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The Relation Between Changes in Patients' Interpersonal Impact Messages and Outcome in Treatment 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: By: Michael J. Constantino Department of Psychology, University of Massachusetts Amherst Holly B. Laws Department of Psychology, University of Massachusetts Amherst Bruce A. Arnow Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center Daniel N. Klein Department of Psychology, State University of New York at Stony Brook Barbara O. Rothbaum Department of Psychiatry, Emory University School of Medicine Rachel Manber Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center Acknowledgement: A version of this article was presented at the 41st annual meeting of the Society for Psychotherapy Research, Asilomar, California, June 2010. This research was supported by Bristol-Myers Squibb. We are grateful to Aline G. Sayer for her statistical guidance. Correspondence concerning this article should be addressed to: Michael J. Constantino, Department of Psychology, University of Massachusetts, 612 Tobin Hall, Amherst, MA 01003-9271 Electronic Mail may be sent 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 without remission, account for about one third of all episodes of major depression ( Kocsis et al., 2003) and affect approximately 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 remarkably high health care costs ( Howland, 1993; Weissman, Leaf, Bruce, & Florio, 1988). However, only recently has chronic depression received heightened conceptual, clinical, and empirical attention (e.g., Cuijpers et al., 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 to arrested social development as both a cause and sustaining consequence of chronic depressive
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a self-report measure. emotion regulation). problem-solving algorithm designed to improve patients' operational thinking by closely analyzing distressing interpersonal experiences. In particular. are characteristic of all forms of depression ( Bifulco. undergraduate subjects viewing non-maladjusted psychiatric interview participants in the non-clinical group) using the Impact Message Inventory (IMI. McBride et al. especially in combination with medication. 2009). nefazodone alone. chronically depressed individuals (according to McCullough's. and their combination. which suggests the need not only for additional efficacy trials but also for process research that might illuminate potential change ingredients that could be highlighted in future refinements of CBASP. expectations. theory) lack the ability to act effectively on their interpersonal environment. Joiner & Timmons. In a well-powered ( N = 681 patients) multi-center non-inferiority trial comparing CBASP alone. Thus. However.symptomatology. Thus. they remain interpersonally unfulfilled and unskilled. 1926. McCullough (2000) developed cognitive-behavioral analysis system of psychotherapy (CBASP) to treat specifically chronic depression. respectively (the modified ITT sample included the 656 participants with depression data for at least one post-randomization session). and defenses need not apply. Evolving from his theory. (2008) formally tested the interpersonal tenets underlying McCullough's (2000) chronic depression theory and examined whether CBASP promoted interpersonal change in theory-specified ways. the current efficacy data on CBASP remain mixed. in a follow-up multi-center non-inferiority trial examining the influence of adding psychotherapy (Phase 2) to continued pharmacotherapy for nonresponders or partial responders ( N = 491) to an initial medication trial (Phase 1) for chronic depression. involves the psychotherapist's use of transference hypotheses to help patients process how their current relationship with him or her is different from past relationships. as well as both an acutely depressed outpatient comparison sample receiving interpersonal therapy (IPT. McCullough has postulated that preoperational functioning in chronically depressed patients often manifests specifically as hostile detachment and excessive submissiveness to a degree that differentiates chronically from acutely depressed people. generally speaking. the interpersonal discrimination exercise (IDE). situational analysis (SA). & Bernazzani. has shown some efficacy in the treatment of chronic depression. (2000) reported modified intent-to-treat (ITT) response rates of 48%. and. CBASP.. the same fears. CBASP is an integrative cognitive. there were no significant differences in Phase 2 response rates among patients whose continued treatment was augmented with CBASP or brief supportive psychotherapy (BSP). Keller et al. 1993). Kiesler & Schmidt. to help patients be more affiliative and connected to their interpersonal environment. Ball. thus. Unable to appraise effectively the consequences of their own behavior or to process accurately feedback and/or cause and effect associations in interpersonal exchanges. These authors first examined interpersonal profiles among the chronically depressed outpatients receiving CBASP in Keller et al. McCullough theorized that chronically depressed individuals function preoperationally ( Piaget. Coyne.'s (2000) trial. Although interpersonal deficits. the findings did not support the value of psychotherapy augmentation over pharmacotherapy augmentation/switching alone. The IMI.e. Finally. is a multi-step. 2000. the third strategy. Across these samples.. is based on the assumption that an individual's interpersonal style can be validly assessed by the . The first. and interpersonal treatment that aims to enhance patients' understanding of the consequences of their actions. 1983). and to help patients become more effectively assertive. or those who continued optimized pharmacotherapy alone ( Kocsis et al. Focusing on the process of change. 2002. assertiveness training. the therapy relationship in CBASP is conceptualized as a central change agent capable of promoting a corrective interpersonal experience.. Counter to predictions. The second. and 73%. nor did they support efficacy value added in CBASP over BSP. As reflected in these interventions. behavioral skill training/rehearsal (BST/R) focuses directly on skill development relevant to social exchange (e. Moran. Constantino et al. as well as emotionally dysphoric. behavioral. especially the IDE.. interpersonal styles were assessed from the perspective of an individual interacting with the patients or the non-clinical comparison group participants (i. 48%. 2010) and a non-clinical comparison sample (Kiesler & Schmidt. These tasks are accomplished through three primary strategies. 1981) when cognitively processing their social interactions.g. 2009). 1976. psychotherapists in the two clinical groups.

