This article was downloaded by: [University of Regina]On: 18 November 2014, At: 09:51Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Psychotherapy ResearchPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/tpsr20

The sooner, the better: temporal patterns in brieftreatment of depression and their role in long-termoutcomeEva Gilboa-Schechtman a & Golan Shahar ba Department of Psychology , Bar-Ilan University , Ramat Gan, Israelb Ben-Gurion University, Department of Psychiatry , Yale University School of Medicine ,Beer-Sheva, IsraelPublished online: 22 Feb 2007.

To cite this article: Eva Gilboa-Schechtman & Golan Shahar (2006) The sooner, the better: temporal patterns inbrief treatment of depression and their role in long-term outcome, Psychotherapy Research, 16:03, 374-384, DOI:10.1080/10503300500485425

To link to this article: http://dx.doi.org/10.1080/10503300500485425

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

The sooner, the better: Temporal patterns in brief treatmentof depression and their role in long-term outcome

EVA GILBOA-SCHECHTMAN1 & GOLAN SHAHAR2

1Department of Psychology, Bar-Ilan University, Ramat Gan, Israel and 2Ben-Gurion University, Beer-Sheva, Israel, and

Department of Psychiatry, Yale University School of Medicine

(Received 26 August 2003; revised 6 June 2005; accepted 14 September 2005)

AbstractTo examine whether temporal patterns of change in brief treatment for depression are predictive of outcome at 18 monthsposttreatment, the authors used data from the National Institute of Mental Health-sponsored Treatment of DepressionCollaborative Research Program. In accordance with their hypotheses, they found that (a) individuals whose level of distressdoes not decrease between intake and Week 4 of therapy (slow remoralizers) exhibited a more severe symptom pattern atfollow-up assessments than those exhibiting immediate relief (rapid remoralizers); (b) rate of symptom reduction duringtreatment is predictive of 12- and 18-month outcomes beyond initial symptom severity; and (c) rate of symptom reduction ismore predictive of 12- and 18 month outcomes in psychotherapy than in nonpsychological treatments. Findings encouragefurther research and clinical attention to temporal patterns of response in brief treatments of depression.

Despite successful treatment, relapse and recurrence

are the rule rather than the exception in the long-

term course of major depressive disorder (MDD).

Thus, the risk of repeated episodes of depression is

estimated to be as high as 80% (e.g., Judd, 1997; see

also Joiner, 2000). Accordingly, understanding the

underpinnings of depression’s chronicity is one of

the most important challenges facing contemporary

research. So far, estimating the risk of relapse and

recurrence of depression has focused on psychiatric

history (e.g., Belsher & Costello, 1988; Hammen,

Mayol, deMayo, & Marks, 1986; Lewinsohn, Zeiss,

& Duncan, 1989; Hart, Craighead & Craighead,

2001), life events (e.g., Billings & Moos, 1984;

Brown & Harris, 1978; Mazure, Bruce, Maciejewski,

& Jacobs, 2000), and dysfunctional cognitions (e.g.,

Segal, Shaw, Vella, & Katz, 1992). As important as

these factors are, they all share the characteristic of

being unrelated to the treatment process. In con-

trast, only few studies have examined how patterns

of response to treatment of depression contribute to

the prediction of the recurrence of depressive symp-

toms. This gap in the literature paves the way to the

present investigation.

Most studies predicting the course of depression

after treatment have examined either posttreatment

depressive symptomatology or the change in this

symptomatology from pre- to posttreatment. All

these measures are aggregates across individuals.

Thus, the precise manner in which an individual

responds to treatment between the initial (pretreat-

ment) time point and the final session is overlooked.

However, it has been observed that the temporal

patterns of patients’ response often differ substan-

tially from the pattern of the average (i.e., aggregate)

group response (cf. Gilboa-Schechtman & Foa,

2001; Tang & DeRubeis, 1999a, 1999b). In parti-

cular, it is possible that although some individuals

exhibit a monotonically decreasing pattern of symp-

tomatology from the beginning to the end of treat-

ment, others show an initial increase, reaching a

peak at idiosyncratic times, again followed by a

decrease. Indeed, Gilboa-Schechtman and Foa

(2001) examined 3-month patterns of natural re-

covery after sexual and nonsexual assault. They

found that the timing of peak distress, which varied

between individuals, was ‘‘washed away’’ by group

aggregation. However, this parameter, together with

rate of symptom reduction, was an important pre-

dictor of long-term posttrauma pathology. In sum,

aggregating over idiosyncratic patterns of response

obscures the predictive importance of individual

patterns of change.

Another individual difference parameter that can

be washed away by group aggregation is a sudden

(yet individually spaced) decrease in symptom

Correspondence: Eva Gilboa-Schechtman, Department of Psychology, Bar-Ilan University, Ramat-Gan 52900, Israel. E-mail:

gilboae@mail.biu.ac.il

Psychotherapy Research, May 2006; 16(3): 374�/384

ISSN 1050-3307 print/ISSN 1468-4381 online # 2006 Society for Psychotherapy Research

DOI: 10.1080/10503300500485425

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

severity that occurs between session intervals, or the

‘‘sudden gains’’ phenomenon. Tang and DeRubeis

(1999b) found that individuals receiving cognitive�/

behavioral therapy (CBT) for depression and ex-

periencing such sudden gains were more likely to

evidence significantly lower levels of depressive

symptomatology at the end of therapy than those

who did not experience such gains. Moreover, this

enhanced recovery held through most of the follow-

up period. Tang and DeRubeis concluded that, by

investigating the time course of individual patients,

meaningful patterns that are shared by many in-

dividual patients might be detected, even if these

patterns are not revealed in the group mean time

course. As has been convincingly argued by Krause,

Howard, and Lutz (1998), ‘‘in order to maximize

relevance for clinical practice, the results of treat-

ment research should always be reported at this most

disaggregated or individual change level.’’ (p. 838).

Given the significance of temporal patterns of

change during treatment for the prediction of long-

term outcome, we sought to examine the relation-

ship between temporal patterns of change and

ensuing outcome using data from the National

Institute of Mental Health-sponsored Treatment of

Depression Collaborative Research Program

(TDCRP; Elkin, 1994). Several features render

these data appropriate for such an investigation.

First, the TDCRP is the single most important

controlled trial juxtaposing several treatment mod-

alities (Elkin, 1994; Elkin et al., 1989). Second, the

TDCRP involved follow-up assessments at signifi-

cantly distant time intervals after initial treatments

(at 12 and 18 months). Third, the TDCRP offers

multiple converging measures of symptom severity,

which were collected at several time points.

Theoretically, we were motivated by the phase

model of treatment (Howard, Lueger, Maling, &

Martinovich, 1993). This model postulates that

patients undergo three distinct phases in treatment:

remoralization (enhancement of the patient’s sense

of subjective well-being), remediation (symptom

reduction), and rehabilitation (recovery of life func-

tioning). Viewing TDCRP as providing information

on the first two phases of treatment, remoralization

and remediation, we sought to examine how para-

meters of temporal response during these two phases

would relate to ensuing outcome.

