Can integrating the Memory Support Intervention into cognitive therapy improve depression outcome? Study protocol for a randomized controlled trial

Cognitive Therapy-as-Usual versus Cognitive Therapy plus the Memory Support Intervention for adults with depression: 12-month outcomes and opportunities for improved efficacy in a secondary analysis of a randomized controlled trial

OBJECTIVE

Patient memory for treatment is emerging as an important transdiagnostic mechanism of treatment outcomes. However, patient memory for treatment is limited. The Memory Support Intervention was developed to improve patient memory for treatment and thereby strengthen treatment outcomes. In this secondary analysis, the primary, preregistered aim was to test the 12-month follow-up outcomes of the Memory Support Intervention when used with cognitive therapy (CT + MS) for major depressive disorder, relative to CT-as-usual. The secondary, exploratory aim was to investigate opportunities to improve efficacy of the Memory Support Intervention.

METHOD

Adults (N = 178) with major depressive disorder were randomized to CT-as-usual or CT + MS. Therapist use of memory support and patient memory for treatment, depression symptoms, and overall functioning were measured in blind assessments.

RESULTS

Findings did not support differences between treatment conditions at 12-month follow-up. Therapists used memory support strategies with a narrow subset of treatment contents, and similarly, patients recalled a narrow subset of treatment contents.

CONCLUSIONS

The findings highlight ways to strengthen the efficacy of the Memory Support Intervention, such as applying memory support strategies across a wider variety of treatment contents, which in turn, may boost patient recall and outcomes.

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression

Background

To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity.

Method

150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator.

Discussion

Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression.

Trial registration

The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

Measuring Memory for Treatment Using Patient Conceptualizations of Clinical Vignettes: A Pilot Psychometric Study in the Context of Cognitive Therapy for Depression

Background

Patient memory for psychological treatment contents is a promising transdiagnostic mechanism of change, but there is little consensus concerning its measurement. We conducted a pilot psychometric investigation of the Conceptualization Task, a novel measure of patient memory for treatment.

Methods

Data were from a trial comparing cognitive therapy-as-usual to cognitive therapy plus the Memory Support Intervention (MSI) for adults with depression (N = 171). For the Conceptualization Task, patients read clinical vignettes and provided written responses to assess three facets of conceptualization: identifying contributing factors to psychopathology, making intervention recommendations, and providing a rationale for recommendations. Higher scores were given to responses reflecting accurate memory for the theoretical model and change strategies used in treatment.

Results

The Conceptualization Task showed excellent inter-rater reliability and sensitivity to change during treatment, but only fair test–retest reliability and insufficient internal consistency. Findings supported discriminant validity with measures of education, IQ, and general memory functioning, but not convergent validity with existing measures of patient memory for treatment. Criterion validity analyses showed that some aspects of the Conceptualization Task were associated with therapist use of memory support strategies from the MSI and treatment outcome. However, findings were mixed, effect sizes were small, and some results did not remain statistically significant after correcting for multiple comparisons.

Conclusions

Further refinement and testing is needed before the Conceptualization Task may be used to assess the patient memory for treatment contents.

The Development and Validation of the Memory Support Treatment Provider Checklist

Patient memory for the contents of treatment is staggeringly poor, and poor memory for treatment is associated with worse treatment outcome. Accordingly, the Memory Support Intervention was developed to improve patient memory for treatment as an adjunct to treatment as usual. As plans to disseminate the Memory Support Intervention are developed, it is important to have efficient, accurate methods of measuring fidelity to the intervention. However, the existing method of assessing fidelity to the Memory Support Intervention, the Memory Support Rating Scale (MSRS), is burdensome and requires trained independent-raters to spend multiple hours reviewing session recordings, which is not feasible in many routine mental health care settings. Hence, a provider-rated measure of fidelity to the MSI has been developed. The goal of this study is to examine the reliability and validity of scores on this measure-the Memory Support Treatment Provider Checklist. A sample of Memory Support Treatment Provider Checklists (N = 319) were completed by providers (N = 8) treating adults with depression (N = 84). Three metrics of the Memory Support Treatment Provider Checklist were evaluated: (a) the internal consistency and structural validity using confirmatory factor analysis based on prior research on the MSRS and the Memory Support Intervention, (b) construct validity, and (c) predictive validity. Results indicate that the Memory Support Treatment Provider Checklist yields reliable and valid scores of fidelity to the Memory Support Intervention. Overall, this checklist offers a viable, brief method of evaluating fidelity to the Memory Support Intervention.

Prospective mental imagery in depression: Impact on reward processing and reward-motivated behaviour

Background

Mental imagery has long been part of cognitive behavioural therapies. More recently, a resurgence of interest has emerged for prospective mental imagery, i.e. future-directed imagery-based thought, and its relation to reward processing, motivation and behaviour in the context of depression.

Method

We conducted a selective review on the role of prospective mental imagery and its impact on reward processing and reward-motivated behaviour in depression.

Results

Based on the current literature, we propose a conceptual mechanistic model of prospective mental imagery. Prospective mental imagery of engaging in positive activities can increase reward anticipation and reward motivation, which can transfer to increased engagement in reward-motivated behaviour and more experiences of reward, thereby decreasing depressive symptoms. We suggest directions for future research using multimodal assessments to measure the impact of prospective mental imagery from its basic functioning in the lab to real-world and clinical implementation.

Conclusion

Prospective mental imagery has the potential to improve treatment for depression where the aim is to increase reward-motivated behaviours. Future research should investigate how exactly and for whom prospective mental imagery works.