friendly–dominant. The chronically depressed patients receiving CBASP in Keller et al. hostile–submissive. Constantino et al. impact messages on their clinicians than the normative comparison groups' impact messages on a rating other. 1996). by the end of treatment. interpersonal behaviors are complementary if similar in affiliation and opposite in control ( Carson.e.'s (2008) findings mostly supported McCullough's (2000) theory in terms of presenting interpersonal profiles. The measurement of impact messages is based on the complementarity principle. The chronically depressed patients also had higher hostile. flexible and friendly–dominant). McCullough's (2000) theory purports that chronically depressed individuals should peak on hostile and submissive impact messages. Importantly. chronically depressed patients were rated as having significantly higher hostile and hostile– dominant. responses evoked in their interactions with the patient. it did not appear that IMI change simply reflected improvement in depression.'s findings by examining whether changes in patients' impact messages. The IMI items form a circumplex comprising eight scales reflecting combinations of the central interpersonal dimensions of affiliation (ranging from hostility to friendliness on the x-axis) and control (ranging from dominance to submission on the y-axis). we hypothesized that (a) a decrease in hostile– submissive impact messages (reflecting more adaptive interpersonal affiliation and balance in self –other reliance) would be associated with greater depression reduction over time and with better posttreatment response.'s (2000) trial presented with more hostile and submissive impact messages than friendly–dominant impact messages (as per their psychotherapists' IMI ratings early in treatment). friendly. relate to depression change and posttreatment response status in Keller et al. and hostile–dominant. Thus. Constantino et al. Although Constantino et al.'s (2000) trial. Consistent with McCullough's theory. it would suggest that the patient's impact message is one of submissiveness—that is. Theoretically. 1969. and friendly–submissive. reflecting the nature of their pathology and their difficulty getting their interpersonal needs met because of their inability to be flexible. delivered either alone or with pharmacotherapy.interpersonal ―impact messages‖ received by an interactant during communication with the individual ( Kiesler. and friendly–submissive by treatment's end. and effectively assertive (i. and hostile– dominant. Furthermore. impact messages on their psychotherapists than acutely depressed patients had on their psychotherapists at a comparable time in brief IPT. affiliative. 1983.'s (2008) findings showed promising initial support for the primary interpersonal tenets of McCullough's (2000) chronic depression theory and theory of change in CBASP. the patient's deference would be evoking complementary dominance in the clinician (dominance is the interpersonal opposite of control). as perceived by their psychotherapist. and significantly lower friendly and friendly–dominant. Method . (2008) also examined how chronically depressed patients' IMI profiles changed by the end of CBASP (as the clinicians also completed the IMI during the final week of the 12-week treatment).. The only exception was friendly–dominant. if a psychotherapist endorsed feeling ―in charge‖ when interacting with a patient. for which the chronically depressed patients continued to be rated significantly lower than the normative comparison sample. CBASP psychotherapists are trained to use the IMI to help identify their own objective countertransference ( Kiesler. it remains unclear if changes in patients' interpersonal impact messages are associated with treatment outcome in the form of depressive symptom reduction. and more friendly. the chronically depressed patients' impact messages were mostly equivalent with those of the two comparison groups. As noted. Such monitoring can inform potential transferential ―hot spots‖ requiring attention in the IDE as well as SA and BST/R. the primary aim of the current study was to extend Constantino et al. hostile – submissive. Furthermore. at this early stage of treatment. 1996)—that is. Kiesler. and significantly lower friendly–dominant. as change was comparable for patients who received CBASP alone or CBASP with pharmacotherapy despite the greater efficacy (in terms of depression reduction) of the combined treatment group. and (b) an increase in friendly–dominant impact messages (reflecting adaptive interpersonal assertiveness) would also be associated with greater depression reduction and better response. The findings were again consistent with CBASP theory in that patients' impact messages were perceived by their psychotherapists as less hostile. For example. 1996).