The first goal of the present study was to examine

whether symptom reduction in the early phases of

treatment is predictive of ensuing outcome. So far,

only a few studies addressed this issue. Fennel and

Teasdale (1987) examined the relationship between

early symptom reduction during brief psychological

treatment for depression and symptom return after

treatment. In their study, 15 individuals receiving

CBT were identified as either rapid (more than 50%

symptom reduction) or slow (less than 50% symp-

tom reduction) responders based on the amount of

symptom reduction observed on the Beck Depres-

sion Inventory (BDI) after the first two initial

sessions. Fennel and Teasdale found that slow

responders reported being more distressed than

rapid responders 12 months after treatment termi-

nation. Similarly, early versus delayed improvement

in symptoms of posttraumatic stress disorder

(PTSD) was predictive of long-term recovery (Gil-

boa-Schechtman & Foa, 2001). More recently,

Santor and Segal (2001) examined in 76 outpatients

with MDD the relationship between symptom re-

turn 3 and 6 months after CBT and pattern of

symptom reduction during treatment. They did not

find a relationship between early symptom reduction

(defined as change score between pretreatment BDI

score and BDI score at Week 3) and symptoms at 3-

and 6-months follow-up. Given the inconsistent

pattern of results emerging from the studies con-

cerning the prognostic value of early improvement,

we sought to reexamine the association between

symptom reduction early in the therapeutic process

and ensuing outcome in the TDCRP data. Specifi-

cally, we examined whether the intrapersonal change

in level of symptom severity (rather than absolute

level of change in the first weeks of treatment) is

indicative of better ensuing outcome.

We predicted that individuals who are slow to

engage in the first, remoralization, phase of treat-

ment (slow remoralizers [SRs]) would exhibit a more

severe symptom pattern at follow-up assessments

than would those who are faster to warm up to

treatment (rapid remoralizers [RRs]). We defined

SRs as those individuals who do not experience a

significant reduction in symptoms over the first 4

weeks of treatment and RRs as those who do

experience some relief. Our choice of 4 weeks of

treatment as the critical period was driven by

theoretical as well as practical considerations. On

the theoretical side, the remoralization phase is

supposed to commence even before the first formal

therapy session, as individuals begin to ‘‘do some-

thing’’ about their problems (such as setting up an

appointment). This phase is purported to be non-

modality specific, because it exerts its influence by

the virtue of establishing a proper context for

therapeutic work. Consistent with previous research,

we assumed that the remoralization phase occurs

between intake and Week 4 of treatment (Ilardi &

Craighead, 1994). On the practical side, the assess-

ment points in the TDCRP were given every 4

weeks; therefore, the critical period coincides with

the first two assessment points (i.e., pretreatment

and first treatment).

Temporal patterns in brief treatment for depression 375

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

The second goal of the present research was to

examine whether the rate of symptom reduction

during the remediation phase of treatment (after the

4-week assessment and continuing until treatment

termination) was predictive of long-term outcome as

indicated by symptom severity at 12- and 18-months

follow-up. To the best of our knowledge, only Santor

and Segal (2001) examined whether the rate of

symptom reduction during treatment was associated

with symptoms at follow-up. Using hierarchical

linear modeling, they found that the rate of symptom

reduction during the first 10 weeks of treatment was

negatively associated with symptoms at 3- and 6-

month follow-up assessments, even after controlling

for initial depression severity. In the present study,

we sought to replicate and extend these results in a

number of ways. First, we examined 12- and 18-

month outcomes, because a more prolonged follow-

up period increases the likelihood of relapse. Second,

we examined the relationship between rate of

symptom reduction during the remediation phase

as measured by self-report as well as by clinician

measures, whereas in Santor and Segal’s study the

examination was limited to self-reports only. In

addition, thus far the study of the relationship

between pattern of change (as indicated by both

rapid and SRs and rate of symptom change) and

long-term outcome has been limited to the examina-

tion of the outcome of CBT. The present study

extends previous investigations by examining tem-

poral patterns of response to treatment modalities

included in the TDCRP (i.e., CBT, interpersonal

therapy [IPT], imipramine plus clinical management

[IMI-CM], inactive placebo plus clinical manage-

ment [PLA-CM]) condition. Specifically, we postu-

lated that the rate of symptom reduction during

treatment, as assessed by self-report as well as

clinician-rated scales, would be predictive of ensuing

outcome beyond initial symptom severity.

A third goal of the current study was to examine

whether the rate of symptom reduction is differen-

tially related to long-term outcome depending on the

modality of treatment. In doing so, we sought to

replicate and extend the findings of Watkins et al.

(1993) study, which compares the temporal course

of response to psychotherapy and pharmacotherapy

in the TDCRP data. Watkins et al. examined group

differences in active pharmacological treatment ver-

sus psychological treatments at discrete time inter-

vals (i.e., 4, 8, and 12 weeks). Although Watkins et

al. have examined the differential effects of modality

during the course of treatment (up to 16 weeks), we

studied ensuing outcome (up to 18 months). Indeed,

previous research has already shown that treatment

modality predicts long-term outcome over and above

the overall success of treatment. For example, after a

successful treatment of depression using CBT, out-

patients show less relapse than those who recover

with antidepressant medication and are then with-

drawn from pharmacotherapy (e.g., Blackburn,

Funson, & Bishop, 1986; Shea et al., 1992). In

line with these findings, we reasoned that rapid

improvement in psychological treatments is likely

to indicate some insight, successful cognitive proces-

sing (Beck, Rush, Shaw, & Emery, 1979), or ‘‘work-

ing through’’ (Freud, 1958) of a painful issue and

thus is likely indicative of future ability to deal with

stress. In contrast, because pharmacological and

placebo treatments are not specifically geared toward

the acquisition of psychological skills (e.g., emotion

regulation, psychological insight), gains made with

the assistance of such treatments, even if rapid, are

likely to be of limited prognostic importance. Thus,

we hypothesized that the nature of the relationship

between rate of symptom recovery and long-term

outcome would vary between psychotherapy and

nonpsychological treatments. Specifically, we ex-

pected that the rate of recovery in therapy would

be a better predictor of long-term outcome than it

would be for pharmacological and placebo treatment

conditions.

Method

Participants and Procedure

The design and procedures of the TDCRP have

been described in detail elsewhere (e.g., Elkin et al.,

1989). In brief, patients were assigned randomly, at

each of three sites, to one of four treatment condi-

tions: IPT, CBT, IMI-CM, or PLA-CM. All treat-

ments were 16 weeks long (range �/ 16�/20

sessions).

