The relationship of depression and stressors to immunological assays: a meta-analytic review.

This is a broad meta-analysis of the relations of both depression and stressors to immunological assays. The number of study samples (greater than 180) and measures (greater than 40) is much more extensive than any so far. Analyses are done by both fixed and random effects. By a fixed-effects analysis, both major depression and naturally occurring acute stressors are associated with (1) an overall leukocytosis, (2) mild reductions in absolute NK-cell counts and relative T-cell proportions, (3) marginal increases in CD4/CD8 ratios, and (4) moderate decreases in T- and NK-cell function. However, the degree of heterogeneity of the studies' results raises questions about their robustness. Therefore, we also did the first random effects analysis to estimate what is likely to appear in future studies. For depression, the analysis showed the immunological correlates included (1) an overall leukocytosis, manifesting as a relative neutrophilia and lymphoenia; (2) increased CD4/CD8 ratios; (3) increased circulating haptoglobin, PGE(2), and IL-6 levels; (4) reduced NK-cell cytotoxicity; and (5) reduced lymphocyte proliferative response to mitogen. For stressors, the random effects analysis showed that future studies are likely to find the following effects: (1) an overall leukocytosis, manifesting as an absolute lymphocytosis; (2) alterations in cytotoxic lymphocyte levels, CD4/CD8 ratios, and natural killer cell cytotoxicity with the direction of change depending on the chronicity of the stressor; (3) a relative reduction of T-cell levels; (3) increased EBV antibody titers; (4) reduced lymphocyte proliferative response and proportion of IL-2r bearing cells following mitogenic stimulation; and (5) increased leukocyte adhesiveness. The random-effects analysis revealed that for both major depression and naturally occurring stressors the following effects are shared: leukocytosis, increased CD4/CD8 ratios, reduced proliferative response to mitogen, and reduced NK cell cytotoxicity. The implications for these findings for disease susceptibility and the pathophysiology of these conditions is discussed.

The factor structure of the working alliance inventory in cognitive-behavioral therapy.

Studies of the therapeutic alliance in cognitive-behavioral therapy (CBT) have varied in their results, necessitating a deeper understanding of this construct. Through an exploratory factor analysis of the alliance in CBT, as measured by the Working Alliance Inventory (shortened, observer-rated version), the authors found a two-factor structure of alliance that challenges the commonly accepted one general factor of alliance. The results suggest that the relationship between therapist and client (Relationship) may be largely independent of the client's agreement with and confidence in the therapist and CBT (Agreement/ Confidence), necessitating independent measures of these two factors, not one measure of a general alliance factor.

The Penn Psychoanalytic Treatment Collection: a set of complete and recorded psychoanalyses as a research resource.

From a set of seventeen complete and tape-recorded psychoanalyses, a sample of findings is presented: (a) the level of agreement of two clinical judges on the psychological health of these patients is adequate for the late sessions, but not for the early sessions; (b) the amount of change during psychoanalysis appears to be similar to that in the Menninger Foundation Psychotherapy Research Project; (c) psychiatric severity measures from the early sessions can yield a significant level of prediction of the later benefits from psychoanalysis. Finally, further research uses of this collection of psychoanalyses are suggested.

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention.

The only clinical and quantitative study since Freud of the preconditions for recurrent symptoms during psychotherapy and psychoanalysis.

In this paper the author aims to evaluate theories of onset conditions both before psychological and before somatic symptoms by the first ever clinical-quantitative assessment of their preconditions, and then to compare these preconditions with Freud (1926) and with other theories of symptom formation. The seven cases in the sample were the only cases of recorded psychotherapy or psychoanalysis, each with recurrent symptoms in segments of sessions before symptoms versus segments of sessions before controls (with no symptoms) that were suitable for 'the symptom-context method'. The recurrent psychological symptom cases were: momentary forgettings, depressive shifts, and phobic feelings and behaviours; the recurrent somatic symptoms were stomach ulcer pains, migraine headaches, absence (petit mal) episodes and premature ventricular contractions (PVC) of the heart. Independent ratings of pre-symptom segments versus pre-control segments showed significant differences in all seven cases. Many emotional state qualities differentiating the pre-symptom from the pre-control segments were similar across cases. These were, in rank order, hopelessness, lack of control, anxiety, feeling blocked, helplessness, concern about 'supplies', depression, hostility to therapist, guilt, involvement with therapist, separation concern and hostility to others. For example, hopelessness significantly differentiated pre-symptom versus pre-control for all seven cases. For the first time, samples of segments of sessions before recurrent symptoms have been both clinically and quantitatively compared with segments without symptoms. Brief segments before recurrent symptoms showed significantly more of certain qualities than brief segments before controls where no symptoms appeared. These qualities led to the author's revised symptom-context theory of symptom formation and then to a comparison with five classical theories of symptom formation.