or to at least two previous courses of empirically supported psychotherapy within the past 3 years. 2000. or (c) a major depressive episode superimposed on antecedent dysthymia.8) for CBASP alone patients and 16. All had several years of experience. & Autry. Hamilton. 1 Thus.Data Set Overview Data for the current study derived from the acute phase of the aforementioned multi-center (12 sites) randomized clinical trial compared 12 weeks of CBASP. antisocial.. Psychopharmacologists were not allowed to conduct formal psychotherapeutic interventions. Spitzer. 179 were excluded from the current analyses because the clinician did not fully complete the IMI measure for at least one of the two assessments. The protocol specified twice-weekly sessions for the initial 4 weeks and weekly sessions thereafter. There were no significant differences between the treatment groups with respect to baseline characteristics and clinical characteristics (when analyzed both across and within sites. with a 300 mg per day dose required by Week 3.. For the overall modified ITT sample ( Keller et al. the final subsample for the current study was 259 patients. Patients averaged 43. the primary outcome analyses discussed above were conducted on a modified intent-to-treat sample that included all patients who had at least one efficacy assessment beyond baseline (total N = 656). Subsequent titration of divided doses was allowed up to 600 mg per day until maximum efficacy and tolerability were achieved. 1967) at screening and at baseline following a 2-week drug-free period. high suicidal risk. session frequency could range from 16 to 20. was manual-guided and 12 weeks long.. 52 psychotherapists conducted CBASP.7 years. substance abuse or dependence in the past 6 months. situational analysis). CBASP. for additional details and descriptive statistics on the total sample). 15–20 min visits conducted weekly during the initial 4 weeks and biweekly thereafter) followed a published manual ( Fawcett. Because no outcome data were collected for dropouts..5 years of age ( SD = 10. Across the sites. 2000). Thus... Elkin. Fiester. nefazodone. Epstein. or severe borderline personality disorder. The institutional review boards at each site approved the study protocol.e. Diagnostic exclusion criteria included the following: a history of bipolar disorder. The three eligible depression forms included the following: (a) major depressive disorder (MDD) lasting at least 2 years. schizotypal. McCullough. Twice-weekly sessions could be extended up to Week 8 if the patient did not demonstrate mastery of the primary therapeutic skill (i. 1987) focused on symptoms. 1995).2 ( SD = 4. range = 18–75 years) and met Diagnostic and Statistical Manual of Mental Disorders (4th ed. side effects.. Medication management (i. The initial dose was 200 mg per day. (b) recurrent MDD with incomplete interepisode remission and a total continuous duration of at least 2 years. the average CBASP session frequency was 16. site supervisors reviewed session videos on a weekly basis to ensure standard protocol administration. an eating disorder within the past year. attended a 2-day workshop conducted by J. & Williams. psychopharmacologists prescribed nefazodone. DSM–IV.e. 2000). 2000).0 ( SD = 4. or dementia. as only CBASP psychotherapists completed the IMI. and their combination for chronic depression ( Keller et al. Patients were also excluded for non-response to at least three previous trials of at least two different classes of antidepressants or electroconvulsive therapy. For the overall modified ITT sample ( Keller et al. Current Subsample The current subsample is restricted to participants in CBASP and combined treatment. see Keller et al. the average final nefazodone dose in the combined group was 460 mg per day ( SD = 139 mg per day). described above. obsessive-compulsive disorder.American Psychiatric Association. During the study. and all participants gave written informed consent before study entry. and demonstrated mastery of the treatment protocol in their work with two pilot cases. Pharmacotherapy consisted of open-label nefazodone in two divided doses. 1994) criteria for a current and principal form of nonpsychotic chronic depression as determined by the Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I. or an unstable medical condition. For the trial. 681 adults were randomly assigned to treatment condition. Gibbon. The average age of our subsample patients (across both .7) for combined treatment patients. In the combined condition. and promotion of a biochemical rationale for depression response. First. Of the 438 patients in these two groups who provided at least one post-randomization data point (modified ITT). Patients also had to receive a score of at least 20 on the 24-item Hamilton Rating Scale for Depression (HRSD.

