. CONCLUSION This is the first effectiveness study to examine FACT in any population. The results suggest that it is effective compared with control, at one week, for patients with depressive symptoms in primary care.
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Affiliation(s)
- B Arroll
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - H Frischtak
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - R Roskvist
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - V Mount
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - F Sundram
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - S Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | - D W Kingsford
- Interior Health Authority, Kelowna, British Columbia, Canada
| | - L Buttrick
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - J Bricker
- Fred Hutchinson Center, Seattle, WA, USA
| | - B van der Werf
- Department of Epidemiology and Biostatistics, Faculty of Medical and Health Sciences, School of Population Health, University of Auckland, Auckland, New Zealand
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Sullivan MJL, Adams H, Yamada K, Kubota Y, Ellis T, Thibault P. The relation between perceived injustice and symptom severity in individuals with major depression: A cross-lagged panel study. J Affect Disord 2020; 274:289-297. [PMID: 32469818 DOI: 10.1016/j.jad.2020.05.129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/25/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perceived injustice has been associated with problematic recovery outcomes in individuals with debilitating health conditions. However, the relation between perceived injustice and recovery outcomes has not been previously examined in individuals with debilitating mental health conditions. The present study examined the relation between perceived injustice and symptom severity in individuals undergoing treatment for Major Depressive Disorder (MDD). METHODS The study sample consisted of 253 work-disabled individuals with MDD who were referred to an occupational rehabilitation service. Participants completed measures of depressive symptom severity, perceived injustice, catastrophic thinking, pain and occupational disability at three time-points (pre-, mid- and post-treatment) during a 10-week behavioural activation intervention. RESULTS Regression analysis on baseline data revealed that perceived injustice contributed significant variance to the prediction of depressive symptom severity, beyond the variance accounted for by time since diagnosis, pain severity and catastrophic thinking. Prospective analyses revealed that early treatment reductions in perceived injustice predicted late treatment reductions in depressive symptom severity. LIMITATIONS The study sample consisted of work-disabled individuals with MDD who had been referred to an occupational rehabilitation service. This selection bias has implications for the generalizability of findings. CONCLUSION The findings suggest that perceived injustice is a determinant of symptom severity in individuals with MDD. The inclusion of techniques designed to reduce perceived injustice might augment positive treatment outcomes for individuals receiving treatment for MDD.
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Affiliation(s)
- Michael J L Sullivan
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Quebec H3A 1G1, Canada.
| | - Heather Adams
- University Centre for Research on Pain and Disability, 5595 Fenwick Street, Suite 314. Halifax, Nova Scotia, B3H 4M2 Canada
| | - Keiko Yamada
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Quebec H3A 1G1, Canada
| | - Yasuhiko Kubota
- Osaka Center for Cancer and Cardiovascular Diseases Prevention, 1-6-107 Morinomiya, Jyoto-ku, Osaka 536-0025, Japan
| | - Tamra Ellis
- Centre for Rehabilitation and Health, 27 Roncesvalles Ave. Unit 510, Toronto, Ontario M6R 3B2, Canada
| | - Pascal Thibault
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Quebec H3A 1G1, Canada
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Shalom JG, Aderka IM. A meta-analysis of sudden gains in psychotherapy: Outcome and moderators. Clin Psychol Rev 2020; 76:101827. [PMID: 32036232 DOI: 10.1016/j.cpr.2020.101827] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
Sudden gains have been shown to be a common phenomenon and an important predictor of outcome in psychotherapy (Tang & DeRubeis, 1999). The present meta-analysis examined the growing literature on sudden gains in psychotherapy, their effects on outcome, and moderators of these effects. We searched PsycINFO, PubMed, ProQuest Dissertations & Theses, Scholar and Web of Science databases for articles between January 1st 1999 and May 31st 2019 and included 50 studies (n = 6355) in the meta-analysis. Sudden gains were found to significantly predict outcome at post-treatment (g = 0.68) and follow up (g = 0.61) above and beyond treatments, disorders and settings. Studies using Tang and DeRubies's (1999) criteria for identification of sudden gains had smaller effect sizes compared to studies using altered criteria. Pretreatment severity levels did not significantly predict the effects of sudden gains and neither did treatment setting (randomized controlled trials vs. naturalistic settings). Finally, number of sessions and sudden gains' reversal rates were both negatively associated with the effect sizes of sudden gains. These findings suggest that sudden gains are a ubiquitous phenomenon in psychotherapy but their effects may be moderated by a number of factors. Research and clinical implications are discussed.
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Affiliation(s)
- Jonathan G Shalom
- Department of Psychology, University of Haifa, Mount Carmel, Haifa 3498838, Israel
| | - Idan M Aderka
- Department of Psychology, University of Haifa, Mount Carmel, Haifa 3498838, Israel.