Predictors of self-help group attendance in cocaine dependent patients.

OBJECTIVE: While referral to self-help groups for patients dependent on drugs other than alcohol has become widespread in the substance abuse treatment field, little is known about the characteristics of people who attend these groups. This study examines particular sociodemographic and clinical characteristics as possible predictors of attendance at self-help groups in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. METHOD: A multicenter study randomly assigned 487 patients (76.8% men) to one of four psychosocial treatments for cocaine dependence. Patients were treated for 24 weeks. Among other measures, the Weekly Self-Help Questionnaire was administered each week and completed, at least once, by 411 subjects. RESULTS: Approximately two thirds of the patients attended one or more self-help meetings during the 24-week period. Patients initially more likely to attend self-help groups frequently were those who were unemployed, had no religious preference, had more severe baseline drug use and reported treatment for prior substance-related problems. Patients with more severe baseline drug use and those who previously received treatment for substance-related problems were more likely to maintain frequent attendance throughout the study period. Only severity of baseline drug use predicted more frequent attendance during Month 6, although there was a trend in Month 6 favoring more frequent attendance by women. These findings remained significant when treatment condition was added to the models. CONCLUSIONS: Although these findings are consistent with past research on alcohol dependent individuals, they challenge popular clinical notions about the types of people who attend self-help groups. These findings demonstrate that self-help groups can appeal to a wide variety of cocaine dependent patients.

A current reader's response to the article of 50 years ago by Karpman, B. (1949): "The principles and methods of objective psychotherapy".

The first aim is to describe the psychotherapy of 1949 in the light of today's psychotherapies. The old psychotherapy is suited to treating severely ill patients. It does not use free association, but rather is focused on current problems. It uses dreams, yet it also uses homework and bibliotherapy. The second aim is to critique the treatment. Consistent with its era. it does not make use of medications, and there is an absence of references to psychotherapy research, which was then just starting. The treatment relies over-heavily on the authority of the therapist. A third aim is to describe the changes in our field in the past 50 years and examine the predictions for the future. Although the treatment is called objective psychotherapy, it does not make use of the most up-to-date means of measuring accuracy of interpretations, such as the Core Conflictual Relationship Theme (CCRT) method and other methods like it.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

BACKGROUND: This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients. METHODS: Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month. RESULTS: Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed. CONCLUSION: Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Predictors of dropout from psychosocial treatment of cocaine dependence.

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

Therapist interventions in early sessions of brief supportive-expressive psychotherapy for depression.

Although psychotherapy manuals provide treatment guidelines, detailed descriptions of therapist interventions in manual-guided therapies are lacking. The purpose of the present investigation was to evaluate the types of therapist interventions in Supportive-Expressive (SE) psychotherapy for depression by using a molecular method of assessment and then to compare the results with those attained with a molar method. Four percent of therapist statements per session early in treatment were interpretations, which most often focused on the patient's parents, significant others, and self in the present time frame. This molecular method for assessing therapist interventions did converge with the molar adherence/competence method.

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence.

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels.

Who's afraid of psychoanalytic research? Analysts' attitudes towards reading clinical versus empirical research papers.

The authors point out that psychoanalytic research papers are cited with less frequency than clinical papers, and, presumably, are read with less frequency. Results from two sets of questionnaires from psychoanalysts indicate that a majority of analysts report high levels of conviction in the rationales and techniques in their clinical work. However, analysts with higher degrees of conviction read fewer research papers than analysts with lower degrees of conviction. The authors speculate that analysts with higher degrees of conviction may have an underlying sense of uncertainty about their analytic work. Their uncertainty may generate concerns that research may raise questions and doubts about their rationales and techniques, and, consequently, they have little interest in empirical psychoanalytic research. Such an attitude would be understandable because analysts sense or explicitly believe that confidence in their work is an important, perhaps essential, element in the mutative effects of treatment, and must be maintained and protected. The authors believe that clinical and research approaches have each contributed to the development of psychoanalysis and that both need to be used.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Repetitive relationship themes in waking narratives and dreams.

The aims of the study were to see whether the core conflictual relationship theme (CCRT) measure can be reliably applied to dreams and to evaluate the degree to which the main components of the CCRT are present in both dreams and waking narratives in psychotherapy. For 13 psychoanalytic cases, the reliability of the CCRT was found to be good. Dreams and narratives were found to contain significant degrees of similarity in their CCRT components and similar and high level of negativity in both dreams and waking narratives. The results support the concept of a central relationship pattern that can be expressed in common in both waking narratives and dreams.

