8/13/2019 The Relation Between Changes in Patients

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The Relation Between Changes in Patients' Interpersonal Impact Messages and Outcome inTreatment for Chronic Depression

Contents

1. Method

2. Data Set Overview

3. Current Subsample

4. Measures and Data Collection

5. Results

6. Preliminary Analyses

7. Primary Analyses

8. Discussion

9. Footnotes

10.References

ListenSelect:American Accent

By: Michael J. ConstantinoDepartment of Psychology, University of Massachusetts Amherst

Holly B. LawsDepartment of Psychology, University of Massachusetts Amherst

Bruce A. ArnowDepartment of Psychiatry and Behavioral Sciences, Stanford University Medical Center

Daniel N. KleinDepartment of Psychology, State University of New York at Stony Brook

Barbara O. RothbaumDepartment of Psychiatry, Emory University School of Medicine

Rachel ManberDepartment of Psychiatry and Behavioral Sciences, Stanford University Medical CenterAcknowledgement: A version of this article was presented at the 41st annual meeting of the Society forPsychotherapy Research, Asilomar, California, June 2010. This research was supported by Bristol-MyersSquibb. We are grateful to Aline G. Sayer for her statistical guidance.Correspondence concerning this article should be addressed to: Michael J. Constantino, Departmentof Psychology, University of Massachusetts, 612 Tobin Hall, Amherst, MA 01003-9271 Electronic Mailmay be sent to:mconstantino@psych.umass.edu.Major depression is highly prevalent and often recurrent in course (Constantino, Lembke, Fischer, &Arnow, 2006). Chronic forms of depression, in which symptoms persist for 2 years or longer withoutremission, account for about one third of all episodes of major depression (Kocsis et al., 2003)and affectapproximately 3%5% of the United States' population (Keller & Hanks, 1995a). To a higher degree than

acute depression, chronic forms are associated with severe vocational and psychosocial impairment(Cassano, Perugi, Maremmani, & Akiskal, 1990;Wells, Burnam, Rogers, Hays, & Camp, 1992),frequent suicide attempts (Howland, 1993;Klein, Taylor, Harding, & Dickstein, 1988), and remarkablyhigh health care costs (Howland, 1993;Weissman, Leaf, Bruce, & Florio, 1988). However, only recentlyhas chronic depression received heightened conceptual, clinical, and empirical attention (e.g.,Cuijpers etal., 2010;Keller & Hanks, 1995b;Keller et al., 2000;Klein & Santiago, 2003;Kocsis et al., 2009).In a comprehensive, interpersonally focused theory of chronic depression,McCullough (2000)pointed toarrested social development as both a cause and sustaining consequence of chronic depressive

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8/13/2019 The Relation Between Changes in Patients

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symptomatology. In particular, McCullough theorized that chronically depressed individuals function pre-operationally (Piaget, 1926,1981)when cognitively processing their social interactions. Unable toappraise effectively the consequences of their own behavior or to process accurately feedback and/orcause and effect associations in interpersonal exchanges, chronically depressed individuals (accordingtoMcCullough's, 2000,theory) lack the ability to act effectively on their interpersonal environment.Thus, they remain interpersonally unfulfilled and unskilled, as well as emotionally dysphoric. Although

interpersonal deficits,generallyspeaking, are characteristic of all forms of depression (Bifulco, Moran,Ball, & Bernazzani, 2002;Coyne, 1976;Joiner & Timmons, 2009), McCullough has postulated that pre-operational functioning in chronically depressed patients often manifestsspecificallyas hostiledetachment and excessive submissiveness to a degree that differentiates chronically from acutelydepressed people.Evolving from his theory,McCullough (2000)developed cognitive-behavioral analysis system ofpsychotherapy (CBASP) to treat specifically chronic depression. CBASP is an integrative cognitive,behavioral, and interpersonal treatment that aims to enhance patients' understanding of the consequencesof their actions, to help patients be more affiliative and connected to their interpersonal environment, andto help patients become more effectively assertive. These tasks are accomplished through three primarystrategies. The first, situational analysis (SA), is a multi-step, problem-solving algorithm designed toimprove patients' operational thinking by closely analyzing distressing interpersonal experiences. The