Participants were outpatients between the ages of

21 and 60 who met research diagnostic criteria for

MDD. Eligible patients scored a minimum of 14 on

a modified Hamilton Rating Scale for Depression

(HRSD; Hamilton, 1967) both at an initial screen-

ing and at a rescreening 1 to 2 weeks later. A total of

250 patients met study entry criteria and were

randomly assigned; of these, 239 actually entered

treatment. According to Elkin et al.’s definition, a

‘‘completer’’ is an individual who has participated in

at least 12 sessions and 15 weeks of treatment.

Following earlier studies, we have focused on 162

completers (see Elkin et al., 1989, or Watkins et al.,

1993, for the use of the same inclusion criteria and

completer sample).

Measures

To assess outcome, we focused on two widely used

measures of depression severity: the Beck Depres-

376 E. Gilboa-Schechtman and G. Shahar

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

sion Inventory (BDI; Beck, Ward, Mendelson,

Mock, & Erbaugh, 1961) and the HRSD (Hamilton,

1960). In addition to these widely used measures of

depression, we also used a composite clinical out-

come variable (Blatt, Zuroff, Quinlan, & Pilkonis,

1996) based on the five primary outcome measures

of the TDCRP: BDI, HRSD, the total score on the

Hopkins Symptom Checklist-90 (SCL-90; Deroga-

tis, Lipman, & Covi, 1973), Global Assessment

Scale (GAS; Endicott, Spitzer, Fleiss, & Cohen,

1976), and the sum of the global ratings from the

Social Adjustment Scale (SAS; Weissman & Paykel,

1974). The BDI and SCL-90 are self-report mea-

sures, and the HRSD, GAS and SAS are interview-

based measures completed by clinical evaluators.

Higher scores on the composite outcome measure

indicated better relative improvement.1

Results

Modeling Individual Change Patterns

As mentioned, we viewed TDCRP as providing

information on the first two phases of treatment:

remoralization (Weeks 0�/4) and remediation (Week

4 to end of treatment). For the remoralization phase,

we defined SRs as those individuals who experience

only a mild (B/ 15%) decrease in distress between

intake and Week 4 of treatment2 and RRs as those

with a more significant distress decrease.

For the remediation phase, we assumed that the

process of symptom reduction proceeds in an

exponential decay fashion, because it is the simplest

and most commonly used model of temporal change

(e.g., Howard et al., 1993; Willett & Sayer, 1994).

This form of the recovery function is assumed

because many studies have found that a more rapid

change in symptoms is being made at early stages

compared with later stages of treatment. This

phenomenon consistently produces a curvilinear

growth curve that is best normalized by a log-linear

transformation of session number (see Howard,

Moras, Brill, Martinovich, & Lutz, 1996; Lambert,

Hansen, & Finch, 2001, for similar discussions and

procedures).

In an exponential decay function, the severity of

the symptoms at a given time point decreases by a

constant proportion over any time interval of a given

length. For example, if the severity of depression

decreased from 27 to 18 from Week 4 to Week 8,

then it is expected to decrease to 12 and 8 for Weeks

12 and 16, respectively (the decay rate being 33%

per month). We are assuming only that the recovery

function is exponential in form; we are not making

any assumption about the parameters of decay (i.e.,

33% or 50%), because this variable is a part of the

individual growth function parameters. Inspection of

the data at the individual level indicated that, for

most patients, exponential decay function was in-

deed a reasonable approximation. The explicit

functional form we estimate is as follows: Distress

(t)�/a*exp(�/b*t). The trajectory of the symptom

reduction depends on the values of parameters a and

b , which vary across individuals. Parameters a and b

determine the magnitude of peak distress and rate of

recovery. Specifically, according to this model, the

magnitude of peak reaction is EXP(a) and the rate of

recovery is 1�/EXP(b). Thus, when time is mea-

sured in months, the model predicts that the degree

of distress is multiplied by EXP(b) every month, and

1�/EXP(b) is the monthly percentage of decrease.

Mathematically, an exponential decay of a distress

reaction is equivalent to its logarithm being a linear

function of time; that is, log(distress(t))�/log(a)�/

b*t. To allow linear modeling of growth curves, we

first transformed them using a log-linear transforma-

tion by session number and then computed the

individual difference parameters.

Rapid Versus Slow Remoralizers

To address our first, early remoralization,

hypothesis*/that SR individuals, who are slow to

engage in the first, remoralization, phase of treat-

ment, would exhibit a more severe symptom pattern

at follow-up assessments than would RR individuals,

who are faster to warm up to treatment*/we

contrasted the parameters of response of these two

groups. Table I presents means and standard devia-

tions of symptoms at intake, end of treatment, and

12- and 18-month follow-up periods and the

monthly rate of symptom reduction for fast and

slow remoralizers.

Results indicate that RRs do not differ from SRs in

their initial levels of distress on composite measures,

whereas on the BDI and the HRSD the RRs were

more distressed than the SRs. However, SRs ex-

hibited a more severe symptomatology at the end of

treatment on all three measures. At 12- and 18-

month follow-up assessments, SRs were more dis-

tressed than RRs on two of the three outcome

measures (the BDI and composite measures but

not HRSD). To ascertain that the end-point and

follow-up differences between SRs and RRs were not

attributable to differences in the initial levels of

distress, we examined the difference between these

groups, controlling for the initial (pretreatment)

level of distress on the corresponding measure

(e.g., we regressed BDI at 12 months on pretreat-

ment BDI and type of remoralizer). The pattern of

results was identical to that presented in Table I.

Finally, the data also indicate that SRs and RRs do

Temporal patterns in brief treatment for depression 377

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

not differ significantly in their rate of symptom

reduction during treatment.

Rate of Symptom Reduction During

Remediation Phase

To examine our second, rapid remediation,

hypothesis*/that the rate of symptom reduction

during treatment would predict ensuing outcome

beyond initial symptom severity*/we conducted

regression analyses. Specifically, we regressed 12-

and 18-month follow-up scores on pretreatment

scores alone, rate of symptom reduction alone,

pretreatment scores and rates of symptom reduction

combined, and finally pretreatment scores, rates

of symptom reduction, and type of remoralizer

(slow vs. rapid) combined. Results are presented in

Table II.

The results of regressions A1�/A3 presented in

Table II, including a single predictor each, indicated

that, for BDI and composite but not HRSD scores,

pretreatment severity predicted long-term outcome;

higher pretreatment scores were associated with

higher scores at follow-up. Results further suggested

that rate of recovery alone predicted 12- and 18-

month outcomes on all three measures. Finally, type

of remoralizer predicted 12- and 18-month out-

comes on the BDI measures and on the composite

measure.

The results of the regression B presented in

Table II, involving pretreatment scores and rate of

symptom reduction as predictors, indicated that, for

BDI, HRSD, and the composite scores for both 12-

and 18-month outcomes, rates of symptom reduc-

tion independently contributed to the prediction of

long-term symptom severity over and above initial

distress.