This review provides a selected update of the literature on prospective mental imagery.

Prospective mental imagery might decrease depression via reward processing and reward-motivated behaviours.

Suggestions for future research to investigate these hypotheses are provided.

Client memory and learning of treatment contents: An experimental study of intervention strategies and relationship to outcome in a brief treatment for procrastination

BACKGROUND AND OBJECTIVES

Client memory and learning is limited for psychological treatment contents. This study investigated different approaches to support client memory and learning of treatment contents and the relationship between memory and learning of treatment contents and outcome.

METHODS

Adult participants (n = 428) were recruited through Amazon's Mechanical Turk and randomized to complete one of three versions of a one-session procrastination intervention. Two versions of the intervention included different amounts of memory support strategy types from the Memory Support Intervention. A control version did not include any types of memory support. Memory and learning of treatment contents were assessed immediately after the intervention and one week later. Procrastination and two mechanisms of procrastination (impulsiveness and self-efficacy) were assessed at baseline and one week after the intervention.

RESULTS

Contrary to the hypotheses, a version of the intervention with multiple types of memory support strategies was not associated with better memory and learning of treatment contents than a version of the intervention with only one type of memory support strategy or the control intervention. Greater memory and learning of treatment contents predicted improvement in mechanisms of procrastination, but not procrastination itself.

LIMITATIONS

The mean level of procrastination in this study was lower than in other treatment studies of procrastination.

CONCLUSIONS

Results partially support the rationale for the Memory Support Intervention that improving client memory and learning of treatment contents can improve outcome. Findings suggest that the Memory Support Intervention may be simplified to include fewer strategies without compromising efficacy.

Working memory moderates the relation between the brain-derived neurotropic factor (BDNF) and psychotherapy outcome for depression

BACKGROUND

Insight into patient characteristics that predict response to treatment for major depressive disorder (MDD) may help to personalize treatment and improve outcomes. One mechanism that has been linked to the success of treatment for MDD is brain-derived neurotropic factor (BDNF). BDNF is implicated in learning and memory and may play a role in the effects of psychotherapy that involves changing cognitions and behaviors. In addition, only in individuals with low BDNF, low working memory capacity has been associated with increased symptoms of depression. However, the role of BDNF and working memory capacity in psychotherapy outcome is unclear. The aim of this study was to investigate the role of BDNF and its interaction with working memory capacity in psychotherapy outcomes for MDD.

METHOD

Adult patients with MDD were randomized to weekly or twice weekly sessions of cognitive behavioral therapy or interpersonal psychotherapy. BDNF Val66Met polymorphism (rs6265) (n = 138) was defined and serum BDNF was quantified before (n = 138) and after psychotherapy (n = 82).

RESULTS

Baseline serum BDNF and the Val66Met polymorphism were not associated with outcome and associations did not differ between treatment conditions. Working memory capacity significantly moderated the relation between baseline serum BDNF and outcome: high serum BDNF at baseline was related to less depressive symptoms following psychotherapy in the presence of high working memory capacity, but not low working memory capacity.

DISCUSSION

These findings, if replicated, might indicate that while BDNF may not be related to psychotherapy outcomes in general, they may play a role in the presence of specific learning processes such as working memory capacity.

The effects of retrieval versus rehearsal of online problem-solving therapy sessions on recall, problem-solving skills and distress in distressed individuals: An experimental study

BACKGROUND AND OBJECTIVES

Improving memory for the content of therapy sessions might increase the effects of psychological interventions. Previous studies showed that healthy individuals who took a memory test (retrieval) of studied material showed better long-term memory retention than individuals who restudied (rehearsal) the material. The aim of the current study was to find out whether we can translate these findings to a subclinical setting.

METHODS

Individuals with moderate levels of distress were randomized into retrieving (n = 46) or rehearsing (n = 49) four weekly sessions of online Problem-Solving Therapy (PST). Session recall, problem-solving skills and distress were measured at baseline, three days after each session and at one-week follow-up.

RESULTS

Retrieval led to overall higher recall, but this difference disappeared when controlling for the time spent on retrieval versus rehearsal. Retrieval did not lead to better problem-solving skills or less distress, compared to rehearsal. Baseline working memory performance moderated the effect of condition on recall after controlling for the time spent on retrieval versus rehearsal: the effect of retrieval compared to rehearsal on recall was larger for individuals with lower working memory performance.

LIMITATIONS

The sample mostly consisted of university students with overall high working memory scores.

CONCLUSIONS

This study provided the first evidence that retrieval of the content of PST sessions may lead to better session recall compared to rehearsal of the PST sessions in individuals with a low working memory score. Implications for the use of cognitive support strategies within a therapeutic setting are discussed.

Patient Memory for Psychological Treatment Contents: Assessment, Intervention, and Future Directions for a Novel Transdiagnostic Mechanism of Change

Patient memory for treatment contents is defined as memory for the ideas, concepts, skills, and/or insights (termed treatment points) that the therapist thinks are important for the patient to remember and implement as a part of therapy. This article reviews key findings on patient memory for treatment contents, describes the development and evaluation of the Memory Support Intervention (MSI), and outlines future directions for research. Patient memory for treatment contents is poor, and worse memory is associated with worse treatment outcome. The MSI is composed of eight memory support strategies that therapists incorporate frequently alongside treatment points delivered during treatment-as-usual. Training therapists to deliver the MSI may yield better treatment outcomes by enhancing patient memory for treatment contents. Future research is needed to understand how to best measure patient memory for treatment contents, and the mediators, moderators, and dissemination potential of the MSI.