second, the interpersonal discrimination exercise (IDE), involves the psychotherapist's use of transferencehypothesesto help patients process how their current relationship with him or her is different from pastrelationships, and, thus, the same fears, expectations, and defenses need not apply. Finally, the thirdstrategy, behavioral skill training/rehearsal (BST/R) focuses directly on skill development relevant tosocial exchange (e.g., assertiveness training, emotion regulation). As reflected in these interventions,especially the IDE, the therapy relationship in CBASP is conceptualized as a central change agent capableof promoting a corrective interpersonal experience.CBASP, especially in combination with medication, has shown some efficacy in the treatment of chronicdepression. In a well-powered (N= 681 patients) multi-center non-inferiority trial comparing CBASPalone, nefazodone alone, and their combination,Keller et al. (2000)reported modified intent-to-treat(ITT) response rates of 48%, 48%, and 73%, respectively (the modified ITT sample included the 656participants with depression data for at least one post-randomization session). However, in a follow-up

multi-center non-inferiority trial examining the influence of adding psychotherapy (Phase 2) to continuedpharmacotherapy for nonresponders or partial responders (N= 491) to an initial medication trial (Phase1) for chronic depression, there were no significant differences in Phase 2 response rates among patientswhose continued treatment was augmented with CBASP or brief supportive psychotherapy (BSP), orthose who continued optimized pharmacotherapy alone (Kocsis et al., 2009). Counter to predictions, thefindings did not support the value of psychotherapy augmentation over pharmacotherapyaugmentation/switching alone, nor did they support efficacy value added in CBASP over BSP. Thus, thecurrent efficacy data on CBASP remain mixed, which suggests the need not only for additional efficacytrials but also for process research that might illuminate potential change ingredients that could behighlighted in future refinements of CBASP.Focusing on the process of change,Constantino et al. (2008)formally tested the interpersonal tenetsunderlyingMcCullough's (2000)chronic depression theory and examined whether CBASP promoted

interpersonal change in theory-specified ways. These authors first examined interpersonal profiles amongthe chronically depressed outpatients receiving CBASP inKeller et al.'s (2000)trial, as well as both anacutely depressed outpatient comparison sample receiving interpersonal therapy (IPT;McBride et al.,2010)and a non-clinical comparison sample (Kiesler & Schmidt, 1983). Across these samples,interpersonal styles were assessed from the perspective of an individual interacting with the patients orthe non-clinical comparison group participants (i.e., psychotherapists in the two clinical groups,undergraduate subjects viewing non-maladjusted psychiatric interview participants in the non-clinicalgroup) using the Impact Message Inventory (IMI;Kiesler & Schmidt, 1993). The IMI, a self-reportmeasure, is based on the assumption that an individual's interpersonal style can be validly assessed by the

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8/13/2019 The Relation Between Changes in Patients

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interpersonal impact messages received by an interactant during communication with the individual(Kiesler, 1996). The IMI items form a circumplex comprising eight scales reflecting combinations of thecentral interpersonal dimensions of affiliation (ranging from hostility to friendliness on thex-axis) andcontrol (ranging from dominance to submission on they-axis). The measurement of impact messages isbased on the complementarityprinciple. Theoretically, interpersonal behaviors are complementary ifsimilar in affiliation and opposite in control (Carson, 1969;Kiesler, 1983,1996). For example, if a

psychotherapist endorsed feeling in charge when interacting with a patient, it would suggest that thepatient's impact message is one of submissivenessthat is, the patient's deference would be evokingcomplementary dominance in the clinician (dominance is the interpersonal opposite of control). Asnoted,McCullough's (2000)theory purports that chronically depressed individuals should peak on hostileand submissive impact messages, reflecting the nature of their pathology and their difficulty getting theirinterpersonal needs met because of their inability to be flexible, affiliative, and effectively assertive (i.e.,flexible and friendlydominant). CBASP psychotherapists are trained to use the IMI to help identify theirown objective countertransference (Kiesler, 1996)that is, responses evoked in their interactions with

the patient. Such monitoring can inform potential transferential hot spots requiring attention in the IDEas well as SA and BST/R.Constantino et al.'s (2008)findings mostly supportedMcCullough's (2000)theory in terms of presentinginterpersonal profiles. The chronically depressed patients receiving CBASP inKeller et al.'s (2000)trial

presented with more hostile and submissive impact messages than friendlydominant impact messages(as per their psychotherapists' IMI ratings early in treatment). Furthermore, at this early stage oftreatment, chronically depressed patients were rated as having significantly higher hostile and hostiledominant, and significantly lower friendly and friendlydominant, impact messages on theirpsychotherapists than acutely depressed patients had on their psychotherapists at a comparable time inbrief IPT. The chronically depressed patients also had higher hostile, hostilesubmissive, and hostiledominant, and significantly lower friendlydominant, friendly, and friendlysubmissive, impact messageson their clinicians than the normative comparison groups' impact messages on a rating other.Constantino et al. (2008)also examined how chronically depressed patients' IMI profiles changed by theend of CBASP (as the clinicians also completed the IMI during the final week of the 12-week treatment),delivered either alone or with pharmacotherapy. The findings were again consistent with CBASP theoryin that patients' impact messages were perceived by their psychotherapists as less hostile, hostile

