Clinical Judgments of Response Profiles: Do They Tell Us What Matters for Whom?

DeRubeis and colleagues (2014a) proposed that psychotherapy research has been limited by underappreciated variability in how patients respond to psychotherapy. They proposed that the relationship between the quality of therapy and outcome varies according to patient response profiles. In a study of cognitive-behavioral therapy (CBT) for depression, we tested clinician ratings of this construct as a moderator of the relationship between therapist adherence to cognitive or behavioral methods in predicting symptom change. Patients (N = 125) participated in CBT for depression. Assessors rated response profiles following the intake and therapists rated them after the first session. We collected data on adherence at the first five sessions and symptoms at the first six sessions. Therapist ratings following the first session, but not assessor ratings at intake, moderated the relationship between each form of adherence and symptom change. Patients given lower ratings (identifying them as spontaneous remitting or easy patients) had a stronger relationship between adherence and greater symptom change, with this relationship reversed such that adherence was related to less robust symptom change for those with the highest ratings (intractable or challenging patients). Our findings suggest promise for clinical evaluation of response profiles. We encourage future research evaluating refinements to such measures.

Testing the reciprocal relationship between depressive symptoms and insomnia.

BACKGROUND: Although the importance of sleep difficulties in emotional disorders has long been acknowledged, the nature of the potential reciprocal relationship between sleep and depressive symptoms is not yet well understood. The coronavirus disease 19 pandemic provided a unique opportunity to study the interrelation of these symptoms over a period marked by increases in sleep and psychological difficulties. METHODS: Using online data collection, we followed 1200 adults (59% male) through 1 year of the pandemic. Measures of sleep disturbance and depressive symptoms were assessed at eight time points. Factor analysis of the items from these two measures suggested separate insomnia and depressive symptom factors. A random intercept cross-lagged panel model was used to assess within-person relationships between factor analysis-informed subscales of insomnia and depressive symptoms. RESULTS: Depressive symptoms predicted subsequent changes in insomnia symptoms; however, insomnia did not predict changes in depressive symptoms. CONCLUSIONS: Our findings suggest the impact of depressive symptoms on insomnia is evident, but the reverse is not. Implications of this finding along with the need for research addressing depressive symptoms and insomnia as treatment targets are discussed.

Seeing is believing: The effect of subtle communication in social media on viewers' beliefs about depression and anxiety symptom trajectories.

OBJECTIVE: One barrier to treatment seeking, uptake, and engagement is the belief that nothing can be done to reduce symptoms. Given the widespread use of social media to disseminate information about important issues, including psychological health, we sought to understand how the influence of social media communication regarding mental health impacts viewers' beliefs about psychopathology recovery. METHOD: Undergraduate participants from a large Midwestern university (N = 322) were randomized to view a series of Tweets characterizing psychopathology from a fixed mindset perspective, a growth mindset perspective, or, in the control condition, Tweets unrelated to psychopathology. Afterward, they completed a series of questionnaires designed to assess beliefs about recovery from depression and anxiety. RESULTS: Participants in the growth mindset condition endorsed less pessimistic beliefs about their ability (i.e., self-efficacy) to alleviate symptoms of depression and anxiety, and they believed these symptoms to be less stable and innate relative to those in the fixed mindset condition. CONCLUSION: Social media communication that characterizes psychopathology from a growth mindset perspective may be a viable intervention for improving beliefs around mental health self-efficacy and the malleable nature of mental illness, particularly depression and anxiety. Clinicians may be able to use social media platforms to promote functional beliefs around mental illness.

Promoting skill use in skill enhanced cognitive behavioral therapy: A case example.

Cognitive behavioral therapy (CBT) appears to achieve its effects at least in part by fostering the development of CBT skills. In an effort to leverage CBT skill development, our group developed and tested a skill-enhanced version of CBT (CBT-SE) in a recent trial. In this paper, we describe our work with a client who participated in a 12-week course of CBT-SE as part of that trial. Although homework is a critical aspect of CBT, the greater emphasis on skill development in CBT-SE means that homework is even more central. This client's course of treatment illustrates the potential benefits of a strong focus on skill development and the use of specific homework assignments to foster mastery and ongoing use of CBT skills. The client developed CBT skills at a rapid pace early in treatment and exhibited enduring symptom reductions. The experience of this client reinforces the value of a focus on CBT skills and highlights strategies for fostering skill development. Given the evidence in support of the therapeutic value of CBT skills and the well-established benefits of homework assignment, we encourage use of skill enhancing procedures, including in-session procedures and assignments that help clients develop and maintain ongoing skill use.