Finally, the results of simultaneous regression C

presented in Table II, using all variables as predic-

tors, indicated that the rate of symptom reduction is

a significant predictor of 12- and 18-month out-

comes, controlling for initial symptoms and for type

of remoralizers for all outcome measures. Type of

remoralizer was a significant predictor of outcome

over and above pretreatment symptoms and rate of

recovery on two of our three measures (i.e., the BDI

and composite).

Treatment Modality

To test our third, treatment modality, hypothesis*/

that the rate of recovery in talk therapy (i.e., CBT

and IPT) would be a better predictor of 12- and

18-month outcomes than it would be for pharma-

cological and placebo treatment conditions*/we

conducted additional regression analyses with treat-

ment modality as a binary variable. Specifically, we

examined whether the rate of symptom reduction

was differentially predictive of treatment outcome

depending on whether the patient participated in a

treatment involving therapy (i.e., IPT or CBT

interventions) or medications (placebo or imipra-

mine interventions). To this end, we regressed

measures of 12- and 18-month outcomes on pre-

treatment severity, rate of symptom reduction,

therapy, a Therapy�/Rate of Reduction interaction,

and a Therapy�/Type of Remoralization interaction

using simultaneous regression. The results of this

analysis are shown in Table III.

Consistent with our hypothesis, inspection of

Table III reveals a significant Therapy �/ Rate of

Reduction interaction when the BDI and the com-

posite score were considered as outcomes. The

examination of the rates of recovery in the psycho-

logical treatments and in the nontalk therapy treat-

ments revealed that rate of recovery was more

predictive of ensuing outcome if the patient was

engaged in active psychological treatment and less

predictive if the patient received pharmacological or

placebo treatment. Further, we also found that

therapy modality interacted with type of remoraliza-

tion on most measures. This lends further indirect

support to the treatment modality hypothesis.

Table I. Means and standard deviations of symptoms at pretreat-

ment (intake), end of treatment, 12- and 18- month follow-up

assessments, and of rate of symptom reduction for fast and slow

remoralizers.

Measure

RRs

(N�/122)

SRs

(N�/40) F (1, 147�/161)

Pretreatment

BDI 27.719/7.37 24.489/8.72 4.72*

HRSD 19.149/4.19 18.999/3.96 .06

Comp 1.159/0.57 1.019/0.50 .19

End of treatment

BDI 7.859/7.56 15.009/11.18 18.17**

HRSD 6.509/5.05 11.759/6.75 22.59**

Comp �/0.869/0.83 0.019/1.11 27.17**

12-Month follow-up

BDI 8.189/8.32 12.039/13.18 3.91*

HRSD 7.309/6.93 9.809/8.64 2.81*

Comp �/0.779/0.96 �/0.209/1.31 6.94**

18-Month follow-up

BDI 7.759/7.60 11.129/12.03 3.52*

HRSD 6.849/5.60 9.639/6.96 5.66**

Comp �/0.859/0.83 �/0.369/1.13 7.09**

Reduction rate (%)

BDI 239/0.29 249/0.31 0.19

HRSD 179/0.25 199/0.24 0.14

Comp 139/0.13 159/0.14 0.71

Note. RRs�/rapid remoralizers; SRs�/slow remoralizers; BDI�/

Beck Depression Inventory; HRSD�/Hamilton Rating Scale for

Depression.; Comp�/composite.

*p B/.05. **p B/.01, one-tailed.

378 E. Gilboa-Schechtman and G. Shahar

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

Discussion

In discussing the therapeutic progress of their

patients, clinicians frequently focus on the manner

in which patients respond to treatment. Were they

quick to warm up to the treatment and the therapist?

Were the first several sessions successful in hooking

the patient to the treatment? Is the progress in

therapy evident right from the start, or is the patient

making barely noticeable progress? In other words,

Table II. Results of regression analyses of long-term outcomes using subsets of pretreatment severity and rate of symptom reduction

variables as predictors.

BDI HRDS Comp

Variable 12mo 18mo 12mo 18mo 12mo 18mo

A1: predictor: pretreatment (alone)

b .20 .20 �/.02 .03 .21 .18

F 6.19* 6.25* .08 .67 6.46* 4.70*

R2 .04 .04 .01 .01 .04 .03

A2: predictor: rate of symptom reduction (alone)

b .31 .22 .24 .21 .29 .26

F 14.30** 6.51* 9.22** 6.69* 12.96** 10.30**

R2 .08 .04 .05 .03 .09 .06

A3: predictor: type of remoralizers (alone)

b .18 .13 .10 .12 .21 .18

F 5.62* 2.77* 1.46 2.31 7.31** 4.89**

R2 .03 .02 .01 .02 .04 .03

B: predictors: pretreatment plus rate of symptom reduction

bPre .21** .22** �/.02 .03 .20** .18*

Rate .30** .21** .22** .17* .29** .26**

F 10.07** 6.92** 2.19 3.78* 10.08** 7.97**

R2 .13 .08 .03 .05 .12 .10

C: predictors: pretreatment plus rate of symptom reduction plus type of remoralizer

bPre .25** .25** �/.01 .06 .23** .20**

Rate .32** .22** .23** .18* .31** .27**

Remoralizer .26** .19* .12 .14 .26** .21**

F 11.01** 6.53** 3.29* 2.48 11.20** 7.91**

R2 .19 .12 .06 .05 .19 .14

Note. BDI�/Beck Depression Inventory; HRSD�/Hamilton Rating Scale for Depression; Comp�/composite.

*p B/.05, two-tailed. **p B/.01, two-tailed.

Table III. Simultaneous regression results for predictors of long-term outcomes in the psychological therapy and nonpsychological therapy

groups.

BDI HRSD Comp

Variable 12 mo 18 mo 12 mo 18 mo 12 mo 18 mo

Beta coefficients of predictors (over all treatment types)

Therapy .03 �/.12 �/.20 �/.14 �/.10 �/.14

Type of remoralizers �/.30* �/.35** �/.30* �/.36** �/.39** �/.42**

Pretreatment .26** .26** �/.01 �/.01 .22** .19*

Rate of symptom reduction .19 .08 .21* .12 .06 .02

Therapy Modality�/Remoralization .22 .35* .36** .38** .31* .39**

Therapy Modality�/Rate of Reduction .23* .30* .09 .23* .23* .27*

F 5.40** 5.12** 2.75* 3.67** 4.31** 4.10**

R2 (adjusted) .16 .18 .11 .14 .16 .15

Beta coefficients rate of symptom reduction for treatment modality groups

Nonpsychotherapy (pills, placebo) .09 .05 .12. .03 .07 .03

Psychotherapy (CBT, IPT) .28** .22* .20* .18 .30** .28**

Note. BDI�/Beck Depression Inventory; HRSD�/Hamilton Rating Scale for Depression; comp�/composite; CBT�/cognitive�/behavioral

therapy; IPT�/interpersonal therapy.

*p B/.05. **p B/.01, one-tailed.