submissive, and hostiledominant, and more friendly, friendlydominant, and friendlysubmissive bytreatment's end. Importantly, it did not appear that IMI change simply reflected improvement indepression, as change was comparable for patients who received CBASP alone or CBASP withpharmacotherapy despite the greater efficacy (in terms of depression reduction) of the combinedtreatment group. Furthermore, by the end of treatment, the chronically depressed patients' impactmessages were mostly equivalent with those of the two comparison groups. The only exception wasfriendlydominant, for which the chronically depressed patients continued to be rated significantly lowerthan the normative comparison sample.AlthoughConstantino et al.'s (2008)findings showed promising initial support for the primaryinterpersonal tenets ofMcCullough's (2000)chronic depression theory and theory of change in CBASP, itremains unclear if changes in patients' interpersonal impact messages are associated with treatmentoutcome in the form of depressive symptom reduction. Thus, the primary aim of the current study was to

extend Constantino et al.'s findings by examining whether changes in patients' impact messages, asperceived by their psychotherapist, relate to depression change and posttreatment response status inKelleret al.'s (2000)trial. Consistent with McCullough's theory, we hypothesized that (a) a decrease in hostilesubmissive impact messages (reflecting more adaptive interpersonal affiliation and balance in selfotherreliance) would be associated with greater depression reduction over time and with better posttreatmentresponse, and (b) an increase in friendlydominant impact messages (reflecting adaptive interpersonalassertiveness) would also be associated with greater depression reduction and better response.

Method

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8/13/2019 The Relation Between Changes in Patients

4/14

Data Set OverviewData for the current study derived from the acute phase of the aforementioned multi-center (12 sites)randomized clinical trial compared 12 weeks of CBASP, nefazodone, and their combination for chronicdepression (Keller et al., 2000). For the trial, 681 adults were randomly assigned to treatment condition.Because no outcome data were collected for dropouts, the primary outcome analyses discussed abovewere conducted on a modified intent-to-treat sample that included all patients who had at least one

efficacy assessment beyond baseline (totalN= 656). Patients averaged 43.5 years of age ( SD= 10.7years; range = 1875 years) and metDiagnostic and Statistical Manual of Mental Disorders(4thed.;DSMIV;American Psychiatric Association, 1994)criteria for a current and principal form ofnonpsychotic chronic depression as determined by the Structured Clinical Interview forDSMIVAxis IDisorders (SCID-I;First, Spitzer, Gibbon, & Williams, 1995). The three eligible depression formsincluded the following: (a) major depressive disorder (MDD) lasting at least 2 years, (b) recurrent MDDwith incomplete interepisode remission and a total continuous duration of at least 2 years, or (c) a majordepressive episode superimposed on antecedent dysthymia. Patients also had to receive a score of at least20 on the 24-item Hamilton Rating Scale for Depression (HRSD;Hamilton, 1967)at screening and atbaseline following a 2-week drug-free period. Diagnostic exclusion criteria included the following: ahistory of bipolar disorder, obsessive-compulsive disorder, or dementia; an eating disorder within the pastyear; substance abuse or dependence in the past 6 months; antisocial, schizotypal, or severe borderline

personality disorder; high suicidal risk; or an unstable medical condition. Patients were also excluded fornon-response to at least three previous trials of at least two different classes of antidepressants orelectroconvulsive therapy, or to at least two previous courses of empirically supported psychotherapywithin the past 3 years. There were no significant differences between the treatment groups with respectto baseline characteristics and clinical characteristics (when analyzed both across and within sites;seeKeller et al., 2000,for additional details and descriptive statistics on the total sample).Across the sites, 52 psychotherapists conducted CBASP. All had several years of experience, attended a2-day workshop conducted by J. McCullough, and demonstrated mastery of the treatment protocol in theirwork with two pilot cases. During the study, site supervisors reviewed session videos on a weekly basis toensure standard protocol administration. In the combined condition, psychopharmacologists prescribednefazodone.CBASP, described above, was manual-guided and 12 weeks long. The protocol specified twice-weekly

