Investigating associations between cortisol and cognitive reactivity to sad mood provocation and the prediction of relapse in remitted major depression.

OVERVIEW: In remitted depressed patients, an increase in dysfunctional thoughts following a sad mood induction can predict relapse over 18 months. The current analysis examined whether salivary cortisol levels could also predict relapse in these same individuals. METHOD: 99 subjects with major depression were first treated to full remission using either antidepressant medication or cognitive behavioural therapy. While in the remitted state, subjects were exposed to sad music to trigger dysfunctional thoughts. In a subset of 55 subjects, salivary cortisol levels taken before and after the mood challenge were also obtained. RESULTS: Unexpectedly, cortisol levels tended to decrease rather than increase following the mood challenge, suggesting that anticipation of the mood challenge was more stressful than the challenge itself. We thus used pre-challenge cortisol levels as the main grouping variable. Based on Kaplan-Meier survival curves, among subjects with low pre-challenge cortisol levels, those with a history of three or more prior episodes had significantly higher rates of relapse than did subjects with two or less prior episodes. In subjects with high pre-challenge cortisol levels, there was no significant difference in rates of relapse based on the number of prior episodes. CONCLUSION: In depressed patients with few prior episodes, assessing risk of relapse and thus establishing the duration for treatment can be a difficult clinical problem. Pending replication, the current results suggest that high anticipatory cortisol levels may have utility in predicting relapse even in patients with few prior episodes.

Recurrence of suicidal ideation across depressive episodes.

BACKGROUND: In recent years it has become clear that depression is a recurrent disorder, with the risk of recurrence in those with two or more episodes being as high as 90%. This has prompted interest in the consistency of individual depressive symptoms across consecutive episodes, an issue that is important for symptoms such as suicidal ideation, where a past history may give important indicators of future behaviour. METHODS: We prospectively examined 69 individuals with a history of Major Depression, over 12 months, 38 of whom experienced a recurrence of major depression during the follow-up period. RESULTS: Spearman's rank order correlations between severity ratings of each symptom of major depression during a previous episode and severity ratings at recurrence showed significant associations for suicidality, guilt or worthlessness and thinking difficulties only. Weighted kappa coefficients indicated relatively low levels of agreement across episodes for most diagnostic symptoms, with suicidality showing the strongest relationship. Using a broad definition of suicidality-- any reporting of thoughts of death or suicide during episode-- a much higher level of agreement (kappa = .64) was found, with 83% of individuals falling into the same category (suicidal/non-suicidal) at both episodes. LIMITATIONS: This study was based on a relatively small sample and examines re-emergence of suicidal ideation in the absence of suicidal behaviour. CONCLUSIONS: This study provides preliminary evidence of cross-episode consistency in the recurrence of suicidal ideation, in line with the differential activation theory of suicidality in depression.

Clinical guidelines for the treatment of depressive disorders. III. Psychotherapy.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section on "Psychotherapy" is 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of psychotherapy in the treatment of depressive disorders. Considerable evidence shows that specific, short-term psychotherapies including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are effective acute-phase treatments. There is also evidence that group and marital/couples formats of psychotherapy are effective. There is only limited evidence that psychotherapy is effective for maintenance treatment of depressive disorders. CONCLUSIONS: Psychotherapy is effective in the treatment of depressive disorders. Despite the evidence for effectiveness of specific psychotherapies, there is still limited access to these treatments in the community.

Clinical guidelines for the treatment of depressive disorders. V. Combining psychotherapy and pharmacotherapy.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Combining Psychotherapy and Pharmacotherapy," was 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of combined psychotherapy and pharmacotherapy for the treatment of depressive disorders. Three methods of combined treatment are identified: concurrent treatment (psychotherapy plus pharmacotherapy) for the acute-treatment phase, sequential treatment (adding the other treatment for nonresponders or partial responders to monotherapy in the acute-treatment phase), and crossover treatment (switching to psychotherapy for the maintenance-treatment phase after response to pharmacotherapy in the acute phase). CONCLUSIONS: Combined treatment with psychotherapy and pharmacotherapy is widely used in clinical practice. The recommendations for use of combined treatment are, however, based on only a limited evidence base.