Temporal patterns in brief treatment for depression 379

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

clinicians experience and discuss their patients as

individuals rather than as prototypical examples of a

certain group. Thus, the questions posed by the

practitioner are typically not about a treatment’s

effectiveness or efficacy but about treatment effec-

tiveness for a particular patient (patient-focused

research; Howard et al., 1996). Patient-focused

questions must be answered by focusing on an

individual and his or her pattern of change rather

than on the changes observed in a group of different

individuals.

So far, the examination of TDCRP data focused

solely on questions pertaining to treatment efficacy,

investigating the average response of a group of

patients. In an effort to assess patient-focused

questions, all of which deal with patterns of change

within the treatment process, we examined the

temporal pattern of responding to brief therapy of

depression as it relates to 12 and 18-month out-

comes. We have found that, controlling for initial

depression severity, individuals who exhibited im-

mediate gains between intake and Week 4 of treat-

ment fared better during the follow-up period than

those who exhibited very mild, if any, relief during

this interval. Our results are consistent with those of

Fennel and Teasdale (1987) in that RRs exhibited a

less severe long-term symptomatology than SRs.

Moreover, our results strengthen those of Fennel

and Teasdale in that we used a less stringent criterion

of improvement (15% vs. 50%). Findings obtained

here indicated that early response to treatment is a

simple predictor of therapy outcome. Psychophar-

macological research has already begun investigating

criteria for treatment discontinuation by analyzing

the patterns of change with certain drug regimens

(e.g., Thase & Kupfer, 1996). Similar criteria might

need to be developed for other treatment modalities,

with the practical implication that if, after an

identifiable number of sessions, a patient has not

improved at least to some degree, the treatment

modality might be reconsidered (see also Lueger et

al., 2001).

Timing of remoralization, whether it occurs at the

onset of treatment (as in rapid remoralization) or at a

later stage (slow remoralization), is an important

predictor of both short-term (i.e., treatment effec-

tiveness) and long-term outcome. Several different,

although not necessarily incompatible, explanations

are possible for this finding. During the first several

weeks of a successful treatment, patients need to

accomplish several important goals to feel remor-

alized (Howard et al., 1993). For example, patients

need to be socialized to the treatment, they need to

formulate (with the help of the health care profes-

sional) a plausible rationale for their distress (Gold-

fried, 1980), they need to gather some hope that

their condition is treatable, and they need to come to

trust their own abilities to obtain such a relief (self-

efficacy; Bandura, 1977). Because an outcome-

relevant, constructive, therapeutic alliance has

shown to be formed early in the treatment process

(Shahar, Blatt, Zuroff, Krupnick, & Sotsky, 2004),

difficulties in establishing such an alliance might

result in a ‘‘false start’’ of a therapeutic process, a

worse outcome of therapy, and, therefore, poorer

prognosis.

Consistent with our second hypothesis, we have

found that faster rate of symptom reduction is

related to better ensuing outcome over and above

initial levels of distress and nature of the initial

response (slow or rapid response). Again, multiple

interpretations are consistent with this finding. First,

it is possible that fast rate of symptom reduction is

related to sudden gains in treatment, which have

been associated with better prognosis (Stiles et al.,

2003; Tang, Luborsky, & Andrusyna, 2002). Alter-

natively, it is also possible that such rapid sympto-

matic improvement is related to patients’ greater

self-efficacy (Bandura, 1977), which, in turn, can

lead to greater compliance with therapeutic proce-

dures. This may assist in modifying patients’ belief in

their ability to handle their symptoms (e.g., have less

difficulty concentrating, ruminate less) and cope

more effectively with the precipitating life situation.

Such greater efficacy may be translated to enhanced

future ability to cope more effectively with stressful

life events. Another explanation focuses on the

interpersonal nature of depression, namely, the fact

that depressive symptoms in general, and MDD in

particular, bring about interpersonal stress and

erode patients’ close relationships (Coyne, 1976a,b;

Hammen, 1991, 1998; Joiner, 2000; Shahar, 2001;

Zuroff, 1992). In that sense, the sooner that

patients’ depression is alleviated, the less likely it is

that their depression will be exacerbated by generat-

ing socially malignant conditions.

Consistent with our third hypothesis, we found

that the rate of symptom reduction is more impor-

tant for long-term outcome prediction in active

psychological therapy than in other treatments

(i.e., active pharmacological treatment and placebo

and clinical management treatment). This finding is

consistent with differential mechanisms related to

symptom reduction in the two treatment modalities.

To benefit from an active psychological intervention,

patients must implement in day-to-day life the

methods and strategies learned in therapy. As men-

tioned, rapid rate of symptom reduction may be

related to a successful integration of new cognitive,

interpersonal, and behavioral habits into one’s daily

routine. Those who successfully acquire such skills

may benefit from a ‘‘protective shield’’ that such

380 E. Gilboa-Schechtman and G. Shahar

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

skills provide when faced with life demands in the

long term. In contrast, the speed of improvement in

pharmacological treatment or in naturalistic recov-

ery is likely to exert its effect through a different

mechanism not under the patient’s conscious con-

trol. Given the high relapse rate after the disconti-

nuation of pharmacological treatment of depression,

we might speculate that the rate of symptom reduc-

tion in the therapeutic stage is unrelated to patients’

future ability to regulate their emotions.

Although the treatment modality effect was mod-

est in size, the findings regarding the differential

association between rate of symptom reduction and

long-term outcome suggest that studying patterns of

individual change allows the examination of the

mechanism of various therapeutic modalities. In-

deed, studies have begun to investigate the patterns

of symptom reduction across different disorders and

treatments (e.g., Nishith, Resick, & Griffin, 2002,

for PTSD; Wilson, Fairburn, Agras, Walsh, &

Kraemer, 2002, for bulimia nervosa). For example,

using session by session ratings of PTSD symptom

clusters, Nishith et al. (2002) suggested that the

exposure components of treatments for PTSD form

the active ingredients of both prolonged exposure

and cognitive processing therapy techniques.

In closing, we should mention several limitations

of the present research. First, in the TDCRP data,

symptom measures were obtained every 4 weeks,

resulting in only five data points for each individual.

This paucity of data points limits the sophistication

of the functional forms of change that can be used to

model the recovery process. Specifically, the avail-

ability of additional data points would have allowed

us to adopt more realistic change trajectories, allow-

ing, for example, the modeling of a trajectory in

which deterioration in treatment is experienced

before improvement is achieved. It is possible that

infrequent assessment distorted the actual shape of

the response pattern. However, this latter interpreta-

tion is unlikely, because our results largely parallel

those of Santor and Segal, in which assessments were

made every week. It should also be noted that our

exclusive reliance on linear regression procedures is

limited in that rate of improvement in treatment

might exert some nonlinear effects on outcome

during follow-up.