The mean baseline HRSD score was 27. respectively. ―When I am with this person.2% met criteria for chronic MDD.5 years). Patients in our subsample also had significantly higher baseline HRSD scores ( M = 27. SD = 10. The mean durations for the current MDD episode and the current dysthymic episode were 9. p < .7 ( SD = 5.18. several significant differences existed.5%) than in those excluded from analyses (36.4%).8%) were diagnosed with a personality disorder than in CBASP alone (34.0). respectively.2% met criteria for recurrent MDD with incomplete interepisode remission.2 years ( SD = 15.9).e. reflects the sum of 7 items. he or she makes me feel…‖ Sample HS items include.94.9 ( SD = 13. and 7 had IMI measurements at Week 12 only (we discuss below our method for deriving the relevant IMI change scores).9). t(436) = 3.‖ Sample FD items include. SD = 5. or vector. as well as the current analyses. and the weighted FD formula is FD + . t(436) = 3. The present study focused on the two theoretically relevant vectors of hostile–submissive (HS. p < .. 6.1 years). However.'s (2000) trial. with the majority being female (64. with average age of onsets of 27.06.2 years) and 24.05. with a majority of studies reporting adequate internal consistency (α ≥ . More patients in the combined group (42.01. Measures and Data Collection Impact Message Inventory (IMI) Following Session 2 (Week 1) and the final session (Week 12). (2004) reporting an intraclass r range from .58. 111 had IMI measurements at Week 2 only. This dichotomized group included patients who either (a) remitted (i. had an HRSD score of no more than 8 at both Weeks 10 and 12 for completers or at the time of withdrawal for noncompleters) or (b) had a satisfactory response (i.187 ( SD = $2. The measure possesses good internal consistency and quasi-circumplex structure based on the underlying dimensions of affiliation and control ( Schmidt.8. 40.8. Ryder.1) than those excluded ( M = 42. SD = 7.1%). Within our subsample.6). Week 12 α = .3. White (93. Week 2 α = . p < . CBASP psychotherapists completed the octant scale version of the IMI ( Kiesler & Schmidt. and 43. The IMI consists of 56 items rated on a 4-point scale ranging from 1 ( not at all) to 4 ( very much so).3 years ( SD = 11. All IMI items begin with the phrase. the only marginally significant difference between CBASP and combined treatment patients was for the diagnosis of a comorbid personality disorder.'s study.86) and friendly– dominant (FD.01. In Keller et al. 1967) was used to assess patient depression at baseline and following treatment Weeks 1. The weighted HS formula is HS + .01.5%).59. Raters were also blind to treatment condition. Interrater reliability estimates are less consistent. p = .6% met criteria for MDD superimposed on preexisting dysthymia.80.‖ For this study. The HRSD was used to assess both depression level. 1999). 141 had IMI measurements for both Weeks 2 and 12. SD = 10. Schuller. had at least a 50% reduction in .e.88. 2004).78). ―… 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. as well as treatment response. 2.46 to .treatment groups) was 44. & Marshall.2) than those excluded ( M = 25.2%). χ 2(1) = 3. Week 2 α = . t(436) = 1.90 to 67. there were significantly more patients in our subsample with a personality disorder diagnosis (40.707 (H + S).2). we calculated weighted vector scores based on the geometry of the circle and taking into account information from adjacent vectors.75. SD = 11. ―… that I could relax and he/she'd take charge‖ and ―… entertained.99. & Kiesler. Bagby. Their average monthly income was $2. with Bagby et al. Patients in our subsample were slightly older ( M = 44. The patients in our subsample were similar to those excluded because of missing IMI data on most of the above sample characteristics. 3.464).8. 10. 8. χ 2(1) = 8. Week 12 α = .2) than those excluded ( M = 6.8% had a non-exclusionary comorbid personality disorder. Hamilton Rating Scale for Depression (HRSD) The 24-item HRSD ( Hamilton. and had a longer length of current MDD episode ( M = 9. The HRSD is the most widely used interviewer-administered depression instrument.70. To promote high interrater agreement in Keller et al. all raters went through a strict certification process in HRSD administration. Finally. Wagner..707 (D + F).6%).9) and 19.3. Diagnostically. and 12. The theoretical range for weighted vector scores is 16. 23. 33.76. p = . Each octant.4 ( SD = 13. 1993) to assess their perceptions of their patients' interpersonal impact messages. a single positive response group was formed. and neither married nor cohabitating (55.8 years ( SD = 10. Of the 259 patients in our subsample.7. With respect to baseline demographic and clinical features for our subsample. SD = 4. 4.

