Using Levels of Residual Symptoms to Decide

To demonstrate the ability of depressive symptoms at the last A-CT session (residual symptoms) to predict relapse/recurrence among responders to ACT (Jarrett et al., 2005), we operationalized depressive symptoms as the common factor score we mentioned earlier and examined the data in two different ways. First, we examined 8 points on the survival function (the probability of remaining well over time), and found that higher depressive symptom factor scores at the last A-CT session predicted quicker relapse/ recurrence as a main effect and also interacted with assignment to C-CT versus assessment only. Specifically, C-CT does not reduce the probability of relapse/recurrence for patients with no or low residual symptoms, but patients with progressively higher residual symptoms relapse less in C-CT compared to assessment-only controls. Thus, the practical value of these results is that patients' scores on any one of a number of readily available symptom severity measures after 20 sessions of CT can aid clinicians and patients in assessing risk for relapse/recurrence and using predicted risk to decide whether to provide C-CT.

As a further illustration, we then divided these same patients (from the clinical trial reported by Jarrett et al., 2001) into lower versus higher residual symptoms, assignment to C-CT or to assessment only, and relapse/recurrence within 24 months. Residual symptoms at the end of A-CT were dichotomized as lower versus higher (approximate cutoffs on individual scale: HRSD < 4 vs. > 5,BDI < 6 vs. > 7, IDS-C < 9 vs. > 10, IDS-SR < 11 vs. > 12, QIDS-C < 3 vs. > 4, and QIDS-SR < 4 vs. > 5) based on the level of depressive symptoms that consistently differentiated C-CT from the control group in relapse/recurrence probabilities. Residual symptom level did not predict relapse/recurrence for patients in C-CT (Fisher's exact test p = .41), but high residual symptoms predicted more relapses/recurrences for patients who did not receive C-CT (Fisher's exact test p < .01). Among patients with lower residual symptoms at the end of A-CT, 30% relapsed or experienced recurrence within 24 months in both the C-CT and assessment-only groups. In contrast, among patients with higher residual symptoms, 90% relapsed or experienced recurrence in assessment-only compared to 50% in C-CT. Moreover, relapses or recurrences tended to come earlier (in the experimental phase) for the assessment-only control, and later (during the follow-up phase) for the C-CT group. Although C-CT does not prevent all relapses or recurrences in high-risk patients, the clinical conclusion is clear: Patients with higher residual symptoms after ACT experience relapse and recurrence less and later with C-CT. In contrast, patients with lower residual symptoms, who do not have other risk factors, may not require C-CT.

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