sessions for the initial 4 weeks and weekly sessions thereafter. Twice-weekly sessions could be extendedup to Week 8 if the patient did not demonstrate mastery of the primary therapeutic skill (i.e., situationalanalysis). Thus, session frequency could range from 16 to 20. For the overall modified ITT sample(Keller et al., 2000), the average CBASP session frequency was 16.2 ( SD= 4.8) for CBASP alonepatients and 16.0 ( SD= 4.7) for combined treatment patients.Pharmacotherapy consisted of open-label nefazodone in two divided doses. The initial dose was 200 mgper day, with a 300 mg per day dose required by Week 3. Subsequent titration of divided doses wasallowed up to 600 mg per day until maximum efficacy and tolerability were achieved. For the overallmodified ITT sample (Keller et al., 2000), the average final nefazodone dose in the combined group was460 mg per day ( SD= 139 mg per day). Medication management (i.e., 1520 min visits conductedweekly during the initial 4 weeks and biweekly thereafter) followed a published manual (Fawcett,Epstein, Fiester, Elkin, & Autry, 1987)focused on symptoms, side effects, and promotion of a

biochemical rationale for depression response. Psychopharmacologists were not allowed to conductformal psychotherapeutic interventions. The institutional review boards at each site approved the studyprotocol, and all participants gave written informed consent before study entry.

Current Subsample

The current subsample is restricted to participants in CBASP and combined treatment, as only CBASPpsychotherapists completed the IMI. Of the 438 patients in these two groups who provided at least onepost-randomization data point (modified ITT), 179 were excluded from the current analyses because theclinician did not fully complete the IMI measure for at least one of the two assessments.1Thus, the finalsubsample for the current study was 259 patients. The average age of our subsample patients (across both

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treatment groups) was 44.8 years ( SD= 10.1 years), with the majority being female (64.5%), White(93.1%), and neither married nor cohabitating (55.2%). Their average monthly income was $2,187 ( SD=$2,464). Diagnostically, 33.2% met criteria for chronic MDD, 23.2% met criteria for recurrent MDD withincomplete interepisode remission, and 43.6% met criteria for MDD superimposed on preexistingdysthymia. The mean baseline HRSD score was 27.7 ( SD= 5.2). The mean durations for the currentMDD episode and the current dysthymic episode were 9.3 years ( SD= 11.2 years) and 24.2 years ( SD=

15.5 years), respectively, with average age of onsets of 27.9 ( SD= 13.9) and 19.4 ( SD= 13.9),respectively. Within our subsample, 40.8% had a non-exclusionary comorbid personality disorder. Withrespect to baseline demographic and clinical features for our subsample, the only marginally significantdifference between CBASP and combined treatment patients was for the diagnosis of a comorbidpersonality disorder. More patients in the combined group (42.8%) were diagnosed with a personalitydisorder than in CBASP alone (34.4%), 2(1) = 3.58,p= .06.The patients in our subsample were similar to those excluded because of missing IMI data on most of theabove sample characteristics. However, several significant differences existed. Patients in our subsamplewere slightly older (M= 44.8, SD= 10.1) than those excluded (M= 42.8, SD= 10.9), t(436) = 1.94,p=.05. Patients in our subsample also had significantly higher baseline HRSD scores (M= 27.7, SD= 5.2)than those excluded (M= 25.8, SD= 4.6), t(436) = 3.88,p< .01, and had a longer length of current MDDepisode (M= 9.3, SD= 11.2) than those excluded (M= 6.3, SD= 7.0), t(436) = 3.18,p< .01. Finally,

there were significantly more patients in our subsample with a personality disorder diagnosis (40.5%)than in those excluded from analyses (36.6%),

2(1) = 8.75,p< .01.Of the 259 patients in our subsample, 141 had IMI measurements for both Weeks 2 and 12, 111 had IMImeasurements at Week 2 only, and 7 had IMI measurements at Week 12 only (we discuss below ourmethod for deriving the relevant IMI change scores).

Measures and Data Collection

Impact Message Inventory (IMI)Following Session 2 (Week 1) and the final session (Week 12), CBASP psychotherapists completed theoctant scale version of the IMI (Kiesler & Schmidt, 1993)to assess their perceptions of their patients'interpersonal impact messages. The IMI consists of 56 items rated on a 4-point scale ranging from 1 ( notat all) to 4 ( very much so). The measure possesses good internal consistency and quasi-circumplexstructure based on the underlying dimensions of affiliation and control (Schmidt, Wagner, & Kiesler,

1999). Each octant, or vector, reflects the sum of 7 items. The present study focused on the twotheoretically relevant vectors of hostilesubmissive (HS; Week 2 = .80, Week 12 = .86) and friendlydominant (FD; Week 2 = .76, Week 12 = .78). All IMI items begin with the phrase, When I am withthis person, he or she makes me feel Sample HS items include, that I should tell him/her not to be

so nervous around me and that he/she thinks he/she can't do anything for him/herself. Sample FDitems include, that I could relax and he/she'd take charge and entertained. For this study, wecalculated weighted vector scores based on the geometry of the circle and taking into account informationfrom adjacent vectors. The weighted HS formula is HS + .707 (H + S), and the weighted FD formula isFD + .707 (D + F). The theoretical range for weighted vector scores is 16.90 to 67.59.