Second, our assessment period was limited to 18

months. Whereas this is a considerable time interval,

longer follow-up periods might reveal other patterns

of recovery. For example, Hollon, Thase, and

Markowitz (2002) have begun to conduct follow-

up intervals of up to 3 years. Clearly, such intervals

are better suited to discover the variables that govern

the recovery from depression. Third, we focused

only on patterns of symptom change. It is possible

that the inclusion of other measures (e.g., overall

well-being, interpersonal functioning) would have

shown a different pattern of results (see footnote 1).

Fourth, the long-term data of TDCRP were natur-

alistic (see Shea et al., 1992). Thus, patients might

have received additional treatment after the main

study treatment has ended or might still have been in

treatment when the assessments were being per-

formed. It is possible that such naturalistic design

affects the nature of the relationships examined in

the study.

Fifth, remoralization is typically defined as an

enhancement in a sense of well-being. In the present

research, remoralization was operationalized as a

decrease in distress rather than an increase on non-

symptom-related measures (e.g., in well-being, opti-

mism, or hopelessness). In particular, this implies

that the remoralization and remediation phases were

measured by the same variables observed at different

times. Future research would benefit from the

inclusion of well-being and optimism measures,

which will more directly assess remoralization and

will also provide a clearer conceptual distinction

between the remoralization and the remediation

phases.

Finally, in interpreting the present results, it is

important to note that a significant percentage of

patients who have completed the treatments offered

in this study have not experienced a complete

remission of their symptoms. This suggests that in

treating depression we need to look beyond symp-

tom reduction to the reduction of vulnerability.

Future studies should attempt to relate pattern of

symptom reduction to the reduction in vulnerability.

Despite these important limitations, our study

confirms and extends previous, albeit relatively

scarce, reports as to the important role of temporal

patterns in the treatment of depression and anxiety.

It is our hope that these findings will encourage

further investigation of the role of temporal patterns

in other samples, disorders, and treatment modal-

ities.

Acknowledgements

The authors thank Sidney J. Blatt and David C.

Zuroff for their helpful comments on earlier versions

of this article. Eva Gilboa-Schechtman thanks the

Department of Psychology at Yale University for its

hospitality.

Notes1 Blatt, Zuroff, and their colleagues (Blatt, Zuroff, Bondi, &

Sanislow, 2000; Zuroff, Blatt, Krupnick, & Sotsky, 2003) have

shown that patients’ enhanced adaptive capacity (EAC), a

TDCRP composite that assesses patients’ ability to cope with

Temporal patterns in brief treatment for depression 381

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

their symptoms and with life stress after treatment (a) is

independent of symptoms, (b) increases during the follow-up

period among patients in psychotherapy (i.e., CBT and IPT)

but not in pharmacotherapy (i.e., imipramine and placebo), and

(c) serves to buffer against life stress during the follow-up

period. To extend our analyses to nonsymptom measures of

functioning, we have regressed the EAC on type of remoralizer

and rate of symptom reduction. Results indicated that EAC at

both 12- and 18-month follow-up assessments were significantly

related (b�/�/.40, p B/.01, and b�/.44, p B/.01, respectively) to

rate of symptom reduction but not to type of remoralizer (bs�/

�/.078 and �/.084, respectively, ns ). However, no significant

interactions between therapy and rate of symptom reduction

were found in predicting EAC.2 Although any cutoff differentiating the two groups would be

arbitrary, we have chosen the 15% cutoff because this change is

distinctly above that expected by daily variations and measure-

ment errors. Specifically, given that the initial severity of

depression as measured by the BDI is approximately 25, 15%

reduction is more than the 3 points, which, in turn, is more than

BDI’s error of measurement. It is of note, however, that we

experimented with various cutoff points in conducting our

analyses. We have obtained an identical pattern of results with

all cutoffs.

References

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of

behavioral change. Psychological Review, 84 , 191�/215.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).

Cognitive therapy of depression . New York: Guilford Press.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J.

(1961). An inventory for measuring depression. Archives of

General Psychiatry, 4 , 561�/571.

Belsher, G., & Costello, C. G. (1988). Relapse after recovery from

unipolar depression: A critical review. Psychological Bulletin ,

104 , 84�/96.

Billings, A. G., & Moos, R. H. (1984). Coping, stress, and social

resources among adults with unipolar depression. Journal of

Personality and Social Psychology, 46 , 877�/891.

Blackburn, I. M., Funson, K. M., & Bishop, S. (1986). A two-year

naturalistic follow-up of depressed patients treated with cogni-

tive therapy, pharmacotherapy and a combination of both.

Journal of Affective Disorders , 10 , 67�/75.

Blatt, S. J., Zuroff, D. C., Quinlan, D. M., & Pilkonis, P. A.

(1996). Interpersonal factors in brief treatment of depression:

Further analyses of the National Institute of Mental Health

Treatment of Depression Collaborative Research Program.

Journal of Consulting and Clinical Psychology, 64 , 162�/171.

Brown, G. W., & Harris, T. (1978). Social origins of depression: A

reply. Psychological Medicine , 8 , 577�/588.

Coyne, J. C. (1976a). Depression and the response of others.

Journal of Abnormal Psychology, 85 , 186�/193.

Coyne, J. C. (1976b). Towards an interactional description of

depression. Psychiatry: Interpersonal and Biological Processes , 39 ,

28�/40.

Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An

outpatient psychiatric rating scale�/Preliminary report. Psycho-

pharmacology Bulletin , 9 , 13�/28.

Elkin, I. (1994). The NIMH Treatment of Depression Collabora-

tive Research Program: Where we began and where we are now.

In A. E. Bergin & S. L. Garfield (Eds.), Handbook of

psychotherapy and behavior change (4th ed., pp. 114�/135).

New York: Wiley.

Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M.,

Collins, J. F., et al. (1989). National Institute of Mental Health

Treatment of Depression Collaborative Research Program:

General effectiveness of treatments. Archives of General

Psychiatry, 46 , 971�/982.

Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976).

The Global Assessment Scale: A procedure for measuring

overall severity of psychiatric disturbance. Archives of General

Psychiatry, 33 , 766�/771.

Fennell, M. J., & Teasdale, J. D. (1987). Cognitive therapy for

depression: Individual differences and the process of change.

Cognitive Therapy & Research , 11 , 253�/271.

Freud, S. (1958). Remembering, Repeating, and Working

Through: (Further recommendations on the technique of

psychoanalysis), Standard Edition (Vol. 12). London: Hogarth

Press and the Institute of Psychoanalysis.

Gilboa-Schechtman, E., & Foa, E. B. (2001). Patterns of recovery

after trauma: Individual differences and trauma characteristics.

Journal of Abnormal Psychology, 110 , 392�/400.

Goldfried, M. R. (1980). Toward the delineation of therapeutic

change principles. American Psychologist , 35 , 991�/999.

Hamilton, M. A. (1960). A rating scale for depression. Journal of

Neurology, Neurosurgery and Psychiatry, 6 , 56�/62.