Predicting anxiety and depression over 12 months of the COVID-19 pandemic: A machine learning study.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic was associated with substantial increases in anxiety and depressive symptoms. To understand individual risk, we examined a large set of potential risk factors for anxiety and depression in the pandemic context. METHODS: Adults in the United States (N = 1200) completed eight online self-report assessments over 12 months of the COVID-19 pandemic. Area under the curve scores summarized cumulative experiences of anxiety and depression over the assessment period. A machine learning approach to elastic net regularized regression was used to select predictors of cumulative anxiety and depression severity from a set of 68 sociodemographic, psychological, and pandemic-related baseline variables. RESULTS: Cumulative anxiety severity was most strongly explained by stress and depression-related variables (such as perceived stress) and select sociodemographic characteristics. Cumulative depression severity was predicted by psychological variables, including generalized anxiety and depressive symptom reactivity. Being immunocompromised or having a medical condition were also important. CONCLUSIONS: By considering many predictors, findings provide a more complete view than previous studies focused on specific predictors. Important predictors included psychological variables suggested by prior research and variables more specific to the pandemic context. We discuss how such findings can be used in understanding risk and planning interventions.

Impact of messaging on views of depression treatment options: Examining credibility and expectations.

OBJECTIVE: Understanding how people respond to information about treatment options is important for informing efforts that promote treatment initiation and adherence. We examined the impact of informational treatment videos on treatment naive participants' views regarding the credibility of and their expectations for three treatment options. MATERIALS AND METHODS: Adults (N = 300) who had experienced elevated depressive symptoms but had not participated in a treatment for depression were randomly assigned to one of four conditions. Three of the conditions were shown videos, providing information about (1) cognitive behavioral therapy (CBT), (2) antidepressant medication (ADM), or (3) the combination of CBT and ADM. The fourth condition was not shown a video. Participants' self-reported views of the credibility of and expectations for treatment served as primary outcome variables. RESULTS: Compared with the control condition, videos about active treatments enhanced credibility and expectations for those treatments. When comparing CBT and ADM alone, messaging about either treatment enhanced credibility of and expectations for that treatment. The CBT only video produced the most positive expectations and highest credibility for CBT. Likewise, the ADM only video led to the most positive expectations and credibility for ADM. The video focused on combined treatment did not lead to particularly positive views of the combined treatment option. CONCLUSION: These findings demonstrate the importance of providing focused messaging to enhance the credibility of and expectations for treatment. Future research is needed to examine the impact of messaging in different contexts, as well as the impact of such messaging on treatment seeking, adherence, and outcomes.

Congruence in patient and therapist-rated alliance predicts subsequent depressive symptoms in cognitive behavioral therapy for depression.

OBJECTIVE: The therapeutic alliance is a dyadic process involving both patient and therapist perspectives. We investigated the effect of patient and therapist agreement on the alliance in cognitive behavioral therapy for depression. METHOD: Patients (N = 191) were drawn from two studies of cognitive behavioral therapy for depression provided over 16 weeks. Alliance data were collected from patients and therapists at the first four sessions. Patients provided symptom data at each session. We used multilevel polynomial regression with response surface analysis to investigate the effect of alliance agreement and disagreement on symptoms. RESULTS: The within-person strength of patient and therapist-rated alliance (given agreement) predicted lower within-person symptoms. The nature and degree of the discrepancy in patient and therapist alliance scores was not a significant predictor. CONCLUSION: Patients and therapist alliance strength in early sessions (given agreement) predicted greater symptom change. Future research is needed to examine whether specific patient characteristics can be used to identify for whom the alliance plays a more or less important role.

Vindicating pollyanna? An experimental test of cognitive restructuring and positive thinking interventions.