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Beard JIL, Delgadillo J. Early response to psychological therapy as a predictor of depression and anxiety treatment outcomes: A systematic review and meta-analysis. Depress Anxiety 2019; 36:866-878. [PMID: 31233263 DOI: 10.1002/da.22931] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/10/2019] [Accepted: 05/25/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Previous studies indicate that early symptomatic improvement, typically observed during the first 4 weeks of psychological therapy, is associated with positive treatment outcomes for a range of mental health problems. However, the replicability, statistical significance, and magnitude of this association remain unclear. AIM The current study reviewed the literature on early response to psychological interventions for adults with depression and anxiety symptoms. METHODS A systematic review and random effects meta-analysis were conducted, including studies found in Medline, PsychINFO, SCOPUS, Web of Science, and through reference lists and reverse citations. RESULTS Twenty-five eligible studies including 11,091 patients measured early response and examined associations with posttreatment outcomes. It was possible to extract and/or calculate effect size data from 15 studies to conduct a meta-analysis. A large pooled effect size (g = 0.87 [95% confidence interval: 0.63-1.10], p < .0001) indicated that early responders had significantly better posttreatment outcomes compared to cases without early response, and this effect was larger in anxiety (g = 1.37) compared to depression (g = 0.76) measures. Most studies were of good quality and there was no evidence of publication bias. The main limitations concerned insufficient statistical reporting in some studies, which precluded their inclusion in meta-analysis, and it was not possible to examine effect sizes according to different outcome questionnaires. CONCLUSION There is robust and replicated evidence that early response to therapy is a reliable prognostic indicator for depression and anxiety treatment outcomes.
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Affiliation(s)
- Jessica I L Beard
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
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Singla DR, Hollon SD, Fairburn CG, Dimidjian S, Patel V. The Roles of Early Response and Sudden Gains on Depression Outcomes: Findings From a Randomized Controlled Trial of Behavioral Activation in Goa, India. Clin Psychol Sci 2019; 7:768-777. [PMID: 31380144 PMCID: PMC6628464 DOI: 10.1177/2167702619825860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/29/2018] [Indexed: 11/15/2022]
Abstract
The Healthy Activity Program (HAP), a brief, lay-counselor-delivered, behavioral activation psychological treatment, was found to be effective in reducing depressive symptoms among primary care attendees in India. We now examine whether early response predicts depression (PHQ-9) outcomes at the primary endpoint of 3 months and sustained recovery at 12 months after enrollment and the extent to which this effect is influenced by sudden gains in the context of the larger randomized controlled trial. HAP participants (N = 245) who exhibited an early response (150 of 245 or 61.2%), as defined by a 50% reduction in depressive symptoms from baseline to Session 3, had lower depressive symptom scores than those who did not at 3 months (5.29 vs. 10.75, F = 33.21, p < .001) and at 12 months (6.56 vs. 11.02, F = 21.84, p < .001). Further exploratory analyses suggested that this advantage was largely confined to the subset of early responders who also showed sudden gains (87 of 150).
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Affiliation(s)
- Daisy R Singla
- Department of Psychiatry, University of Toronto, and Sinai Health System, Toronto, Canada
| | | | | | - Sona Dimidjian
- Department of Psychology and Neuroscience, University of Colorado Boulder
| | - Vikram Patel
- Sangath Center, Goa, India.,Department of Global Health and Social Medicine, Harvard Medical School.,Department of Global Health and Population, Harvard TH Chan School of Public Health
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8
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Long-term stability of early sudden gains in an acceptance and values-based intervention. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2019. [DOI: 10.1016/j.jcbs.2019.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Trajectories of Change in a Group Behavioral Activation Treatment for Severe, Recurrent Depression. Behav Ther 2019; 50:504-514. [PMID: 31030869 DOI: 10.1016/j.beth.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 08/21/2018] [Accepted: 08/28/2018] [Indexed: 11/20/2022]
Abstract
Depression is a common and costly problem. Behavioral Activation (BA) is an effective treatment for depression when delivered 1:1, but group treatments often do not perform as well as 1:1 treatments. One way to begin to understand how group treatments perform is to assess the process of change during treatment. This study examined trajectories of change across 10-session group BA for individuals with severe, chronic, or recurrent forms of depression. We also tested whether individuals who had associated sudden gains or depression spikes had better outcomes than those who did not have these change patterns. We examined psychological and sociodemographic predictors of the patterns of change. Participants were 104 individuals who met diagnostic criteria for major depressive disorder and participated in one of 10 BA groups, provided over a 2-year period. A linear, but not quadratic or cubic, rate of change fit the data and the effect size for the change in mood symptoms from baseline to posttreatment was large, Cohen's d = 1.25. Although 34% (26 of the 77 who provided outcome data) of individuals had a sudden gain and 10% (7/77) had a depression spike, neither sudden gains nor depression spikes predicted posttreatment outcomes. None of the demographic or psychological factors (rumination, behavioral activation) predicted the pattern of change. These results suggest that although group BA may help to reduce depressive symptoms in individuals with severe, recurrent, and/or chronic forms of depression, the overall linear pattern of change is different from quadratic patterns of change reported for 1:1 BA.