001).12. The linear rate of change in depression was negative. Specifically. We fit a series of models to the HRSD data to determine the shape of patients' depression change trajectories over the treatment course. all error terms were allowed to vary). We did this to ensure that these are two distinct constructs (as opposed to early HS impact messages simply being redundant with negative alliance quality). or both for study completers or at the time of withdrawal for noncompleters). Specifically.045.023. Given that previous analyses of Keller et al. Results indicated no significant relations between the early HS vector and early alliance ( r = –. 2004) to fit a two-wave model of change to each individual's data and obtained the model-based empirical Bayes estimates of each person's change score for use in the primary analyses. indicating that. Change in patients' FD impact messages was significantly different from zero and positive (γ = 3. Results Preliminary Analyses To capture change on the relevant HS and FD weighted IMI vectors.. Tracey & Kokotovic. Raudenbush & Bryk. early. middle. on average. we analyzed data using growth curve modeling in HLM 6. Primary Analyses To test our primary questions. patients became significantly more FD by treatment's end. middle alliance ( r = –. 2001. 2002).'s (2000) trial data showed that early and middle patient-rated therapeutic alliance quality were positively associated with posttreatment outcome ( Klein et al.e. as indicated in Table 1.05).36 in HRSD scores per week. and late treatment). with a total score of 15 or less at these times. thus suggesting the distinctness of these constructs. as well as linear change across the 12 treatment weeks. the rate of depression deceleration started out more steeply and slowed toward the final therapy sessions. but of more than 8 at Week 10. This empirical Bayes estimate of change is a composite that combines information about change from each individual and information from the group as whole. we created latent difference scores using hierarchical linear modeling (HLM. p > . N = 256) = 238. p > ..e. with each part weighted by its reliability. whereas positive scores indicate an increase. Also. Week 12. A chisquare comparison test between the deviance fit statistics for the two models indicated that the quadratic model was a significantly better fit to the data than the linear model. we also examined the association between the early HS vector and alliance (as assessed with the brief version of the Working Alliance Inventory. & Congdon. p < . Bryk.045. patients' depression rating at the midpoint (Week 6) of therapy was 18. p < . Individuals with one data point provide less reliable evidence for change and therefore change estimates for those with only one IMI measure were weighted toward the group mean change score. 2002). On average. and quadratic fixed effects were all significantly different from zero (see Table 1). tests of the variance components (random effects) confirmed that there was significant variability around the linear and curvilinear facets of depression change. The intercept. Δχ 2(4.HRSD score from baseline to Weeks 10 and 12.Collins & Sayer.27..05). on average.001).05). or late alliance ( r = . . 2 Negative scores indicate a decrease in interpersonal characteristics from Week 2 to Week 12. p < .020.97. we used the HLM 6 program ( Raudenbush. with variability to be predicted around the deviations from the average (i.001. 5 The significant quadratic term was positive. we assessed the bivariate correlations between the early HS vector and all measures of alliance quality in this data set (i. on average. indicating that. 2003). linear. 1989). suggesting that predictors could be added to the model to determine if patients varied systematically on relevant characteristics. p > . the unconditional 4 model selected for all subsequent analyses was the quadratic trajectory model. This is a standard approach for handling missingness in hierarchical linear models ( Raudenbush & Bryk. 3 Thus. We compared a model including only linear change in depression to a quadratic model that accounted for the curvature in change. Change in HS was significantly different from zero and negative. with an average decrease of 1. patients' HS impact messages decreased significantly over time (γ = –4.