Hamilton Rating Scale for Depression (HRSD)The 24-item HRSD (Hamilton, 1967)was used to assess patient depression at baseline and followingtreatment Weeks 1, 2, 3, 4, 6, 8, 10, and 12. The HRSD is the most widely used interviewer-administered

depression instrument, with a majority of studies reporting adequate internal consistency ( .70;Bagby,Ryder, Schuller, & Marshall, 2004). Interrater reliability estimates are less consistent, withBagby et al.(2004)reporting an intraclass rrange from .46 to .99. To promote high interrater agreement inKeller etal.'s (2000)trial, all raters went through a strict certification process in HRSD administration. Raters werealso blind to treatment condition. The HRSD was used to assess both depression level, as well astreatment response. In Keller et al.'s study, as well as the current analyses, a singlepositive responsegroup was formed. This dichotomized group included patients who either (a) remitted(i.e., had an HRSD score of no more than 8 at both Weeks 10 and 12 for completers or at the time ofwithdrawal for noncompleters) or (b) had a satisfactory response (i.e., had at least a 50% reduction in

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8/13/2019 The Relation Between Changes in Patients

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HRSD score from baseline to Weeks 10 and 12, with a total score of 15 or less at these times, but of morethan 8 at Week 10, Week 12, or both for study completers or at the time of withdrawal fornoncompleters).

Results

Preliminary Analyses

To capture change on the relevant HS and FD weighted IMI vectors, we created latent difference scoresusing hierarchical linear modeling (HLM;Collins & Sayer, 2001;Raudenbush & Bryk, 2002).Specifically, we used the HLM 6 program (Raudenbush, Bryk, & Congdon, 2004)to fit a two-wavemodel of change to each individual's data and obtained the model-based empirical Bayes estimates ofeach person's change score for use in the primary analyses. This empirical Bayes estimate of change is acomposite that combines information about change from each individual and information from the groupas whole, with each part weighted by its reliability. Individuals with one data point provide less reliableevidence for change and therefore change estimates for those with only one IMI measure were weightedtoward the group mean change score. This is a standard approach for handling missingness in hierarchicallinear models (Raudenbush & Bryk, 2002).2Negative scores indicate a decrease in interpersonalcharacteristics from Week 2 to Week 12, whereas positive scores indicate an increase. Change in HS wassignificantly different from zero and negative, indicating that, on average, patients' HS impact messages

decreased significantly over time ( = 4.97,p< .001). Change in patients' FD impact messages wassignificantly different from zero and positive ( = 3.12,p< .001); on average, patients becamesignificantly more FD by treatment's end.Given that previous analyses ofKeller et al.'s (2000)trial data showed that early and middle patient-ratedtherapeutic alliance quality were positively associated with posttreatment outcome (Klein et al., 2003),we also examined the association between the early HS vector and alliance (as assessed with the briefversion of the Working Alliance Inventory;Tracey & Kokotovic, 1989). We did this to ensure that theseare two distinct constructs (as opposed to early HS impact messages simply being redundant withnegative alliance quality). Specifically, we assessed the bivariate correlations between the early HS vectorand all measures of alliance quality in this data set (i.e., early, middle, and late treatment). Resultsindicated no significant relations between the early HS vector and early alliance ( r=.023,p> .05),middle alliance ( r=.020,p> .05), or late alliance ( r= .045,p> .05), thus suggesting the distinctness

of these constructs.Primary AnalysesTo test our primary questions, we analyzed data using growth curve modeling in HLM 6. We fit a seriesof models to the HRSD data to determine the shape of patients' depression change trajectories over thetreatment course. We compared a model including only linear change in depression to a quadratic modelthat accounted for the curvature in change, as well as linear change across the 12 treatment weeks. A chi-square comparison test between the deviance fit statistics for the two models indicated that the quadraticmodel was a significantly better fit to the data than the linear model, 2(4,N= 256) = 238.045,p