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Keinonen K, Kyllönen H, Astikainen P, Lappalainen R. Early sudden gains in an acceptance and values-based intervention: Effects on treatment outcome for depression and psychological flexibility. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2018. [DOI: 10.1016/j.jcbs.2018.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Strosahl KD, Robinson PJ. Adapting empirically supported treatments in the era of integrated care: A roadmap for success. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2018. [DOI: 10.1111/cpsp.12246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Mychailyszyn MP, Carper MM, Gibby B. Exploring the occurrence of sudden gains among anxious youth receiving evidence-based cognitive-behavioral therapy. Child Adolesc Ment Health 2018; 23:251-257. [PMID: 32677298 DOI: 10.1111/camh.12254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is limited information on the occurrence of 'sudden gains' - recognized improvements of substantial magnitude occurring between individual sessions of treatment. This study explores changes in anxiety across sessions of CBT for youth anxiety disorders to determine whether evidence exists for sudden gains in this population. METHOD A total of 133 anxious youth (Mage = 10.16 years; 55.6% male) were randomly assigned to receive 16 sessions of individual cognitive-behavioral therapy (ICBT), family-based CBT (FCBT), or a family-based educational support and attention control (FESA). At each treatment session, youth completed a measure of anxiety. Sudden gains were calculated from weekly state anxiety scores using methods consistent with previous research (i.e., Tang & DeRubeis, 1999). RESULTS Three participants experienced a sudden gain at any point during treatment; all experienced a reversal of the sudden gain, although one experienced a regain of the improvement that occurred during the sudden gain. CONCLUSIONS While sudden gains have been demonstrated in some studies, in a relatively new topic to the literature such as this, it should also be considered that many evidence-based treatments are actually intended to produce more steady/gradual gains - which may be particularly true for youth who are not as cognitively advanced as adults and who have much to learn about how psychopathology - and for this analysis, anxiety - operates.
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Affiliation(s)
| | | | - Brittany Gibby
- Florida State University Ringgold Standard Institution, Tallahassee, FL, USA
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Pilot Study of an Exercise Intervention for Depressive Symptoms and Associated Cognitive-Behavioral Factors in Young Adults With Major Depression. J Nerv Ment Dis 2017; 205:647-655. [PMID: 27805982 DOI: 10.1097/nmd.0000000000000611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study assesses the feasibility of integrating motivational interviewing (MI) with an exercise intervention. It also explores patterns of depressive symptom changes (cognitive, affective, and somatic subscales) and their relationship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a marker for inflammation) across the exercise intervention. Twelve young adults (20.8 ± 1.7 years) meeting DSM-IV criteria for major depressive disorder received a brief MI intervention followed by a 12-week exercise intervention. Assessments were conducted preintervention, postintervention, throughout the intervention, and at follow-up. Preliminary results show differential effects of exercise, with the largest standardized mean improvements for the affective subscale (-1.71), followed by cognitive (-1.56) and somatic (-1.39) subscales. A significant relationship was observed between increased behavioral activation and lower levels of IL-6. Despite study limitations, the magnitude of changes suggests that natural remission of depressive symptoms is an unlikely explanation for the findings. A randomized controlled trial has commenced to evaluate effectiveness of the intervention.
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O'Mahen HA, Wilkinson E, Bagnall K, Richards DA, Swales A. Shape of change in internet based behavioral activation treatment for depression. Behav Res Ther 2017; 95:107-116. [PMID: 28618298 DOI: 10.1016/j.brat.2017.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 04/14/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022]
Abstract
Shape of change, sudden gains and depression spikes were examined in an online 12-session Behavioral Activation (BA) treatment for depression. Client and therapist factors related to sudden gains were examined to investigate processes associated with outcome. METHODS Participants were postpartum Women with Major Depressive Disorder (n=42) who received online BA supported in 30-minute telephone sessions by a mental health worker. Depression symptoms were assessed at each session and number of sessions completed were recorded by the online program. Therapist records were rated for client stressful life event and therapist concrete focus. A quadratic pattern provided the best fit with the data; a cubic pattern was a poor fit. Sudden gains, but not depression spikes, predicted lower depression scores at 17-week outcome. Women who had higher baseline social functioning, did not experience a stressful life event during therapy, and completed more online modules, but not more telephone sessions, were more likely to have a sudden gain. A concrete therapist focus was associated with sudden gains. These results extend research on trajectories of change and sudden gains to an online BA treatment and to postpartum depression, and suggest important client and therapist factors associated with sudden gains.
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Affiliation(s)
- Heather A O'Mahen
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
| | | | - Kara Bagnall
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
| | - David A Richards
- University of Exeter Medical School, St. Lukes Campus, South Cloisters, Exeter EX1 2LU, UK.
| | - Amanda Swales
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
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