Interpersonal styles in major and chronic depression: A systematic review and meta-analysis

How to improve reward sensitivity - Predictors of long-term effects of a randomized controlled online intervention trial

BACKGROUND

Reward sensitivity is a central maintaining factor of depression. Current treatments fail at sufficiently and reliably modifying reward processing. Therefore, we employed interventions targeting reward sensitivity and evaluated the long-term efficacy of different online interventions, additionally exploring predictors of changes in reward sensitivity.

METHODS

This four-arm randomized controlled trial (RCT) tested the long-term stability of treatment effects during a four-month follow-up in 127 participants of a two-week online intervention (behavioral activation vs. mindfulness and gratitude vs. combination of both). In addition, we investigated predictors of treatment success defined as improvement in reward sensitivity. Predictors we investigated were depressive expectations, stress and the type of reward implemented in the exercises of the intervention (physical activities and social encounters).

RESULTS

The improvement concerning reward sensitivity, as well as the reduction of anhedonia and depressive symptoms was stable over a four-month follow-up. We did not find evidence for differences between the active intervention groups. Positive changes in depressive expectations were a significant predictor of long-term improvements in reward sensitivity.

LIMITATIONS

Only self-report measures were used and the interpretation of the long-term efficacy of the online interventions is limited since the waitlist control condition was not extended to the follow-up.

CONCLUSIONS

Clinicians should focus on violating depressive expectations to facilitate updating the prediction and anticipation of future rewarding experiences. This could be a vital mechanism of change in reward sensitivity. However, future research still needs to unravel what kind of interventions are most effective in targeting reward insensitivity.

Psychological profiles among people with HIV: A latent profile analysis and examination of the relationship with interpersonal personality

People living with HIV (PWH) often experience an increased vulnerability to psychiatric disorders as a result of social stigma and discrimination. This study utilized latent profile analysis on a sample of 3040 Chinese PWH to identify distinct psychological profiles. Furthermore, the study investigated the relationships between these profiles with interpersonal personalities, demographic characteristics, social variables and disease-related variables using a three-step regression (R3STEP). The findings from the latent profile analysis revealed that the psychological symptoms of PWH can be categorized into three distinct classes. Multinomial logistic regression analysis indicated that interpersonal personalities, region, sex, age, religious beliefs, marital status, occupation, monthly income, time of HIV infection diagnosis and transmission route were significant factors associated with the psychological profiles of PWH. These findings provide valuable insights for the development of individualized management strategies for PWH and contribute to a deeper understanding of the mechanisms underlying psychological symptoms of PWH.

Psychometric and Circumplex Properties Evaluation of the International Personality Item Pool-Interpersonal Circumplex (IPIP-IPC) in Chinese People Living with HIV (PLWH)

Background and Purpose

With the improved life expectancy of people living with HIV (PLWH) due to widespread use of antiretroviral therapy (ART), there is a greater emphasis on enhancing long-term well-being and overall quality of life for PLWH. Understanding interpersonal personalities of PLWH can gain further insight into how to improve the overall quality of life in this population. The International Personality Item Pool-Interpersonal Circumplex (IPIP-IPC) scale has been developed to assess interpersonal personalities of individuals, and this scale has been translated into Chinese. However, the Chinese version of IPIP-IPC has not been tested among PLWH in China. In this study, we aimed to test the psychometric properties and circumplex structure of this scale.

Methods

This study was based on cross-sectional, multi-center, large sample data. We employed the Chinese version of IPIP-IPC scale on 3040 PLWH from April 2022 to April 2023 in China to test its psychometric as well as circumplex properties. The structural summary method (SSM) was employed to analyze the circumplex structure of the scale.

Results

The total scale exhibited a Cronbach's alpha of 0.85 and McDonald's omega of 0.91. Out of the 288 possible relationships, 275 relationships satisfy the circular properties hypothesis. The scale demonstrates good reliability and validity, meeting the requirements of psychometrics.

Conclusion

Our findings demonstrate that the Chinese version of the IPIP-IPC scale is a reliable tool for evaluating interpersonal personalities in this population. These results highlight the validity and applicability of the IPIP-IPC scale specifically in the Chinese context, providing valuable insights into the intricacies of interpersonal traits among PLWH.

CBT for difficult-to-treat depression: self-regulation model

BACKGROUND

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat.

AIM

The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT.

METHOD

The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components.

RESULTS

A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation.

CONCLUSIONS

A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.

Effects of resilience and timing of adverse and adaptive experiences on interpersonal behavior: a transdiagnostic study in a clinical sample

Adverse childhood experiences (ACE) have been linked to less prosocial behavior during social exclusion in vulnerable groups. However, little is known about the impact of the timing of ACE and the roles of protective factors. Therefore, this study investigated the association of the behavioral response to experimental partial social exclusion with adverse and adaptive experiences across age groups and resilience in clinical groups with persistent depressive disorder and borderline personality disorder, i.e., groups with high ACE, and in healthy controls (HC) (N = 140). Adverse and adaptive experiences during childhood, youth, and adulthood were assessed with the Traumatic Antecedents Questionnaire, and resilience was measured with the Connor Davidson Resilience Scale. A modified version of the Cyberball paradigm was used to assess the direct behavioral response to partial social exclusion. In patients, adverse events during youth (B = - 0.12, p = 0.016) and adulthood (B = - 0.14, p = 0.013) were negatively associated with prosocial behavior, whereas in the HC sample, adaptive experiences during youth were positively associated with prosocial behavior (B = 0.25, p = 0.041). Resilience did not mediate these effects. The findings indicate that critical events during youth may be particularly relevant for interpersonal dysfunction in adulthood.