OBJECTIVE: Despite its considerable potential, psychotherapy research has made limited use of small-scale experimental study designs to test intervention components. This study employs such a design to test the immediate effects on emotional experience of two approaches to changing negative thoughts, cognitive restructuring and fostering positive thinking. Cognitive restructuring draws on the strategies core to cognitive behavioral therapies. Fostering positive thinking has also received attention, though less so as a psychological intervention. METHOD: We tested the benefits of these strategies over a brief interval by randomizing 230 participants to complete a worksheet introducing one of the two strategies. Participants reported their skills prior to exposure to these worksheets and affect was assessed immediately prior to and following use of worksheets. RESULTS: Participants' negative affect reduced following both strategies. Conditions did not differ significantly in affect change. Analysis of potential moderators showed that, among those with higher levels of cognitive behavioral therapy skills, the positive thinking condition produced greater gains in positive affect than the cognitive restructuring condition. CONCLUSIONS: These results indicate that both forms of brief interventions promote reductions in negative affect. Positive thinking interventions, which are not focused on the accuracy of one's thinking, appear to be particularly effective in promoting positive affect.

Using Socratic Questioning to promote cognitive change and achieve depressive symptom reduction: Evidence of cognitive change as a mediator.

Socratic questioning has long been thought to play a critical role in cognitive behavioral therapy (CBT) for depression. Though use of Socratic questioning is theorized to achieve symptom reduction by promoting cognitive change, research has yet to investigate this pathway. In a sample of 123 clients participating in CBT for depression, we tested cognitive change as a mediator of the relation between Socratic questioning and symptom change in early treatment sessions. We found evidence of a significant indirect effect, consistent with cognitive change mediating the effect of Socratic questioning on change in depressive symptoms. Further analyses showed that pre-treatment CBT skills moderated the effect of Socratic questioning on cognitive change, with this relationship being stronger for clients who started treatment with lower CBT skills. These findings provide support for the view that Socratic questioning contributes to therapeutic gains in CBT through cognitive change. This study also provides initial evidence to suggest the use of Socratic questioning is particularly important for clients who begin treatment with particularly low CBT skills.

Framing an intervention as focused on one's strength: Does framing enhance therapeutic benefit?

INTRODUCTION: A capitalization approach to enhancing client skills in cognitive behavioral interventions is focused on enhancing skills that represent relative strengths. This approach may bolster outcomes because the targeted skills are those that clients can most effectively use to recover from negative moods. Alternatively, the benefits might be due to client attitudes about these skills, such as their confidence that they can use these skills effectively. METHODS: In an unselected sample of 616 undergraduates, we randomized to one of two brief interventions (a cognitive or mindfulness intervention) and one of two framing conditions (framing the intervention as focusing on a relative strength or a weakness), resulting in four conditions. Participants were then asked to use the skill targeted in their intervention to recover from a sad mood induction. RESULTS: Framing conditions did not differ on expectations of benefit from sustained use of an intervention but did differ on mood recovery. Participants told that the intervention focused on a strength recovered more quickly following the mood induction. There was no difference between the skill interventions. DISCUSSION: Our finding suggests intervention framing positively contributes to the effects of strengths focused treatments, though perhaps not by enhancing treatment expectations.

The therapeutic alliance and dropout in cognitive behavioral therapy of depression.

Identifying predictors of dropout is an important step in improving treatment outcomes. The alliance is the most frequently studied psychotherapy process variable, but its relation to dropout in cognitive behavioral therapy (CBT) of depression is not well understood.We evaluated the alliance at session one as reported by clients and therapists as predictors of dropout among 126 clients with major depressive disorder participating in CBT for depression.Over a similar time period, those who dropped out experienced less symptom change than those who did not. Client, but not therapist reported alliance was related to reduced risk for dropout. This relation remained significant even when clients' pre-treatment predictions of the alliance were included as a covariate. Concurrent use of medication did not moderate the alliance-dropout relation.Our findings are consistent with alliance being an important contributor to risk of dropout in CBT for depression. Future research should investigate intervention strategies that might promote the alliance as a means of reducing dropout.

Working with Black vs. White patients: an experimental test of therapist decision-making in cognitive behavioral therapy for depression.

