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

Self-critical perfectionism, dependency and entropy during cognitive behavioural therapy for depression

OBJECTIVES

This study examined whether 'personality vulnerability' (i.e., self-critical perfectionism or dependency) predicts the trajectory of change, as well as variability and instability (i.e., entropy) of symptoms, during cognitive behaviour therapy (CBT) for depression.

DESIGN

Study participants were outpatients (N = 312) experiencing a primary mood disorder. Participants received CBT for depression group sessions over 15 weeks. Self-report measures of self-critical perfectionism, dependency, and depression were collected longitudinally.

METHODS

A latent growth mixture modelling (LGMM) statistical approach was used to evaluate the presence of latent classes of individuals based on their longitudinal pattern of symptom change during CBT and to evaluate whether baseline self-critical perfectionism or dependency predicts class membership. A Latent Acceleration Score (LAS) model evaluated whether perfectionism or dependency led to variability in depression symptom change (e.g., velocity) by considering changes in velocity (e.g., acceleration and/or deceleration).

RESULTS

LGMM indicated the presence of two latent classes that represent symptom improvement (N = 239) or minimal symptom improvement over time (N = 73). Elevated baseline self-critical perfectionism, but not dependency, predicted a greater likelihood of membership in the class of participants who demonstrated minimal symptom improvement over time. The second analysis examined whether baseline self-critical perfectionism also predicts depression symptom variability and instability. The LAS perfectionism model demonstrated that perfectionism accelerates depression symptom change during the first seven sessions of treatment, then has a decelerating effect on depression symptom change.

CONCLUSIONS

Results indicated that higher baseline self-critical perfectionism predicted higher variability and instability in depression symptoms and variability in acceleration and deceleration, over the course of treatment.

Levels of depressed mood and low interest for two years after response to cognitive therapy for recurrent depression

BACKGROUND

Major depressive disorder (MDD) involves depressed mood (high negative affect, predominantly) and low interest/pleasure (low positive affect). In past research, negative affect has improved more than positive affect during acute-phase antidepressant medication or cognitive therapy (CT). We extended this literature by differentiating depressed mood and two dimensions of low interest (general and sexual), assessing persistence of symptom differences after acute-phase CT response, and testing whether continuation treatment acted differently on depressed mood versus low interest.

METHODS

We analyzed data from two randomized controlled trials. Patients with recurrent MDD first received acute-phase CT. Then, responders were randomized to 8-month continuation treatments and assessed for 16-24 additional months.

RESULTS

Depressed mood and low general interest improved more than low sexual interest during acute-phase CT. Among responders, these symptom differences persisted for at least 2 years and were not changed by continuation CT or antidepressant medication.

LIMITATIONS

Generalization of findings to other patient populations and treatments is uncertain. Depressed mood and low interest scales were constructed from standard symptom measures and overlapped empirically.

CONCLUSIONS

Less improvement during CT, and persistent low sexual interest despite continuation treatment, highlights the need for MDD treatments more effectively targeting this positive affective symptom.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

Gains in QOL made during response to acute-phase CT are relatively stable and may help protect against relapse/recurrence. Continuation CT or fluoxetine may not further improve QOL among acute-phase CT responders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

Non-social comorbid anxiety disorders may reduce the efficacy of acute-phase CT for MDD by diminishing both short- and longer term outcomes relative to depressed patients without comorbid anxiety disorders. Comorbid social anxiety disorder may increase relative reductions in depressive symptoms during acute-phase CT for MDD, but patients with comorbid social anxiety disorder may require specialized focus on social avoidance during CT.

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

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

Responding to acute-phase CT with a defined trajectory (orderly pattern) of symptom reduction predicts better longer term outcomes, but which defined trajectory (linear, log-linear, or one-step) appears unimportant. Frequent measurement of depressive symptoms to identify un/defined CT response trajectories may clarify need for continued clinical monitoring and treatment.

Cognitive Therapy to Prevent Depressive Relapse in Adults

The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT's preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.

Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression

OBJECTIVE

We tested nomothetic and idiographic convergence and change in 3 symptom measures during acute-phase cognitive therapy (CT) for depression and compared outcomes among patients showing different change patterns.

METHOD

Outpatients (N = 362; 69% women; 85% White; age M = 43 years) with recurrent major depressive disorder according to criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) completed the Hamilton Rating Scale for Depression (Hamilton, 1960), Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), and Inventory for Depressive Symptomatology-Self-Report (Rush, Gullion, Basco, Jarrett, & Trivedi, 1996) on 14 occasions as well as pre/post-CT measures of social-interpersonal functioning and negative cognitive content.

RESULTS

The 3 symptom measures marked the same severity and change constructs, and we offer improved formulas for intermeasure score conversions via their common factor. Pre/post-CT symptom reductions were large (ds = 1.71-1.92), and nomothetic symptom curves were log-linear (larger improvements earlier and smaller improvements later in CT). Nonetheless, only 30% of individual patients showed clear log-linear changes, whereas other patients showed linear (e.g., steady decreases; 20%), 1-step (e.g., a quick drop; 16%), and unclassified (34%) patterns. Log-linear, linear, and 1-step patients were generally similar to one another and superior to unclassified patients post-CT in symptom levels, response and stable remission rates, social-interpersonal functioning, and cognitive content (median d = 0.69).

CONCLUSIONS

Reaching a low-symptom "destination" at the end of CT via any coherent "path" is more important in the short term than which path patients take. We discuss implications for theories of change, clinical monitoring of individuals' progress in CT, and the need to investigate long-term outcomes of patients with differing patterns of symptom change.