Comparison of the effect of hostility on the level of depression of drug addicts and non-addicts and the mediating role of sense of life meaning between them

BACKGROUND

The level of depression among drug addicts is generally higher than normal. Hostility and sense of life meaning may influence depression and become risk factors for depression. This study has three research purposes. First, to analyze whether drug use can aggravate hostility and depression levels. Second, to assess whether the hostility has different effects on depression among drug addicts and non-addicts. Third, to examine whether the sense of life meaning has a mediating role between different groups (drug addicts and non-addicts).

METHODS

This study was conducted from March to June 2022. 415 drug addicts (233 males and 182 females) and 411 non-addicts (174 males and 237 females) were recruited in Chengdu, Sichuan Province. After signing informed consent, their psychometric data were obtained using the Cook-Medley Hostility Scale (CMI), Beck Depression Inventory (BDI) and Meaning in Life Questionnaire (MLQ) questionnaires. Linear regression models were used to assess the impact of hostility and depression among drug addicts and non-addicts. Bootstrap mediation effect tests were used to further test the mediation effect of sense of life meaning between hostility and depression.

RESULTS

The results showed four main outcomes. First, compared with non-addicts, drug addicts had higher levels of depression. Second, hostility exacerbated depression in both drug addicts and non-addicts. Compared with non-addicts, hostile affect had a greater effect on depression in drug addicts. Third, the sense of life meaning among females was higher than males. Fourth, for drug addicts, the sense of life meaning showed a mediating effect between social aversion and depression, while for non-addicts, the sense of life meaning showed a mediating effect between cynicism and depression.

CONCLUSIONS

Depression is more severe in drug addicts. More attention should be paid to the mental health of drug addicts, because the elimination of negative emotions is conducive to reintegration into society. Our results provide a theoretical basis for reducing depression among drug addicts and non-addicts. As a protective factor, we can reduce their hostility and depression by improving the sense of life meaning.

Concept of Affective Dependence and Validation of an Affective Dependence Scale

Background

There is a degree of affective interdependence that is considered normal and only becomes pathological if it causes excessive suffering, both for the subject and for those close to them. Our objective was to introduce and psychometrically validate a short and effective affective dependency scale, the Affective Dependence Scale (ADS-9).

Methods

We used a sample of 762 participants (clinical: emotional dependent subjects n = 212, comparison: non-emotionally-dependent addicted subjects n = 272, and general population n = 278) to assess the factor structure, the psychological construct validity and the measurement invariance for the ADS-9 by means of independent exploratory factor analyses for each sample group and subsequent multigroup confirmatory factor analyses.

Results

Our results confirm that ADS-9 is a psychometrically consistent instrument, with construct and clinical validity, as well as configural, metric and scalar invariance across different sample groups (clinical, comparison and general population). A hypothesized two-dimensional structure was confirmed by means of factor analyses. Both sub-scales of this abbreviated form, Submission and Craving, showed a good agreement with the previously validated Relationships and Sentimental Dependencies Inventory (IRIDS-100).

Conclusion

The ADS-9 is a brief instrument that appears to reliably detect the dependent and pathological components of affective dependence. It consists of two sub-scales, describing Submission (adaptation, accommodation, and subjugation) and Craving (imperative need for the other with the presence of disturbing states). We suggest that it is a versatile scale that may be useful for clinicians and researchers.

Psychometric Properties of the Chinese Version of the Brief Interpersonal Competence Questionnaire for Adolescents

This study aimed to evaluate the psychometric properties of the Brief Interpersonal Competence Questionnaire (ICQ-15) administered to Chinese adolescents. A sample of 1705 adolescents (Mean age = 14.08, SD = 3.22, 46.5% male) completed a questionnaire including the Chinese version of the ICQ-15, as well as measurements of well-being, psychological resilience, and depression. To examine the psychometric properties of the ICQ-15, item analyses (item-total correlation and normality test), confirmatory factor analysis, concurrent validity analyses, multi-group analyses, and internal consistency analyses were performed. The results of the item analyses suggested a good item-total correlation, and the item scores were distributed approximately normally. The confirmatory factor analysis showed that the five-factor model had acceptable fit indices. The concurrent validity analyses indicated that the Chinese version of the ICQ-15 had a satisfactory concurrent validity. The multi-group analyses proved the measurement invariance across females and males, as well as participants in early, middle, and late adolescence. The ICQ-15 demonstrated satisfactory internal consistency reliability among Chinese adolescents. The ICQ-15 presents good psychometric properties and can be used to assess interpersonal competence in Chinese adolescents.