Whether and how therapists' delivery of cognitive behavioral therapy (CBT) for depression differs by patients' ethnicity or race remains unclear. In this study, 218 therapists were randomized to clinical vignettes that involved the same text but varied in whether the accompanying image depicted a Black or White patient. Therapists exhibited three key differences in their views of clinical strategies for working with Black as compared to White patients. They viewed cognitive change strategies as less therapeutic and validation strategies as more therapeutic for Black patients. They reported similar differences for the time they would spend on each kind of strategy. When asked to compare the relative importance of cognitive change vs. validation strategies specifically, therapists rated validation as more important for Black than White patients. Among therapists presented with Black patients, positive racial attitudes were associated with viewing cognitive change and validation strategies as more therapeutic. These results suggest therapists tend to believe it is desirable to incorporate cognitive methods more limitedly when working with Black patients. Whether such adaptations enhance or detract from the care of Black patients is an important issue that merits future investigation.

Assessing the disproportionality of depressive reactions to life stress.

BACKGROUND: Prior to DSM-5, depression had long been conceptualized as symptoms without cause or disproportionate to one's circumstances. A central challenge to considering whether a depressive reaction is disproportionate is the lack of measures assessing disproportionality. Drawing on a study of patients participating in cognitive behavioural therapy for depression, we evaluate two new measures of the disproportionality of one's depressive symptoms to their recent life circumstances. METHODS: To assess the disproportionality of depressive symptoms, we developed an interview-based assessment and a brief self-report measure. We employed both assessments in a sample of 126 patients who participated in cognitive behavioural therapy for depression. RESULTS: Initial evidence for the reliability and validity of both self-report and interview-based approaches appeared promising. Interview judges demonstrated strong inter-rater reliability on life stress ratings, and both forms of disproportionality showed a pattern of correlations with variables reflecting greater clinical complexity, including self-reported personality dysfunction and symptom severity. Comorbid generalized anxiety disorder (GAD) was the only previously proposed marker of complicated depression to significantly predict both disproportionality scores. LIMITATIONS: The sample had limited ethnic diversity and tended to be highly educated. Participants all met criteria for major depressive disorder and sought treatment. CONCLUSIONS: Two assessments of the disproportionality of depressive reactions demonstrated evidence of reliability and validity. Despite limited efforts at assessment to date, these results suggest these measures may be able to reliably distinguish the disproportionality of depressive reactions and allow clinicians to better assess contextual life stress depressive disorders.

When Are Therapists' Efforts to Bring about Cognitive Change Effective? Considering Interpersonal Vulnerabilities as Contextual Factors.

We examined interpersonal variables as moderators of the relation between therapists' use of cognitive change (CC) strategies and CC in a sample of 125 adults who participated in cognitive behavioral therapy for depression. We measured self-reported maladaptive personality characteristics, interpersonal problems, and social skills at intake. Observers rated therapist adherence to cognitive methods for the first five sessions. Patients reported in-session CC following each session. Cognitive methods predicted greater CC. The relation between cognitive methods and CC was moderated by maladaptive personality traits; this relation was stronger for patients with greater maladaptive personality traits. We encourage future research investigating moderators of therapist interventions of putative therapeutic mechanisms.

Who Benefits From a Cognitive vs. Behavioral Approach to Treating Depression? A Pilot Study of Prescriptive Predictors.

Although experts have suggested ways that cognitive behavioral therapy (CBT) of depression might be personalized for individual clients, there has been little empirical examination of this issue. We examine cognitive behavioral skills and vulnerabilities (i.e., dysfunctional thinking, behavioral inactivation, and avoidance) as potential prescriptive predictors to cognitive vs. behavioral interventions. Forty-two adults with major depressive disorder were randomized to eight weeks of cognitive-only (n = 21) or behavioral-only (n = 21) individual psychotherapy. Clients completed pre-treatment measures of cognitive and behavioral skills and vulnerabilities. Dropout rates were comparable across treatments (21% overall). Treatment outcomes did not differ significantly between treatments (g = .13). Cognitive skills were associated with superior outcomes in the behavioral-only treatment, but additional analyses suggested general skillfulness (i.e., the tendency to have high scores across cognitive and behavioral assessments), rather than cognitive skills per se, predicted a larger response to behavioral interventions. Similarly, behavioral avoidance of social and non-social domains were associated with worse outcomes in the behavioral-only treatment, indicating that behavioral approaches yield less positive outcomes for clients high in behavioral avoidance. If replicated, the results of this pilot study suggest ways that a cognitive behavioral therapist could select intervention strategies to suit individual clients and thereby improve treatment outcomes.