and quadratic equations. had a more curved trajectory of change. the course of depression change is different depending on the type of treatment. a 6. described in terms of how much of the variance in each aspect of patients' depression was explained by each predictor (i.e.396. These findings indicate that in addition to posttreatment depression outcome.01% reduction in unexplained variance around the curvature of depression change (quadratic term). p < . the average rate of change at midpoint. This treatment model was a significantly better fit to the data than the unconditional quadratic model. the treatment condition variable was retained for subsequent analyses. treatment condition (CBASP alone vs. Finally. . The effect size in growth curve models is represented by a pseudo change in R2 statistic.17% reduction of unexplained variance in the rate of depression change at midpoint (linear term). linear. combined CBASP plus medication) was added to the intercept. depression at treatment midpoint. Treatment condition was a significant predictor of the average depression level at treatment midpoint. with a steeper decline in depression early in therapy and a slower rate of change toward the later therapy sessions (see Figure 1). N = 256) = 13.79% reduction of unexplained variance around the midpoint depression score (intercept). and the average curvature of depression change throughout treatment (see the Treatment Model column in Table 2). the shape of change for the CBASP alone group had less curvature in depression decline than the combined group. depression change at midpoint. the combined group had a lower midpoint depression level than the CBASP alone group. and a 3. Because the treatment effect was significant both at the level of fixed effects and in overall model fit. First. Δχ 2(3.Baseline Quadratic Model of Depression Change Across 12 Treatment Weeks Next.. the combined group. The treatment condition predictor accounted for a 3.01. Specifically. Also. and depression change curvature across treatment). we added the predictors to the unconditional quadratic model. relative to CBASP alone.

Model Comparison and Parameters for Treatment Condition and Hostile–Submissive (HS) Change Predicting Depression Change Over 12 Weeks of Treatment .

23% of the variance in depression change above the variance explained by the model with only the treatment condition predictor. HRS Depression = Hamilton Rating Scale for Depression. Finally. the HS change variable was added as a predictor to the model. a model adding the interaction of HS change and treatment condition showed no significant interaction effect on any aspect of depression change over therapy.01. this model was a better fit to the data than the model with the treatment condition predictor alone. 6 . The model estimated significant effects on the linear parameter. Next. p < . N = 26) = 12. Given that combined treatment patients fared significantly better than CBASP only patients in terms of treatment depression reduction. In addition. Depression change over 12 weeks for patients who received cognitive-behavioral analysis system of psychotherapy (CBASP) alone versus those who received the combination of CBASP plus nefazodone. Δχ 2(3. This suggests that the relation between change in HS impact messages and depression is the same for both treatment groups (see Figure 2). This effect accounted for an additional 6. Patients whose psychotherapists perceived less HS impact messages over the treatment course had significantly more reduction in depression. the fact that the association between HS change and depression reduction is the same for both treatment groups suggests that HS change is not simply capturing symptom change.53. or rate of change in depression (see the Treatment and HS Change Model column in Table 2).Figure 1.

A model testing whether there was an interaction between FD change and treatment condition similarly showed no significant interaction effect on any of the depression level or change parameters.35. Decreases in patients' hostile–submissive (HS) impacts predict greater depression reduction in both cognitive-behavioral analysis system of psychotherapy (CBASP) and combined CBASP plus nefazodone groups.254. respectively. N = 256) = 2. we conducted logistic regression analyses to predict the probability that a patient would respond to treatment. We also estimated a similar model testing whether change in FD over the treatment course predicted depression outcome over time. Values for HS Decrease and HS Increase are the 10th and 90th percentiles.880. As in the growth curve model. Decreases in HS impact messages over therapy were also associated with a greater probability of responding to treatment (see Figure 3).50. A logistic regression testing whether FD change predicted response did not significantly improve the model fit compared to the model with only the treatment condition predictor.Figure 2. Results indicated no significant relation between FD change and either depression level at midpoint or change across treatment. Table 3 shows the logistic regression coefficient.76.02. and odds ratio for each of the predictors. 7 . N = 259) = 5. p = . and the model fit did not significantly improve from the model with only treatment condition as a predictor. We compared a model with treatment condition and HS change to a model with the treatment predictor alone. The model correctly classified 69% of responders versus nonresponders. Finally. HRS Depression = Hamilton Rating Scale for Depression. being in the combined CBASP and medication condition versus CBASP alone was associated with a greater probability of responding to treatment. The model with both the HS change and treatment condition predictors was a statistically significant improvement over the model with only the treatment condition predictor. p = . Δχ 2(3. Med = medication. χ 2(1. Both the treatment condition and HS change predictors had significant partial effects. N = 259) = 0. Wald test. p > . χ 2(1.