Temporal Associations between Depression and Hostility in the Context of a Divorce Intervention

Divorce interventions have been found effective in reducing negative outcomes for newly divorced people, including depression and hostility. Typically, divorce interventions cover a variety of issues that may influence people's level of depression and hostility. However, it is unclear whether the interventions differentially affect the outcomes. That is, it may be that intervention participation leads to a reduction in depression, which is associated with a prospective reduction in hostility - or vice versa. The current study used a sample of 1,856 recently divorced Danes, who completed questionnaires at baseline, 3-, 6-, and 12-month post-divorce. Structural equation modeling revealed that while depression and hostility were concurrently associated, there were no prospective associations, except for baseline depression predicting 3-month hostility. Moreover, the associations did not differ by gender. The results suggest that the intervention content may have influenced both depression and hostility. These findings may be useful in guiding future divorce intervention developments.

Metacognitive Beliefs Uniquely Contribute to Interpersonal Problems: A Test Controlling for Adult Attachment, Big-5 Personality Traits, Anxiety, and Depression

Interpersonal difficulties are common across psychological disorders and are a legitimate target of treatment. Psychotherapeutic models differ in their understanding of interpersonal problems and how these problems are formulated and treated. It has been suggested that they are both the cause and effect of emotional distress symptoms, that they result from early attachment experiences, and that they are related to personality dimensions. However, the metacognitive model of psychopathology predicts that emotion disorder symptoms and interpersonal problems are linked to a common set of factors involving dysfunctional metacognition. In support of this view, metacognitive therapy has substantially reduced interpersonal problems in patients with anxiety and depression even though interpersonal problems are not directly targeted, indicating a role for metacognitive change. Nevertheless, the relationship between interpersonal problems and metacognitive beliefs remains underexplored, and the statistical control of emotion symptoms, personality, and attachment is important in substantiating any metacognition effects. The aim of the present study was therefore to test metacognitive beliefs as statistical predictors of interpersonal problems while controlling for anxiety/depression, adult attachment, and the Big-5 personality dimensions. In a cross-sectional study, 296 participants completed a battery of self-report questionnaires. We found that positive- and negative-metacognitive beliefs, cognitive confidence, and cognitive self-consciousness accounted for significant and unique variance in interpersonal problems together with avoidant attachment and conscientiousness when the overlap between all predictors was controlled. These findings support the notion that metacognitive beliefs are relevant to interpersonal problems with the potential implication that metacognitive therapy could have particularly broad effects on both emotion disorder symptoms and interpersonal problems.

Change in Interpersonal and Metacognitive Skills During Treatment With Cognitive Behavioral Analysis System of Psychotherapy and Metacognitive Therapy: Results From an Observational Study

Background: Interpersonal skills deficits and dysfunctional metacognitive beliefs have been implicated in the etiology and maintenance of depression. This study aimed to investigate the association between changes in these skills deficits and change in depressive symptoms over the course of treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT). Methods: In this prospective, parallel group observational study, data was collected at baseline and after 8 weeks of an intensive day clinic psychotherapy program. Based on a shared decision between patients and clinicians, patients received either CBASP or MCT. Ninety patients were included in the analyses (CBASP: age M = 38.7, 40.5% female, MCT: age M = 44.7, 43.3% female). Interpersonal deficits were assessed with the short-form of the Luebeck Questionnaire for Recording Preoperational Thinking (LQPT-SF) and the Impact Message Inventory (IMI-R). Metacognitive beliefs were assessed with the Metacognition Questionnaire-30 (MCQ-30). The Quick Inventory of Depressive Symptomatology (QIDS-SR16) was utilized to assess depressive symptoms. A regression analysis was conducted to assess variables associated with outcome. ANCOVAs were utilized to investigate whether improvement in skills deficits is dependent on type of treatment received. Results: Improvements in preoperational thinking and increases in friendly-dominant behavior were associated with change in depressive symptoms. There was no association between reductions in dysfunctional metacognitive beliefs and a decrease in depressive symptoms. While both treatment groups showed significant improvements in interpersonal and metacognitive skills, there was no significant between-group difference in the change scores for either of these skills. Conclusion: Our findings suggest that changes in interpersonal skills seem to be of particular relevance in the treatment of depression. These results have to be replicated in a randomized-controlled design before firm conclusions can be drawn.

