A self-report version of the Ways of Responding: Reliability and validity in a clinical sample.

OBJECTIVE: The Ways of Responding (WOR) instrument measures compensatory skills, a central construct in some theories of the mechanism of cognitive therapy for depression. However, the instrument is time-consuming and expensive to use in community settings, because it requires trained independent judges to rate subjects' open-ended written responses to depressogenic scenarios. The present study evaluated the reliability and validity of a self-report version of the WOR (WOR-SR) in a community mental health sample with depressive symptoms (N = 467). METHOD: Subjects completed the WOR-SR, a modified version of the original WOR, and other measures of depressive symptoms, dysfunctional cognitions, functioning, quality of life, and interpersonal problems at multiple time points. RESULTS: An exploratory factor analysis confirmed the two-factor structure of the WOR-SR. The positive and negative subscales both demonstrated excellent internal consistency (Cronbach's alphas = .91) and moderate convergent validity with other measures. CONCLUSION: The WOR-SR is a reliable and valid measure of compensatory skills in patients receiving treatment for depression at community mental health centers.

The Measurement of Cognitive Schemas: Validation of the Psychological Distance Scaling Task in a Community Mental Health Sample.

OBJECTIVE: The purpose of this study was to examine the validity of the Psychological Distance Scaling Task (PDST), a measure of cognitive schema organization, in a community mental health setting. We also compared validity among African Americans and Caucasians. METHOD: In order to accommodate participants with low education levels, 26 out of 80 PDST word stimuli were replaced with similar words at a lower reading level. A sample of 466 (42% African American; 50% Caucasian; 8% other) community patients with major depressive disorder completed the PDST and a variety of depressive symptom measures. RESULTS: The modified PDST demonstrated acceptable validity within all subscales. Validity coefficients resembled those reported in prior studies and were similar within minority and non-minority subsamples. CONCLUSIONS: The modified PDST appears to be a valid measure of schema organization in a low-income, racially diverse population seeking treatment for depression at community clinics.

Mechanisms of change in cognitive therapy for major depressive disorder in the community mental health setting.

OBJECTIVE: This study examined the relation of change in theory-relevant cognitive variables to depressive symptom change over the course of cognitive therapy, as well as the specificity of change mechanisms to cognitive therapy as compared with dynamic therapy. METHOD: There were 237 adult outpatients who were randomized to either cognitive (n = 119) or dynamic (n = 118) therapy for major depressive disorder in a community mental health setting. Assessments of compensatory skills (Ways of Responding Community Version and Self-Report Version), dysfunctional attitudes (Dysfunctional Attitudes Scale), and depressogenic schemas (Psychological Distance Scaling Task) were obtained at baseline and months 1, 2, and 5 following baseline. Primary outcome was measured using the Hamilton Rating Scale for Depression. RESULTS: Across both therapy conditions, change in all 3 cognitive domains was associated with concurrent change in depressive symptoms. After controlling for other cognitive variables, increased interconnectedness of the positive achievement-related schema was significantly associated with concurrent symptom change in cognitive (rp = .26, p < .001) but not dynamic therapy (rp = .08, p = .29). Increases in positive compensatory skills were associated with subsequent change in depressive symptoms in cognitive therapy (rp = -.36, p = .003), but not in dynamic therapy (rp = .11, p = .386). CONCLUSIONS: Results provide support for the compensatory skills model of cognitive therapy (CT) within a community mental health setting. Additional research is necessary to understand other possible mechanisms of change in CT in the community setting. (PsycINFO Database Record

Methods for Incorporating Patient Preferences for Treatments of Depression in Community Mental Health Settings.

We developed three methods (rating, ranking, and discrete choice) for identifying patients' preferred depression treatments based on their prioritization of specific treatment attributes (e.g., medication side effects, psychotherapy characteristics) at treatment intake. Community mental health patients with depressive symptoms participated in separate studies of predictive validity (N = 193) and short-term (1-week) stability (N = 40). Patients who received non-preferred initial treatments (based on the choice method) switched treatments significantly more often than those who received preferred initial treatments. Receiving a non-preferred treatment at any point (based on rating and choice methods) was a significant predictor of longer treatment duration. All three methods demonstrated good short-term stability.

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial.

IMPORTANCE: Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies. OBJECTIVE: To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting. DESIGN, SETTING, AND PARTICIPANTS: From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016. INTERVENTIONS: Short-term DT or CT. MAIN OUTCOMES AND MEASURES: Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression. RESULTS: Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, -0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = -7.07; P = .001), and competence in CT (t115 = -7.07; P = .001). CONCLUSIONS AND RELEVANCE: This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01207271.