Logistic Regression Predicting Treatment Response From Treatment Condition and Hostile–Submissive (HS) Change Over Treatment Figure 3. a decrease in HS impact messages was associated with greater depression reduction over time and with positive posttreatment response. 2000). irrespective of treatment condition. Our findings were also consistent with previous analyses conducted on the full modified ITT sample from which the current subsample derives (seeKeller et al. were associated with depression change and treatment response status in theoretically consistent ways following 12 weeks of CBASP or CBASP plus nefazodone. as perceived by their psychotherapists. Probability of responding to treatment based on change in hostile–submissive impacts for cognitive-behavioral analysis system of psychotherapy (CBASP) alone versus CBASP plus nefazodone groups. . an increase in FD impact messages was unrelated to depression reduction and posttreatment response. Discussion The goal of this study was to assess whether changes in chronically depressed patients' interpersonal impact messages (namely hostile–submissive [HS] and friendly–dominant [FD]).. our subsample patients in the combined treatment group evidenced better depression outcome at midpoint and across time than patients in the CBASP only group. Counter to our prediction. As predicted.

2009). it could still be the case that greater friendly–dominance has an adaptive influence on chronically depressed patients. Kocsis et al. and can be replicated. Unexpectedly. However. For now. thus. it is important to stress that this study did not isolate the specific therapist. Thus. It might be that hostility is more readily detected and thus more aversive to deal with in interpersonal exchanges than problems in assertiveness. mixed analyses of variance). only affiliation level at treatment's end predicted positive response status. it seems possible that change in affiliation (both toward self and others) is more important for depression change than an increase in dominance/autonomy-taking. becoming less hostile and more affiliative) has a more profound interpersonal impact than increasing dominance or assertiveness. and that the effect (at least with regard to decreased HS impact messages) is associated with reduced depression. And. Again. the notion of friendly–dominance also includes increased affiliation coupled with autonomous acting on others. 2008). more affiliative and balanced in their self –other reliance. One line of such mechanism work could focus on the quality of the therapeutic alliance. and Jarrett (2004) in a study of cognitive therapy for recurrent depression. it is also important to emphasize that the correlational nature of the study cannot rule out the possibility of reverse causation (i. Of course. patient. 2003). Such changes suggest that these chronically depressed patients became. However. it may be that greater change is required before affecting depression. The present study could also not fully tease apart the respective contributory roles of HS impact messages and alliance on treatment outcome.Consistent with our previous findings ( Constantino et al. it is possible that the efficacy of CBASP could be improved by focusing its interpersonal strategies more centrally on the affiliation/hostility dimension. 2008). but with a different methodology (HLM-derived change scores vs..e. Keller et al. This is perhaps not surprising given Constantino et al. It is important to consider refinements for CBASP given its currently mixed efficacy findings (cf. It is possible that a quality alliance provides an interpersonal vehicle through which an individual can change their HS ways of relating to others. It is possible that the specific interpersonal foci of CBASP (including SA.. future research will need to focus on the specific processes that causally foster the intended interpersonal effect of CBASP. In this sense. increased FD impact messages did not predict depression reduction or treatment response. coupled with the HS findings. To the extent that this finding is accurate. and BST/R).'s (2000) chronic depression sample (see Klein et al. Thus. 2000).. we found that patients' HS impact messages as perceived by their psychotherapists (across both treatment conditions) decreased significantly from early to late treatment. could mean that change on the affiliation dimension (i.e... a theoretically adaptive blend of interpersonal functioning that should theoretically promote greater interpersonal effectiveness and a corresponding decrease in depressive symptomatology ( McCullough.. Of course. consequently. Thus. The present findings are consistent with those reported by Vittengl. as intended. reductions in hostility might bring about more improvements in interpersonal functioning than increases in assertiveness and. while their FD impact messages increased significantly (across both treatment conditions). Of course. This perspective on affiliation is also consistent with our previous finding that the affiliation dimension may be the most central factor differentiating chronic depressives' pathology from normal functioning ( Constantino et al. distinctly lower at treatment's end than a normative comparison . the present findings suggest that an effect on interpersonal impacts is present. decreased HS might mediate the known association between alliance quality and outcome in Keller et al. and/or treatment processes that led to the interpersonal changes. Clark. promote greater affiliation and reduced hostility on the part of chronically depressed patients. at least as perceived by their psychotherapists..'s (2008) finding that FD impacts remained. relate to greater depression reduction. in examining the association of these variables with depression. 