Negative Effects of a Multimodal Inpatient CBASP Program: Rate of Occurrence and Their Impact on Treatment Outcome in Chronic and Treatment-Resistant Depression

Background: A growing number of studies indicate that the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is effective in treating chronic depression. However, there is no systematic research into possible negative effects. Therefore, the objectives of the study were to investigate the rate of occurrence of negative effects of an inpatient CBASP program and their impact on treatment response. Methods: Patients with chronic depression and treatment resistance who completed the 12-week multimodal inpatient CBASP treatment program in an open trial (N = 52) retrospectively completed the Inventory for the Assessment of Negative Effects of Psychotherapy (INEP) during follow-up data collection. Severity of depressive symptoms was assessed self- and observer-rated at admission, discharge, and 6 months follow-up. Rates of occurrence of negative effects were calculated and binary logistic regression analyses were conducted to determine the relationship to treatment outcome. Results: The results indicate that 92.3% of patients reported having experienced at least one negative effect and 45.2% indicated dependence on their therapist. Stigmatization and financial concerns as well as intrapersonal changes were reported by about one-third. Only dependence on the therapist negatively impacted treatment outcome in both outcome measures. Conclusions: While almost all patients reported at least one negative effect of a multimodal inpatient CBASP treatment program, most of the reported negative effects appear to be benign. However, dependence on the therapist seems to have a negative impact on treatment outcome. If these results can be replicated in future large-scale, randomized controlled prospective studies, CBASP therapists should be aware of possible dependence and consciously address it during treatment.

Self-Reported Depressive Symptoms and Suicidality in Adolescents with Attention-Deficit/Hyperactivity Disorder: Roles of Bullying Involvement, Frustration Intolerance, and Hostility

This study examined the relationships of cyberbullying and traditional bullying victimization and perpetration, perceived family function, frustration discomfort, and hostility with self-reported depressive symptoms and suicidality in adolescents diagnosed as having attention-deficit/hyperactivity disorder (ADHD). Both the self-reported severity of depressive symptoms on the Center for Epidemiological Studies Depression Scale and the occurrence of suicidal ideation or a suicide attempt on the suicidality module of the Kiddie Schedule for Affective Disorders and Schizophrenia were assessed in 195 adolescents with ADHD. The adolescents completed the Cyberbullying Experiences Questionnaire, Chinese version of the School Bullying Experience Questionnaire, Frustration–Discomfort Scale, Buss–Durkee Hostility Inventory, and Family APGAR Index. Caregivers completed the ADHD problems component of the Child Behavior Checklist for Ages 6–18. Multiple regression analyses were used to examine the correlates for each of self-reported depressive symptoms and suicidality. The results showed that after the effects of gender, age, ADHD symptoms, and family function were controlled, greater frustration discomfort and bullying perpetration significantly predicted self-reported depressive symptoms. Being cyberbullying victims and displaying hostility significantly predicted the risk of suicidality. Various types of bullying involvement, frustration intolerance, and hostility significantly predicted self-reported depressive symptoms and suicidality in adolescents with ADHD. By monitoring and intervening in these factors, we can reduce the risk of depression-related problems and suicidality in adolescents with ADHD.

Perpetration of and Victimization in Cyberbullying and Traditional Bullying in Adolescents with Attention-Deficit/Hyperactivity Disorder: Roles of Impulsivity, Frustration Intolerance, and Hostility

Victimization and perpetration of cyberbullying and traditional bullying are prevalent among adolescents with attention-deficit/hyperactivity disorder (ADHD). This study examined the associations of impulsivity, frustration discomfort, and hostility with victimization and with the perpetration of cyberbullying and traditional bullying in adolescents with ADHD. Self-reported involvement in cyberbullying and traditional bullying was assessed in 195 adolescents with a clinical diagnosis of ADHD. Adolescents also completed questionnaires for impulsivity, frustration discomfort, and hostility. Caregivers completed the Child Behavior Checklist for adolescents’ ADHD, internalization, oppositional defiance, and problems with conduct. The associations of impulsivity, frustration discomfort, and hostility with victimization and perpetration of cyberbullying and traditional bullying were examined using logistic regression analysis. The results demonstrated that after the effects of demographic characteristics and behavioral problems were controlled for, frustration intolerance increased the risks of being cyberbullying victims and perpetrators whereas hostility increased the risks of being the victims and perpetrators of traditional bullying. Impulsivity was not significantly associated with any type of bullying involvement. Prevention and intervention programs should alleviate frustration intolerance and hostility among adolescents with ADHD.

Cognitive Behavioral Analysis System of Psychotherapy for inpatients with persistent depressive disorder: a naturalistic trial on a general acute psychiatric unit

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was originally developed for outpatients with persistent depressive disorder (PDD). We adapted CBASP as inpatient treatment on a general acute psychiatric ward and evaluated its outcome and feasibility. Sixty PDD patients received a 12-week multidisciplinary CBASP program. Hamilton Depression Rating Scale (HAMD₂₄) and Beck Depression Inventory (BDI-II) served as primary and secondary outcome measures. Childhood maltreatment at baseline and change in interpersonal distress from pre to post were investigated as predictors of treatment outcome. A 6-month follow-up assessment was conducted. Feasibility was assessed through dropouts and satisfaction with the program. Fifty patients completed the program (16.7% dropouts). An ANOVA with three repeated measurements (pre, post, FU) in the ITT sample revealed a main effect of time. For the primary outcome, depressive symptoms decreased from pre (28.3) to post (11.5, response rate: 72.7%, d = 1.8), and from pre to FU (13.9, d = 1.2). Four patients relapsed. The secondary outcome confirmed the results; however, the response rate was lower (BDI-II: 31.7%, pre to post: d = 0.8, pre to FU: d = 0.3), and ten patients relapsed at FU. Reduction in interpersonal distress, but not childhood maltreatment, predicted BDI-II response. Key limitations of this naturalistic open trial are the lack of a comparison group and non-blinded HAMD₂₄ ratings. Inpatient CBASP for PDD appears feasible on a general acute psychiatric ward with effect sizes comparable to specialized psychotherapy wards and to the outpatient setting.