Hamilton, M. A. (1967). Development of a rating scale for

primary depressive illness. British Journal of Social and Clinical

Psychology, 6 , 278�/296.

Hammen, C. (1991). Generation of stress in the course of

unipolar depression. Journal of Abnormal Psychology, 100 ,

555�/561.

Hammen, C. (1998). The emergence of interpersonal approaches

to depression. In T. Joiner & J. C. Coyne (Eds), The

interpersonal nature of depression (pp. 21�/35). Washington DC:

American Psychological Association.

Hammen, C., Mayol, A., deMayo, R., & Marks, T. (1986). Initial

symptom levels and the life-event-depression relationship.

Journal of Abnormal Psychology, 95 , 114�/122.

Hart, A. B., Craighead, W. E., & Craighead, L. W. (2001).

Predicting recurrence of major depressive disorder in young

adults: A prospective study. Journal of Abnormal Psychology,

110 , 633�/643.

Hollon, S. D., Thase, M. E., Markowitz, J. C. (2002). Treatment

and prevention of depression. Psychological Science in the Public

Interest , 3 , 39�/77.

Howard, K. I., Lueger, R. J., Maling, M. S., & Martinovich, Z.

(1993). A phase model of psychotherapy outcome: Causal

mediation of change. Journal of Consulting and Clinical Psychol-

ogy, 61 , 678�/685.

Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W.

(1996). Evaluation of psychotherapy: Efficacy, effective-

ness, and patient progress. American Psychologist , 51 , 1059�/

1064.

Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific

factors in cognitive-behavior therapy for depression. Clinical

Psychology: Science and Practice , 1 , 138�/156.

Joiner, T. E., JR. (2000). Depression’s vicious scree: Self

propagatory and erosive factors in depression chronicity.

Clinical Psychology: Science and Practice , 7 , 203�/218.

Judd, L. J. (1997). The clinical course of unipolar major

depressive disorders. Archives of General Psychiatry, 54 , 989�/

991.

Krause, M. S., Howard, K. I., & Lutz, W. (1998). Exploring

individual change. Journal of Consulting and Clinical Psychology,

66 , 838�/845.

Lambert, M. J., Hansen, N. B., Finch, A. E. (2001). Patient-

focused research: Using patient outcome data to enhance

382 E. Gilboa-Schechtman and G. Shahar

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

treatment effects. Journal of Consulting and Clinical Psychology,

69 , 159�/172.

Lewinsohn, P. M., Zeiss, A. M., & Duncan, E. M. (1989).

Probability of relapse after recovery from an episode of

depression. Journal of Abnormal Psychology, 98 , 107�/116.

Lueger, R. J., Howard, K., Martinovich, Z., Lutz, W., Anderson,

E. E., & Grissom, G. (2001). Assessing treatment progress

of individual patients using expected treatment response

models. Journal of Consulting and Clinical Psychology, 69 ,

150�/158.

Mazure, C. M., Bruce, M. L., Maciejewski, P. K., & Jacobs, S. C.

(2000). Adverse life events and cognitive-personality character-

istics in the prediction of major depression and antidepressant

response. American Journal of Psychiatry, 157 , 896�/903.

Nishith, P., Resick, P. A., & Griffin, M. G. (2002). Pattern

of change in prolonged exposure and cognitive-processing

therapy for female rape victims with posttraumatic stress

disorder. Journal of Consulting and Clinical Psychology, 70 ,

880�/886.

Santor, D. A., & Segal, Z. V. (2001). Predicting symptom

return from rate of symptom reduction in cognitive-behavior

therapy for depression. Cognitive Therapy and Research , 25 ,

117�/135.

Segal, Z. V., Shaw, B. F., Vella, D. D., & Katz, R. (1992).

Cognitive and life stress predictors of relapse in remitted

unipolar depressed patients: Test of the congruency hypothesis.

Journal of Abnormal Psychology, 101 , 26�/36.

Shahar, G. (2001). Personality, shame, and the breakdown of

social ties: The voice of quantitative depression research.

Psychiatry: Interpersonal and Biological Processes , 64 , 228�/239.

Shahar, G., Blatt, S. J., Zuroff, D. C., Krupnick, J. L., & Sotsky, S.

M. (2004). Perfectionism impedes social relations and response

to brief treatment for depression. Journal of Social and Clinical

Psychology, 23 , 140�/154.

Shea, M. T., Elkin, I., Imber, S. D., Sotsky, S. M., Watkins, J. T.,

Collins, J. F., et al. (1992). Course of depressive symptoms over

follow-up: Findings from the National Institute of Mental

Health Treatment of Depression Collaborative Research Pro-

gram. Archives of General Psychiatry, 49 , 782�/787.

Stiles, W. B., Leach, C., Barkham, M., Lucock, M., Iveson, S.,

Shapiro, D. A., et al. (2003). Early sudden gains in psychother-

apy under routine clinic conditions: Practice-based evidence.

Journal of Consulting and Clinical Psychology, 71 , 14�/21.

Tang, T. Z., & DeRubeis, R. J. (1999a). Reconsidering rapid early

response in cognitive behavioral therapy for depression. Clinical

Psychology: Science and Practice , 6 , 283�/288.

Tang, T. Z., & DeRubeis, R. J. (1999b). Sudden gains and critical

sessions in cognitive�/behavioral therapy for depression. Journal

of Consulting and Clinical Psychology, 67 , 894�/904.

Tang, T. Z., Luborsky, L., & Andrusyna, T. (2002). Sudden gains

in recovering from depression: Are they also found in psy-

chotherapies other than cognitive-behavioral therapy? Journal of

Consulting and Clinical Psychology, 70 , 444�/447.

Thase, M. E., & Kupfer, D. J. (1996). Recent developments in the

pharmacotherapy of mood disorders. Journal of Consulting and

Clinical Psychology, 64 , 646�/659.

Watkins, J. T., Leber, W. R., Imber, S. D., Collins, J. F., Elkin, I.,

Pilkonis, P. A., et al. (1993). Temporal course of change of

depression. Journal of Consulting and Clinical Psychology, 61 ,

858�/864.

Weissman, M. M., & Paykel, E. S. (1974). The depressed woman:

Study of social relationships . Chicago: University of Chicago

Press.

Willett, J. B., & Sayer, A. G. (1994). Using covariance structure

analysis to detect correlates and predictors of individual change

over time. Psychological Bulletin , 116 , 363�/381.

Wilson, G. T., Fairburn, C. C., Agras, W. S., Walsh, B. T., &

Kraemer, H. (2002). Cognitive-behavioral therapy for bulimia

nervosa: Time course and mechanisms of change. Journal of

Consulting and Clinical Psychology, 70 , 267�/274.

Zuroff, D. C. (1992). New directions for cognitive models of

depression. Psychological Inquiry, 3 , 274�/277.