Mood-induced changes on the Implicit Association Test in recovered depressed patients.

A mood induction paradigm was used to examine dysphoria-related changes in two types of cognitive processing in individuals who had previously experienced depression. Formerly depressed patients (n = 23) and never-depressed controls (n = 27) completed the Dysfunctional Attitudes Scale, a self-report measure of effortful processing, and performed the Implicit Association Test, an automatic-reaction time task that measures evaluative bias, before and after a negative-mood induction. The formerly depressed group showed both an increase in endorsement of dysfunctional attitudes and a more negative evaluative bias for self-relevant information after the induction, relative to controls--however, there was no association between the mood-linked changes observed on these two measures. The shift in evaluative bias shown by the formerly depressed group was similar to that seen in a group of 32 currently depressed individuals. These findings suggest that even a mild negative mood in formerly depressed individuals can reinstate some of the cognitive features observed in depression itself.

A cognitive-interpersonal case study of a self.

This article presents an integrated conception of the self based on cognitive and interpersonal theories. Implications for clinical practice are outlined, which include understanding the therapeutic relationship as a laboratory and change as involving self-expansion. Implications for clinical research are also presented and exemplified by two strategies, which are demonstrated in a single case study of a patient who successfully underwent a brief-term treatment. The first involves the use of Interpersonal Scenarios, which are structured idiographic vignettes scaled on several parameters, to measure change between psychotherapy sessions. The second involves the use of the Structural Analysis of Social Behavior, a measure of interpersonal process, and the Experiencing Scale, a measure of emotional involvement, to measure change within a session.

Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy.

This study evaluated mindfulness-based cognitive therapy (MBCT), a group intervention designed to train recovered recurrently depressed patients to disengage from dysphoria-activated depressogenic thinking that may mediate relapse/recurrence. Recovered recurrently depressed patients (n = 145) were randomized to continue with treatment as usual or, in addition, to receive MBCT. Relapse/recurrence to major depression was assessed over a 60-week study period. For patients with 3 or more previous episodes of depression (77% of the sample), MBCT significantly reduced risk of relapse/recurrence. For patients with only 2 previous episodes, MBCT did not reduce relapse/recurrence. MBCT offers a promising cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients.

Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients.

Previous research on depressed and suicidal patients and those with posttraumatic stress disorder has shown that patients' memory for the past is overgeneral (i.e., patients retrieve generic summaries of past events rather than specific events). This study investigated whether autobiographical memory could be affected by psychological treatment. Recovered depressed patients were randomly allocated to receive either treatment as usual or treatment designed to reduce risk of relapse. Whereas control patients showed no change in specificity of memories recalled in response to cue words, the treatment group showed a significantly reduced number of generic memories. Although such a memory deficit may arise from long-standing tendencies to encode and retrieve events generically, such a style is open to modification.

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

Cognitive therapy for bipolar depression: a pilot study.

OBJECTIVE: While the efficacy of cognitive-behaviour therapy (CBT) for the treatment of acute unipolar major depression is well-documented, there is almost no data evaluating its utility in the treatment of bipolar depression. This pilot study compares the efficacy of CBT combined with mood-stabilizer pharmacotherapy for bipolar depression and CBT alone for unipolar depression. METHOD: A matched-case control design was used to evaluate outcomes following 20 sessions of CBT in 11 depressed bipolar patients and 11 matched recurrent unipolar depressed control subjects. RESULTS: Bipolar depressed patients achieved similar levels of reduction in depressive symptoms following CBT, as did the unipolar depressed group. However, on measures of more pervasive dysfunctional attitudes, bipolar patients did not improve to the same degree. CONCLUSIONS: Preliminary findings suggest that CBT warrants further investigation as an effective psychosocial intervention for depression in bipolar patients already receiving ongoing mood-stabilizing pharmacotherapy.

Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression.

This study examined the nature of cognitive reactivity to mood changes in formerly depressed patients. Patients who recovered either through cognitive-behavior therapy (CBT; N = 25) or through pharmacotherapy (PT; N = 29) completed self-reported ratings of dysfunctional attitudes before and after a negative mood induction procedure. In response to similar levels of induced sad mood, PT patients showed a significant increase in dysfunctional cognitions compared with patients in the CBT group. To evaluate the effects of such cognitive reactivity on the subsequent course of depression, follow-up analyses reassessed 30 patients several years after initial testing. Results indicated that patients' reactions to the mood induction procedure were predictive of depressive relapse. These findings argue for differential effects of treatment on cognitive reactivity to mood induction and for the link between such reactivity and risk for later depressive relapse.