A randomized controlled trial examining the impact of individual trauma-focused therapy for individuals receiving group treatment for depression

OBJECTIVES

Adverse life events are associated with increased likelihood of depression and poorer prognosis. Trauma-focused treatments (TFT) appear to be effective in decreasing comorbid depressive symptoms. Accordingly, the aim of this study was to evaluate the effectiveness of a TFT on the memories of aversive events for individuals with a primary diagnosis of depression.

METHODS

A randomized controlled trial was conducted with 49 participants recruited from a 10-day outpatient group programme. All participants showed symptoms of depression with a subgroup (80%) meeting the DSM-5 criteria for a major depressive episode. Participants received treatment as usual (TAU); three additional individual trauma-focused sessions; or three additional individual assertiveness training sessions. Participants were assessed with regards to depression diagnosis and related symptoms.

RESULTS

For participants with a major depressive episode, the addition of trauma-focused sessions significantly increased the likelihood of remission when compared to TAU, or additional assertiveness training. While no significant treatment difference was noted in depressive symptom change post-treatment, six weeks after treatment those who received an adjunct treatment were more likely to maintain treatment gains than those who received TAU. Furthermore, at 12-week follow-up, participants who received a TFT reported significantly fewer depressive symptoms than those who received assertiveness training.

CONCLUSIONS

While differences in outcomes were minimal immediately post-treatment, differences among treatment groups increased over time. Thus, as few as three additional TFT sessions may impact positively on symptom change for people completing a group programme for the treatment of depression.

PRACTITIONER POINTS

Depression is the greatest cause of disability worldwide. Adverse experiences are linked with an increased likelihood of depression, more severe symptoms and poor treatment outcomes following evidence-based interventions. As few as three trauma-focused sessions can improve treatment outcomes in terms of depression diagnosis and related symptoms for individuals receiving group cognitive behavioural therapy.

Development of a Structured Interview to Explore Interpersonal Schema of Older Adults Living Alone Based on Autobiographical Memory

With a growing public interest in the social health of older adults, studies focusing on social networks and interpersonal relationships of older adults are needed. The present study was conducted to develop a structured interview to evaluate the interpersonal schema based on Self-Defining Memory of older adults. First, the word cues that the older adults often report on interpersonal events were confirmed. Next, the indices and scoring rules were prepared, including Relationship frequency (RF), Conflict frequency (CF), Dominance mean (Dm), and Warmth mean (Wm). Healthy older adults living alone (mean age = 71.81, SD = 3.95) were interviewed. Finally, the correlation between each index and Short form of Korean Inventory of Interpersonal Problems Circumplex Scales (KIIP-SC) was analyzed for criterion validity. The inter-rater reliability was substantial (Kappa = 0.61~0.66). Based on the analysis of criterion validity, the indices of CF, Dm, and Wm indices showed an appropriate level of criterion validity. This study developed a structural interview based on a novel system of reporting autobiographical memory and established indices with appropriate validity to evaluate interpersonal relationships. The interview is expected to identify the characteristics of interpersonal relationships of the older adults and contribute to the establishment of the older adults’ community accordingly.

Interpersonal clarification effects in Cognitive-Behavioral Therapy for depression and how they are moderated by the therapeutic alliance

BACKGROUND

Although a wide body of research links depression to interpersonal deficits, Cognitive-Behavioral Therapy (CBT), considered the gold standard in the treatment of this condition, has not been developed to specifically address interpersonal difficulties. However, cognitive changes on a relational level occurring during CBT might play an important role in the treatment of depression. Interpersonal clarification refers to the process of better understanding the nature of one's interpersonal patterns during therapy. The aim of this study is to analyze the effects of interpersonal clarification in CBT and how they are moderated by the therapeutic alliance.

METHODS

A sample of 621 patients diagnosed with depression were treated with CBT by 126 therapists in a university outpatient clinic. Patients completed measures of interpersonal problems and depression severity at baseline, measures of symptomatic evolution before each session and process measures (assessing interpersonal clarification and alliance) after each session. Multilevel models separating between-patient (BP) and within-patient (WP) effects of interpersonal clarification, and including BP and WP alliance effects as covariates and moderators of the interpersonal clarification effects were conducted.

RESULTS

Analyses showed both significant BP and WP effects interpersonal clarification, even when adjusting for alliance effects. Furthermore, significant interactive effects were found between outcome of WP interpersonal clarification with both BP alliance and WP alliance.

LIMITATIONS

Interpersonal clarification was measured with one single-item and adherence to CBT was not explicitly measured.

CONCLUSIONS

The results present preliminary evidence for considering interpersonal clarification a meaningful change process in CBT for depression, especially in the context of a stronger therapeutic alliance.