Does cognitive behavioral therapy for depression target positive affect? Examining affect and cognitive change session-to-session.

OBJECTIVE: Researchers have been interested in the role of negative affect (NA) and positive affect (PA) in cognitive behavioral therapy (CBT) for depression. We examined cognitive change (CC) and these two affect variables across the course of CBT. METHOD: Patients (N = 125; M age = 31.7, SD = 13.35; 60% female; 83% Caucasian) participated in 16 weeks of CBT for depression. They completed the Beck Depression Inventory-II (BDI-II) and the Immediate Cognitive Change Scale at each session and a measure of affect before and after each session. RESULTS: NA decreased (rate of change p < .001, d = -1.08) and PA increased (p < .001, d = 0.53) during treatment. CC predicted next-session PA, 0.06, 95% CI [0.01, 0.11], and NA, -0.09, 95% CI [-0.14, -0.04], and was concurrently associated with change in PA, 0.36, 95% CI [0.30, 0.42], and NA, -0.32, 95% CI [-0.42, -0.26], over the course of a session. Presession PA, 0.22, 95% CI [0.17, 0.26], and NA, -0.13, 95% CI [-0.17, -0.08], predicted postsession CC, while pre to postsession change in PA, -0.05, 95% CI [-0.09, -0.002], and NA, 0.06, 95% CI [0.01, 0.11], predicted change in depressive symptoms. CONCLUSIONS: Although NA and PA both change in CBT, the changes in PA are more modest. Both NA and PA predict symptom change, consistent with the possibility that increasing PA may be beneficial. CC and affect change are reciprocally related, suggesting that CC may contribute to affect change, while affect may also facilitate CC. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

What Do People Really Think of Me? Evaluating Bias in Interpersonal Predictions Over the Course of Cognitive-Behavioral Therapy of Depression.

Cognitive behavioral therapy (CBT) of depression is hypothesized to achieve its effects by correcting negative biases. However, little research has tested how biases change over the course of CBT. We focus on biases in interpersonal judgments and examine whether changes in biases occur in CBT and are associated with symptom improvements. A sample of 126 adults (60% women, mean age 31.7, 83% White) participated in CBT of depression. Observers provided ratings of patients participating in two interpersonal tasks on three occasions. Patients were asked to predict observers' ratings. In a thin slice (TS) task, observers evaluated how patients came across in a brief segment in which patients talked about themselves. In a Standard Interaction Task (SIT), observers rated the social skills patients displayed in challenging role plays. The difference between patient predictions and observer ratings provided measures of bias in these interpersonal judgments. TS and SIT bias became significantly less pessimistic and more realistic over the course of CBT. Improvements in TS bias were associated with a faster reduction in symptoms, whereas there was a non-significant trend for improvement in SIT bias being associated with faster symptom reduction. Consistent with the CBT model, negative interpersonal biases became more realistic throughout a course of CBT for depression and at least some of the changes in bias were related to therapeutic outcomes. We encourage future researchers to continue examining for whom and under which conditions correcting such biases produces the greatest benefits.

Adhering to COVID-19 health guidelines: Examining demographic and psychological predictors of adherence.

The effort to limit the spread of the coronavirus (COVID-19) has relied heavily on the general public's compliance with health guidelines limiting social contact and mitigating risk when contact occurs. The aim of this study was to identify latent variables underlying adherence to COVID-19 guidelines and to examine demographic and psychological predictors of adherence. A sample of US adults (N = 1,200) were surveyed in late April to mid-May 2020. The factor structure of adherence was examined using exploratory factor analysis. Machine learning regression models using elastic net regularization were used to examine predictors of adherence. Two factors characterized adherence: avoidance and cleaning. Elastic net models identified differential demographic and psychological predictors of these two forms of adherence. Religious affiliation, denial coping, full-time employment, substance use coping, and being 60 or older predicted lower avoidance adherence. Behavioral and mindfulness emotion regulation skills, agreeableness, and Democrat political affiliation predicted greater avoidance adherence. For cleaning adherence, interpersonal and behavioral emotion regulation skills and conscientiousness emerged as strong predictors of greater cleaning. Efforts to promote compliance with COVID-19 health guidelines may benefit from distinguishing avoidance and cleaning adherence and considering predictors of each of these aspects of adherence.

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.