Rumination and distraction in major depression: assessing response to pharmacological treatment.

BACKGROUND: Response style theory of depression (RST) predicts that individuals who ruminate in response to their depressed mood will suffer an amplification and prolongation of that mood, whereas individuals who engage in distraction responses will alleviate and attenuate their depressed mood. RST has been shown to predict prolonged depression in samples of non-clinical, untreated individuals with mild to moderate depression but has not been tested in samples of depressed patients undergoing treatment. OBJECTIVE: In this preliminary investigation we examined: (1) whether RST predicts non-response to pharmacotherapy with outpatients suffering from major depression, and (2) whether distractive and ruminative responses are associated with clinical variables hypothesized to be associated with them. METHODS: Eighty-nine depressed outpatients being treated with standard antidepressant pharmacotherapy were administered the Response Style Questionnaire, a scale designed to measure rumination and distraction, prior to treatment. RESULTS: Distraction, but not rumination, predicted change in depression severity over the course of treatment and overall treatment outcome. Neither rumination nor distraction was associated with previous number of depressive episodes or duration of current depressive episode. DISCUSSION: These results provide only partial support for RST as a predictor of treatment response. Future investigations are needed to determine if rumination and distraction are predictive of recurrent depressive episodes in recovered depressed patients. LIMITATIONS: As the data in this study was retrieved from a clinical database, the conclusions of this report must be viewed tentatively. Replication with other clinical samples is needed.

Cognitive-behavioral group therapy for patients with irritable bowel syndrome.

This article is divided into two parts, the first of which focuses on a general overview of irritable bowel syndrome (IBS) and provides a rationale for the use of cognitive-behavioral therapy (CBT) for IBS based on both theoretical and research perspectives. This section includes a critical review of CBT therapies for IBS and provides a model of CBT for IBS. The second section provides the clinician with practical information concerning the application of cognitive-behavioral group therapy for IBS. Possible scripts and case examples are incorporated into this section to highlight factors that may arise in working with IBS patients relative to other clinical groups. The second section also contains themes that are suggested content areas for group sessions. Contingent on the formulation of the presenting or emerging issues and goals, the order and inclusion of themes can be changed to fit the particular needs of a given group. Finally, this section provides initial preliminary data from a randomized controlled study that is suggestive of the efficacy of cognitive-behavioral therapy for IBS.

A cognitive science perspective on kindling and episode sensitization in recurrent affective disorder.

A cognitive science analysis of the interaction between psychological stress and the neurobiology of affective illness highlights a number of mechanisms relevant to the study of recurrence in major depressive disorder. It builds on observations previously offered by Post (1992) regarding the importance of kindling and sensitization effects in determining activation of neural structures, and proposes a model of knowledge structure activation that follows similar parameters. Vulnerability to depressive relapse/recurrence is determined by the increased risk of particular negative patterns of information processing being activated in depressed states. As is found in studies of kindling and behavioural sensitization, the likelihood of cognitive patterns being activated is dependent on the frequency of past usage, and increased reliance on these patterns of processing makes it easier for their future activation to be achieved on the basis of increasingly minimal cues. This model suggests that the processes related to relapse/recurrence and episode onset may not be isomorphic and, as such, treatments that emphasize relapse prevention strategies should take this distinction into account.

Effects of self-generated sad mood on regional cerebral activity: a PET study in normal subjects.