Interpersonal Change During Inpatient CBASP Treatment: Focus on Group Therapy

Background: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has been tailored specifically to the demands of patients with persistent depressive disorder (PDD). According to the CBASP model, PDD patients are supposed to live perceptually disconnected from their social environment, which consequently maintains depression. While initially developed as an individual treatment modality, the adaptation for group therapy yields an important interpersonal space. However, little is known about the specific factors that contribute to patients' benefit from the CBASP group modality. Methods: The analyzed sample comprised N = 87 PDD patients who completed a 12 week multimodal inpatient treatment including 2 weekly CBASP-specific individual and group sessions, respectively, as well as CBASP-unspecific medical contacts, pharmacotherapy and complementary therapies. Group sessions included trainings in situational analysis and interpersonal skills. Interpersonal change over therapy was examined based on the patients' self-perceived interpersonal problems (IIP) and the impact messages as perceived by their individual therapists (IMI). Pre and post-treatment data were compared using within-sample t-tests. Additionally, patients evaluated CBASP group therapy on a feedback form. They were invited to reflect on individual benefits and its helpful and unhelpful aspects. Qualitative content analysis with inductive category development was used to analyze feedback. Inter-rater reliability was computed to confirm categories before summarizing the frequencies of reported factors. Results: Self-perceived interpersonal distress significantly decreased over therapy. Patients reported reduced interpersonal problems and therapists reported more friendly and dominant impact messages. Interestingly, patients who showed a significant depressive symptom reduction described higher change scores. Regarding qualitative data, patients reported five main benefits from group therapy: Gain in social competence, self-confidence, self-reflection, interpersonal dynamics, and optimism/universality. Patients responding to CBASP identified significantly more factors than non-responders. Conclusions: Compared to studies with individual CBASP only, the present findings suggest that CBASP group therapy may contribute to the improvement of interpersonal behavior. Group therapy is discussed as a potential boosting effect for individual CBASP. However, as the present data were collected in a multimodal inpatient setting without competitor, randomized controlled trials are warranted that investigate the specific benefits of the group modality or the combined individual and group therapy over individual CBASP only.

Reduced Social Connectedness and Compassion Toward Close Others in Patients With Chronic Depression Compared to a Non-clinical Sample

Reduced social functioning in depression has been explained by different factors. Reduced social connectedness and prosocial motivation may contribute to interpersonal difficulties, particularly in chronic depression. In the present study, we tested whether social connectedness and prosocial motivation are reduced in chronic depression. Forty-seven patients with persistent depression and 49 healthy controls matched for age and gender completed the Inclusion of the Other in the Self Scale (IOS), the Compassionate Love Scale (CLS), the Beck Depression Inventory-II, and the Childhood Trauma Questionnaire. A Multivariate analysis of variance (MANOVA) with IOS and CLS as dependent variables revealed a highly significant difference between both groups. The IOS and the CLS-subscale Close Others were lower in persistent depression, whereas there was no difference in the CLS-subscale Strangers/Humanity. IOS and CLS-Close Others showed significant negative correlations with depressive symptoms. Connectedness to family members as measured by the IOS was negatively correlated with childhood trauma in patients with chronic depression. The results indicate that compassion and perceived social connection are reduced in depressed patients toward close others, but not to others in general. Implications for the treatment of depression are discussed.

Loneliness, Social Isolation and Their Difference: A Cross-Diagnostic Study in Persistent Depressive Disorder and Borderline Personality Disorder

Background: Interpersonal difficulties are a key feature of persistent depressive disorder (PDD) and borderline personality disorder (BPD). Caught in a vicious circle of dysfunctional interpersonal transaction, PDD and BPD patients are at great risk of experiencing prolonged loneliness. Loneliness, in turn, has been associated with the development of mental disorders and chronic illness trajectories. Besides, several factors may contribute to the experience of loneliness across the lifespan, such as social network characteristics, a history of childhood maltreatment (CM), and cognitive-affective biases such as rejection sensitivity (RS). This cross-diagnostic study approached the topic of perceived loneliness by comparing PDD and BPD patients with healthy controls (HC) in its interplay with symptom burden, social network characteristics, RS as well as CM. Method: Thirty-four PDD patients (DSM-5; 15 female, Mage = 38.2, SD = 12.3), 36 BPD patients (DSM-5; 19 female, Mage = 28.8, SD = 9.2), and 70 age- and gender-matched HC were assessed cross-sectionally using the following self-report measures: UCLA Loneliness Scale, Social Network Index (SNI; size, diversity, and embeddedness), Beck Depression Inventory (BDI-II), Borderline Symptom List (BSL-23), Childhood Trauma Questionnaire (CTQ), and Rejection Sensitivity Questionnaire (RSQ). Results: Both patient groups reported significantly higher levels of perceived loneliness, symptom severity, and smaller social network characteristics compared to HC. Loneliness was significantly correlated with severity of self-reported clinical symptoms in PDD and at trend level in BPD. Besides, loneliness tended to be related to social network characteristics for all groups except PDD patients. Both PDD and BPD patients showed higher RS as well as CTQ scores than HC. A history of emotional abuse and emotional neglect was associated with loneliness, and this association was mediated by RS as demonstrated by an exploratory mediation analysis. Discussion: Loneliness is highly prevalent in PDD and BPD patients and contributes to the overall symptom burden. Interestingly, loneliness showed an association with prior experiences of CM as well as current RS. We therefore propose a comprehensive model on how intra- und interpersonal aspects may interplay in the dynamics of loneliness in light of CM. Finally, this model may have further implications for psychotherapeutic interventions.