Zusammenfassung

Je eher, desto besser: Zeitmuster in der kurzenBehandlung von Depression und ihre Rollefur Langzeitkatamnesen

Um zu untersuchen, ob zeitliche Veranderungsmuster inkurzer Behandlung von Depression den Behandlungser-folg bei einer Katamnese nach 18 Monaten voraussagenkonnen, benutzten die Autoren Daten des ‘NationalInstitute of Mental Health Treatment of DepressionCollaborative Research Program’. In Ubereinstimmungmit ihren Hypothesen fanden sie, dass a) Patienten, derenStressniveau nicht zwischen der Aufnahme und der viertenTherapiewoche abnahm (Patienten mit langsamer Verbes-serung) bei der Katamnese eine schlechteres Symptombildzeigten als Patienten mit unmittelbarer Stresserleichterung(Patienten mit schneller Verbesserung), b) die Hohe derSymptomreduktion wahrend der Behandlung den Zustandzu den Zeitpunkten von 12 und 18 Monaten nach derBehandlung, uber den anfanglichen Schweregrad derSymptome hinaus, vorherzusagen kann und c) dass dieHohe der Symptomreduktion fur die Zeitraume von 12und 18 Monaten nach der Behandlung bei Psychotherapiebesser als bei nicht-psychologischen Behandlungenvorhergesagt werden kann. Die Ergebnisse ermutigen zuweiterer Forschung und zu einer erhohten klinischenAufmerksamkeit fur zeitliche Veranderungsmuster beikurzen Behandlungen von Depression.

Resume

Plus c’est vite, et mieux c’est : patterns temporelsdans le traitement bref de la depression et leurrole pour les resultats a long terme

Pour examiner si des patterns temporels de changementdans le traitement bref de la depression predisent leresultat 18 mois apres la fin du traitement, les auteursont utilise les donnees du Programme de RechercheCollaborative du Traitement de la Depression, sponsorisepar l’Institut National de Sante Mentale. En accord avecleurs hypotheses, ils ont trouve que (a) les individus dont leniveau de detresse ne diminue pas entre l’entree et lasemaine 4 de la therapie (ceux qui retrouvent le morallentement) font preuve d’un pattern de symptomes plussevere a l’evaluation catamnestique que ceux qui montrentun soulagement immediat (qui retrouvent le moral rapide-ment) ; (b) le taux de diminution des symptomes au coursdu traitement predit les resultats a 12 et a 18 moisindependamment de la severite initiale des symptomes ;et (c), le taux de diminution des symptomes preditdavantage les resultats a 12 et 18 mois pour la psychother-apie que pour les traitements non psychologiques. Ces

Temporal patterns in brief treatment for depression 383

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014

resultats devraient encourager des recherches ulterieures etune attention clinique pour les patterns temporels dereponse dans le traitement bref de la depression.

Resumen

Cuanto antes, mejor. Pautas temporales para laterapia breve de la depresion y su rol en losresultados a largo plazo

Para estudiar si las pautas temporales de cambio en laterapia breve de la depresion pueden predecir el resultadoa los dieciocho meses de terminado el tratamiento, losautores utilizaron datos del Programa de investigacion delTratamiento Colaborativo de la depresion patrocinado porel Instituto Nacional de Salud Mental (National Instituteof Mental Health-sponsored Treatment of DepressionCollaborative Research Program): De acuerdo con suhipotesis, encontraron que a) los individuos en los cualesel nivel de distres no disminuye entre la admision y lacuarta semana de terapia (recicladores (recicladores ) lentos)exhibieron una pauta de sıntomas mas severa en lasestimaciones de seguimiento que los que mostraron unalivio inmediato (recicladores (remoralizers) rapidos); b) latasa de reduccion de sıntomas durante el tratamientopredice resultados a los doce y dieciocho meses posterioresa los sıntomas iniciales; y c) la tasa de reduccion desıntomas es mas predictiva de los resultados a los doce y losdieciocho meses en tratamientos psicoterapeuticos que enotros tipos de tratamientos. Los hallazgos estimulan aproseguir investigaciones y observaciones clınicas depautas temporales de respuesta para las terapias brevesde la depresion.

Resumo

Quanto mais cedo melhor: Padroes Temporais noTratamento Breve da Depressao e o seu Papelno Resultado a longo prazo

Para examinar se os padroes temporais de mudanca emtratamentos breves para a depressao sao preditivos doresultado terapeutico aos 18 meses pos-tratamento, osautores usaram dados do Programa Colaborativo deInvestigacao do Tratamento da Depressao do InstititutoNacional de Saude Mental dos Estados Unidos. De acordocom as hipoteses, verificaram que (a) os indivıduos cujosnıveis de sintomatologia nao diminiuiam entre a admissaoe a 4a semana de terapia (re-moralizadores lentos) exibiampadroes mais severos de sintomas nas avaliacoes deseguimento (follow-up) que os que mostravam melhoriasimediatas nesse perıodo (re-moralizadores rapidos); (b) o

ritmo de reducao sintomatica durante o tratamento epreditor do resultado terapeutico entre os 12 e os 18 mesesindependentemente da gravidade sintomatica inicial; e (c)o ritmo de reducao sintomatica e mais preditivo doresultado terapeutico, entre os 12 e os 18 meses, notratamento psicoterapeutico que nos tratamentos naopsicologicos. Os resultados encorajam futuras investiga-coes e a atencao clınica aos padroes temporais da respostaao tratamento breve da depressao.

Sommario

Quanto prima, tanto meglio: modelli temporali neltrattamento breve della depressione ed il lororuolo nell’esito a lungo termine

Nell’esaminare se i modelli temporali di cambiamento neltrattamento breve della depressione sono predittivi dell’e-sito a 18 mesi dal trattamento, gli autori hanno usato i datidell’Istituto Nazionale di Salute Mentale, responsabile delProgramma di Ricerca d’equipe sul Trattamento dellaDepressione.

In accordo con le loro ipotesi, hanno trovato che:

a. gli individui i cui livelli di disagio non decresce-

vano tra immissione e 4 settimane di terapia

(lento ) manifestarono un tipo di sintomi piu

gravi alle valutazioni di follow-up rispetto a quelli

che avevano mostrato sollievo immediato;

b. il tasso di riduzione dei sintomi durante il

trattamento e predittivo degli esiti a 12 e 18

mesi indipendentemente dalla gravita iniziale dei

sintomi;

c. il tasso di riduzione dei sintomi e piu predittivo

degli esiti a 12 e 18 mesi nella psicoterapia

rispetto ai trattamenti non psicologici.

I risultati incoraggiano ulteriori ricerche e attenzioneclinica ai modelli temporali di risposta nel trattamentobreve della depressione.

384 E. Gilboa-Schechtman and G. Shahar

Dow

nloa

ded

by [

Uni

vers

ity o

f R

egin

a] a

t 09:

51 1

8 N

ovem

ber

2014