Onset conditions for psychological and psychosomatic symptoms during psychotherapy: a new theory based on a unique data set.

OBJECTIVE: The author's goal was to evaluate theories of the conditions that exist before onset of psychological and somatic symptoms by assessing these preconditions clinically and quantitatively. METHOD: He assembled a set of texts from the cases of seven patients who had recurrent psychological or somatic symptoms and examined the segments of texts that came before the symptoms occurred; he then compared these segments with segments of text that occurred before control points in the same case. The recurrent psychological symptoms were momentary forgetting, shifts in level of depression, and phobic behavior; the recurrent somatic symptoms were stomach ulcer pains, migraine headaches, absence epilepsy (petit mal) episodes, and premature ventricular contractions of the heart. RESULTS: 1)Independent ratings of presymptom segments compared with precontrol segments revealed some significant differences in all seven cases. 2) Some variables that distinguished the presymptom from the precontrol segments occurred in all of the cases. In rank order of their effect size across cases, these variables were hopelessness, lack of control, anxiety, feeling blocked, helplessness, concern about "supplies," depression, and hostility toward the therapist. For example, hopelessness was significant in seven of the seven cases. CONCLUSIONS: For the first time, segments of texts of psychotherapy sessions that occurred before recurrent symptoms have been assembled and analyzed. These brief segments before recurrent symptoms showed more of certain qualities than did segments before control points where no symptoms appeared. On the basis of these results the author constructed a new symptom-context theory of symptom formation and compared this new theory with five classical theories of symptom formation, drawing implications for research and for treatment techniques.

Effects of therapist adherence and competence on patient outcome in brief dynamic therapy.

The authors examined the relation between therapist process variables (adherence and competence) and subsequent symptomatic change in patients. Twenty-nine depressed patients were seen in 16 sessions of weekly supportive expressive (SE) dynamic psychotherapy. Change in depression from intake to Session 3 predicted higher ratings of adherence to expressive (interpretative) techniques during Session 3 but not their competent delivery. Partialling pretreatment psychiatric severity, therapists' adherence to use of expressive techniques, and previous symptomatic improvement, relatively competent delivery of SE-specific expressive techniques predicted subsequent improvement in depression. Secondary analyses addressing alternative explanations (such as the role of either therapeutic alliance or general therapeutic skills) did not change the results.

Relation of stressors and depressive symptoms to clinical progression of viral illness.

OBJECTIVE: The aim of this research was to determine whether and in whom stressors and depressive symptoms facilitate clinical recurrence of herpes simplex virus (HSV) and progression of HIV. METHOD: Meta-analytic techniques were used to review the relations of stressors and depressive symptoms to clinical recurrence of HSV in 16 published studies and to indicators of HIV progression in 19 published studies. The authors calculated average effect sizes, performed fixed effect and random effect inferential analyses, tested for heterogeneous findings, and identified potential moderating variables. RESULTS: Depressive symptoms were associated with a slightly increased risk of HSV recurrence and increased reports of HIV-related symptoms, whereas stressors were not. However, depressive symptoms were not associated with objective indicators of accelerated HIV progression. Stressor studies, especially those that ascertained population-specific life events, found numerical and functional decrements in circulating natural killer cell populations. The candidate moderators identified include, for HSV recurrence, age, sex, and medication status, and for HIV-related symptoms, age, race, disease stage, and co-infection with HSV. CONCLUSIONS: Depressive symptoms, but not stressors, increase the risk of HSV recurrence generally. Depressive symptoms do not appear to accelerate HIV progression ubiquitously, although they are associated with increased reporting of HIV-related symptoms. Future studies that ascertain population-specific stressors should determine whether reductions in cytotoxic lymphocytes influence HIV disease progression. Moreover, researcher should investigate the role of the identified moderators and recognize psychoimmune moderators in existing and novel study groups. These analyses could confirm that certain individuals are especially susceptible to the effects on disease progression of stressors, depressive symptoms, or both.

Dynamic change in psychotherapy: mastery of interpersonal conflicts.

This study investigated the relationship between the mastery of maladaptive interpersonal patterns (assessed from narratives told during psychotherapy) and outcome of psychotherapy. Transcripts from the psychodynamic psychotherapy of 41 patients were scored using a content analysis mastery scale. Changes in mastery level over the course of therapy were significantly related to changes in observer and therapist ratings. In addition, the patients' own judgments of changes in their symptoms and main problems paralleled changes in the mastery of interpersonal conflicts found in their narratives. These results are consistent with the proposition that symptoms abate with the mastery of core interpersonal conflicts.