Understanding versus feeling the emotions of others: How persistent and recurrent depression affect empathy

Empathy refers to the ability to understand the emotions of others. It encompasses a cognitive component of decoding a mental state, and an affective component that relates to an emotional response. Deficits in empathy have been associated with social dysfunction in depression. It is further assumed that impairments are aggravated when depression takes a chronic course. Existing evidence in the literature, however, is scarce and heterogeneous. The present study investigated empathy in patients with persistent and recurrent depression as well as in healthy controls (N = 102). Empathy measurements included both self-report (Interpersonal Reactivity Index, IRI) as well as a laboratory task (Multifaceted Empathy Task, MET). A mixed model analyses of covariance, which accounted for differences in executive functioning, found no evidence for impaired cognitive empathy in depression. All three groups performed equally well in understanding mental states. However, both IRI and MET confirmed the hypothesis of significant deficits in affective empathy. Patients reported higher personal distress than controls, and showed lower affective responses towards positive emotions in others. There was no difference between patient groups. Childhood maltreatment was further related to reduced affective empathy. The present results contribute to our understanding of social dysfunction in depression, since loss of emotional reactivity to the feelings of others is considered to reduce the desire to engage in social interaction, thus leading to isolation and aggravation of depression.

A comparison of the three year course between chronic depression and depression with multiple vs. few prior episodes

This study tested the hypothesis that chronic depression (CD) is more similar to depression with multiple prior episodes (ME) than to depression with few prior episodes (FE). Data from participants (n = 1013) with mild to moderate depressive symptoms (Patient Health Questionnaire [PHQ-9] score 5 - 14) who took part in a randomized control trial of an internet intervention for depression (EVIDENT trial) were re-analyzed. The MINI-interview was conducted to diagnose CD (n = 376). If CD was not diagnosed, the self-reported number of depressive episodes was used to categorize participants as having episodic depression with up to five (FE, n = 422) or more than five (ME, n = 215) prior episodes. Over a three-year period, participants were assessed repeatedly regarding the course of depression (PHQ-9, QIDS), quality of life (SF-12) and therapeutic progress (FEP-2). At baseline, most scores were different between CD and FE but comparable between CD and ME. Time to remission did not differ between CD and ME but was longer in CD compared to FE. Results suggest that ME closely resembles CD and that CD differs from FE.

Preoperational Thinking as a Measure of Social Cognition Is Associated With Long-Term Course of Depressive Symptoms. A Longitudinal Study Involving Patients With Depression and Healthy Controls

BACKGROUND

Deficits in social cognition, referred to as preoperational thinking, are assumed to play a key role in the pathogenesis of persistent depression. The aim of this study was to explore the effect of preoperational thinking on the two-year course of depressive symptoms in a sample of persistently depressed, episodically depressed as well as healthy participants.

METHODS

We recruited 43 persistently depressed participants, 26 episodically depressed participants and 16 healthy control participants. Preoperational thinking was assessed at baseline with the Luebeck Questionnaire for Recording Preoperational Thinking. Over the period of two years, the course of depressive symptom severity was measured every three months using the Inventory of Depressive Symptomatology.

RESULTS

Using linear mixed model analysis we found a significant effect for the influence of preoperational thinking on the severity of depressive symptoms in the observation period. We found a non-significant statistical trend for an association of preoperational thinking with the change of depressive symptom severity.

CONCLUSION

Our analyses suggest that a high degree of preoperational thinking is associated with a higher severity of depressive symptoms and possibly less symptom improvement. These findings support the notion that preoperational thinking is a relevant factor for the further course of depression and might indeed contribute to the maintenance of persistent depression.

Patients' interpersonal problems as moderators of depression outcomes in a randomized controlled trial comparing mindfulness-based cognitive therapy and a group version of the cognitive-behavioral analysis system of psychotherapy in chronic depression

OBJECTIVES

Interpersonal problems were examined as moderators of depression outcomes between mindfulness-based cognitive therapy (MBCT) and cognitive behavioral analysis system of psychotherapy (CBASP) in patients with chronic depression.

METHODS

Patients received treatment-as-usual and, in addition, were randomized to 8-weeks of MBCT (n = 34) or 8-weeks of CBASP (n = 34). MBCT and CBASP were given in a group format. The Hamilton depression rating scale (HAM-D) was the primary and the Beck Depression Inventory (BDI-II) the secondary outcome. The subscales of the Inventory of interpersonal problems (IIP-32) were moderators. Multilevel models were performed.

