Mechanisms of Change and Predictors of Outcome in CT for Depression

Given the success of CT for depression, a number of ancillary questions arise, including questions related to how CT exerts its influence and whether the treatment is more or less appropriate for clients with known characteristics. The first of these questions was examined by mediational analyses and the examination of therapy processes related to outcome. Results of these studies include the observation that early completion of homework is associated with better clinical outcome (Startup & Edmonds, 1994); that attention to the specific techniques of CT are associated with more change than are the nonspecific aspects of treatment (DeRubeis & Feeley, 1990; Feeley, DeRubeis, & Gelfand, 1999); and that patients with a sudden but sustained decrease in depression severity scores tend to have better long-term outcomes than patients with more gradual but equal outcomes (Tang & DeRubeis, 1999; Tang, DeRubeis, Beberman, & Pham, 2005). These studies, as well as many others that explore the assumptions of the cognitive model of depression (Clark et al., 1999), reveal aspects of how to optimize treatment outcomes.

Experimental analyses of the effective components of CT of depression are rare. The major study to date used an incremental dismantling strategy and randomly assigned depressed outpatients to receive 20 sessions of behavioral activation (BA) interventions, 20 sessions of BA and cognitive restructuring interventions, or 20 sessions of the full CT treatment (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996). All three conditions had equal outcomes in this study, both in the acute phase of treatment, and in the 2 years of follow-up. Taken literally, the results of this study indicate that adding cognitive interventions to the BA components of therapy do not enhance short-term outcome or reduce relapse; in other words, they call into question the clinical utility of the cognitive interventions in CT! Although these results raise provocative questions about the mechanisms of change in CT for depression, replication is needed to understand the full implications of these results.

The other approach that has explored clinically relevant questions about CT has examined predictors of outcome. It has generally been demonstrated that patients with more severe initial depression, as well as those with more chronic depression, do worse than less severely or less chronically depressed patients in CT for depression (Hollon & Beck, 1994; Hollon, Thase, & Markowitz, 2002), but other patient predictors of outcome have been notoriously difficult to establish (Hamilton & Dobson, 2002). It has also been difficult to establish therapist predictors of outcome (Hollon & Beck, 1994). Although therapist adherence to CT techniques appears to predict outcome, the rated competence of CT therapists has only been demonstrated to have a positive relationship to outcome in a few studies (Jacobson et al., 1996; Shaw et al., 1999; Trepka, Rees, Shapiro, Hardy, & Barkham, 2004). Further study of these questions, and perhaps improved instrumentation, is needed to understand more fully these issues.

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