This study investigated the cerebral regions modulated by self-generated sad mood in normal subjects. Eleven healthy men experienced a temporary sad mood by recalling sad personal memories. Two control states were used for comparison: a resting condition, and a condition involving the recall of affectively neutral personal events. Regional cerebral blood flow (rCBF) images were obtained using [15O]-H2O Positron Emission Tomography. A statistical comparison of the images during negative mood and neutral recall conditions revealed that sad mood was associated with a decrease in rCBF in the left dorsolateral prefrontal, left medial prefrontal, and left temporal cortex; no increase in activity was noted in this comparison. Our results are consistent with the noted left prefrontal decrease in metabolism found in depressed patients through a variety of methodologies; however, our results contrast with findings of increased left or bilateral prefrontal activity in transient induced negative mood states reported for women (George et al., 1995, Am J Psychiatry 152:341-341) and for mixed-gender (Pardo et al., 1993, Am J Psychiatry 150:713-719) subject groups. The study brings to light a number of methodological issues, including the crucial importance of the baseline condition used for the isolation of the emotional components of a given task.

A priming methodology for studying self-representation in major depressive disorder.

The authors investigated processing of self-descriptive emotional information in depression using a modified Stroop color-naming task. Depressed (n = 58) and nondepressed control (n = 44) participants were required to name the color in which positive and negative adjectives, differing in the degree to which they described the person, were presented. These target adjectives were primed by emotional phrases that also varied according to degree of self-reference. Analyses indicated that depressed participants showed slower color-naming latencies for self-descriptive negative targets primed by self-descriptive negative phrases than for any other prime-target condition. No effect of prime-target relation was found for positive material with depressed participants, and nondepressed controls showed no effect of prime-target relation for material in either valence. These results support the hypothesis that negative information about the self is highly interconnected in the cognitive system of depressed patients.

Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy.

The growing consensus regarding the importance of interpersonal process in psychotherapy, as well as of interpersonal factors in self-definition, has underscored the relevance of examining patient interpersonal functioning as it relates to the development of the therapeutic alliance. This study examined the relationship of patient pretreatment interpersonal functioning (as measured by the Inventory of Interpersonal Problems and the Million Clinical Multiaxial Inventory) to the therapeutic alliance (as measured early in treatment by a patient self-report version of the Working Alliance Inventory). On the basis of an interpersonal circumplex interpretation, the results generally indicated that friendly-submissive interpersonal problems were positively related to the development of aspects of the alliance and that hostile-dominant problems were negatively related to the development of aspects of the alliance early in short-term cognitive therapy.

Cognitive assessment of unipolar depression: measuring products, processes and structures.

In this article we survey current and emerging approaches to the cognitive assessment of affective disorder. Our review begins with an evaluation of the role of cognition in prevailing multidimensional models of unipolar depression. Within this framework, we distinguish three classes of cognitive variables that are operative in depression, and review strategies for assessing them. First, we consider methods of measuring cognitive product variables in depression (e.g. automatic thoughts, attributions, negative self-evaluations). Next, we focus on the assessment of cognitive and social cognitive mechanisms (e.g. irrational thought processes, social comparison processes) thought to play a proximal role in the development and maintenance of depressive phenomenology. Third, we review strategies for measuring the content and organization of the knowledge structures (i.e. schemas) postulated to underlie both products and processes. We conclude with a discussion of general issues and future directions for research.

Cognitive and life stress predictors of relapse in remitted unipolar depressed patients: test of the congruency hypothesis.

Remitted depressed subjects (N = 59) were followed longitudinally to determine whether dependent or self-critical persons are more vulnerable to relapse after exposure to life events that have a bearing on interpersonal or achievement concerns. Regression analyses indicated that congruency effects, as measured by the occurrence of achievement-related adversity in the lives of self-critical subjects, accounted for a significant increment in relapse variance over each variable entered singly. When data from the 2 months just before relapse were analyzed, some evidence of congruency effects in dependent subjects experiencing interpersonal-related adversity was obtained. These findings highlight the dimensional qualities of life even impact and call for greater differentiation in modeling the activation of a diathesis and precipitation of depression after life stress.

Combining cognitive therapy and pharmacotherapy in treating depression on an in-patient basis.

The authors present a case of a 40-year-old female with a history of recurrent unipolar depression in which combined treatment with cognitive therapy and medication was associated with significant clinical improvement. Rather than providing a straightforward example of combined interventions for depressed inpatients, it is hoped that some of the complexities involved in such an endeavour will be highlighted. Specifically, issues concerning planned communication between relevant staff, orientation of ward staff to nonorganic treatments, choice of treatment targets, and potential strains in the collaborative relationship between the cognitive therapist and treating physician are explored.