RESULTS

Higher scores on the "vindictive/self-centered" subscale were associated with a better outcome in MBCT than in CBASP (HAM-D: p < .01; BDI-II: p < .01). Higher scores on the "nonassertive" subscale were associated with a better outcome in CBASP than in MBCT (HAM-D: p < .01; BDI-II: p < .01).

CONCLUSIONS

If these results can be replicated in larger trials, MBCT should be preferred to CBASP in chronically depressed patients being vindictive/self-centered, whereas CBASP should be preferred to MBCT in chronically depressed patients being nonassertive.

Persistent depressive disorder across the adult lifespan: results from clinical and population-based surveys in Germany

BACKGROUND

Although the individual and economic disease burden of depression is particularly high for long-term symptoms, little is known of the lifetime course of chronic depression. Most evidence derives from clinical samples, and the diagnostic distinction between persistent depressive disorder (PDD) and non-chronic major depression (NCMDD) is still debated. Thus, we examined characteristics of PDD among clinical vs. non-clinical cases, and the associated disease burden at a population level.

METHODS

Data were drawn from the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH, 2009-2012, n = 4483) and a clinical sample of PDD inpatients at Charité - Universitätsmedizin Berlin (2018-2019, n = 45). The DSM-5 definition of PDD was operationalized a priori to the study using interview-based DSM-IV diagnoses of dysthymia and major depression lasting at least 2 years in both surveys. Additional depression characteristics (depression onset, self-classified course, suicidality, comorbid mental disorders, treatment history and current depressive symptoms [Patient Health Questionnaire-9]) were assessed. In the DEGS1-MH, health-related quality of life (Short Form Health Survey-36, SF-36), chronic somatic conditions, number of sick days (past 12 months) or days with limitations in normal daily life activities (past 4 weeks), and health service utilization (past 12 months) were compared for PDD vs. NCMDD.

RESULTS

PDD cases from the clinical sample had a significantly earlier depression onset, a higher proportion of self-classification as persistent course, and treatment resistance than PDD and NCMDD cases in DEGS1-MH. At a population level, PDD cases showed worse outcomes compared with NCMDD cases in terms of somatic comorbidity, SF-36 mental component score, and activity limitations owing to mental health problems, as well as a higher risk for outpatient mental health care contact.

CONCLUSIONS

The distinction between PDD and NCMDD proposed for DSM-5 seems warranted. Early onset depression, self-classification as persistent depressive course, and treatment resistance are suggested as markers of more severe and chronic depression courses. At a population level, PDD is associated with remarkably higher individual and economic disease burden than NCMDD, highlighting the need to improve medical recognition of chronic courses and establish specific treatment concepts for chronic depression.

Social Cognition and Interpersonal Problems in Persistent Depressive Disorder vs. Episodic Depression: The Role of Childhood Maltreatment

Objective: Little is known about the specific psychological features that differentiate persistent depressive disorder (PDD) and episodic depression (ED). Thus, the present study aimed to investigate differences in social cognition and interpersonal problems between these two forms of depression and healthy controls. In addition, we aimed to examine childhood maltreatment (CM) as a possible origin of these alterations. Methods: In a cross-sectional study, adult patients with a current PDD (n = 34) or in a current episode of ED (n = 38), and healthy controls (n = 39) completed questionnaires about depression severity, empathy, interpersonal problems, and CM, as well as tests of affective theory of mind and facial emotion recognition. Results: Patients with PDD reported higher empathic distress than patients with ED and healthy controls. Both depressive groups recognized angry faces with higher accuracy and reported more interpersonal problems, with no differences between PDD and ED. Empathic distress and interpersonal problems mediated the link between CM and depression in the combined sample. Limitations: Patient groups were not drug-naïve and antidepressant intake might have influenced social-cognitive functions. Self-report measures of empathy and interpersonal problems are vulnerable to bias. The cross-sectional design does not allow causal conclusions. Conclusion: Depressed patients may not show deficits in decoding the affective states of others and in feeling with others. However, depressed individuals-in particular patients with PDD-may feel easily overwhelmed by emotionally tense situations, resulting in empathic distress and avoidant/submissive interpersonal behavior. Exposure to CM might be an origin of alterations in social cognition and interpersonal problems.

A systematic review of the impact of social cognitive deficits on psychosocial functioning in major depressive disorder and opportunities for therapeutic intervention

Social cognition is the ability to identify, perceive and interpret socially relevant information from the external world. It is an important adaptive trait, but is frequently affected in major depressive disorder by a mood-congruent interpretive bias. The present review examined the existing body of literature to determine (i) the impact social cognitive deficits in depression have on psychosocial functioning; and (ii) the utility of psychotropic, psychological and procedural interventions employed to target these deficits. A total of 107 studies met inclusion criteria for review. Social cognitive performance was found to adversely impact depressed patients' psychosocial functioning across the key domains of general cognitive functioning and quality of life. Secondly, many current therapies were found to have a normalising effect on the social cognitive abilities of subjects with major depressive disorder, both at a neural and functional level. In particular, certain anti-depressant medications corrected facial affect recognition deficits, while several psychotherapeutic approaches improved impairments in theory of mind and negative interpretive bias.