2000. In their study. that reduced depression promotes changes in therapists' ratings of their patients' interpersonal impact messages). the researchers found that both self-directed affiliation and autonomy (a construct roughly comparable to friendly–dominant) increased significantly over 12 weeks of acute phase treatment. This lack of association. it would follow that change on this dimension might have the most significant influence on depression reduction. dyadic. as predicted. the IDE. in the same chronic depression sample as the current study. the decrease in HS impact messages perceived by their psychotherapists was associated with a faster reduction in depression over treatment and with positive therapeutic response. as vectors on a circumplex.

given its currently mixed efficacy findings. Such time and opportunity might require a longer course of CBASP. used a piecewise mixed effects linear model to examine differences between their three treatment conditions on linear rate of depression change from baseline to Week 4 and then from Week 4 to Week 12 (or the final visit). it is important to consider refinements for CBASP. which can be useful both in treatment selection and planning as well as in response/non-response monitoring.'s (2000) results. thus restricting the generalizability of such assessment to the patient's own experience and to other important relationships. The patient–psychotherapist relationship is inherently asymmetrical. however. For example. the IMI assesses interpersonal functioning from just one perspective and within one relationship (in this case. Keller et al. This rate difference. Ansell. another possible explanation of the non-finding for FD impact messages is that increased friendly–dominance has adaptive clinical consequences not captured by a pure depression measure. Furthermore. it is plausible that increased FD impact messages could affect other constructs like increased quality of life or increased relational satisfaction. It should be noted. it might be important for CBASP clinicians to pay close attention to subtle themes of patient assertiveness. they might need more time and opportunities to practice these skills in a manner that will relate to significant changes in interpersonal relating. the IDE). The current study has several limitations. the present findings should be interpreted cautiously. Week 4 was selected because it was the earliest time that the nefazodone was predicted to have a therapeutic effect. Relevant to the current study.'s analysis. which slowed toward the end of treatment. Altenstein. First. which could be indirectly associated with depression reduction or even relapse prevention. the psychotherapists' IMI ratings could be biased both early in treatment (when knowledge about the theory of chronic depression could influence ratings) and late in treatment (when expectations that the patient has improved in theory-consistent ways could influence ratings). while the combined group had a more curved trajectory—that is. especially as they relate to the work being done in the context of the psychotherapeutic relationship (e. these authors found that patients in combined CBASP plus nefazodone evidenced a greater rate of depression reduction from baseline to Week 4 than patients in CBASP alone. the duringtreatment effect of treatment condition on depression change was still evident 2 weeks further into the treatment. This is a question for future study. It might also be that such changes in assertiveness simply take longer than the 12 weeks in the present treatment. Clinically then. Thus. the findings point to a more efficient response to combined CBASP and nefazodone for chronically depressed patients. In particular. The difference in findings for HS and FD impact messages might also be a function of the special nature of the therapeutic relationship. Although patients might be on their way to greater assertiveness following 12 weeks. and detecting increased assertiveness in this specific context might be more difficult than detecting reductions in hostility. In the current study. Thus. the clinician's perspective in the context of a therapy relationship). and to conduct additional research on its process of change.g. Note that we examined the actual midpoint of Week 6 compared to Week 4 in Keller et With more sensitive detection. which suggested that the rate of depression change was different for the two groups. Alternatively. such changes might significantly predict depression outcomes. Clinically. our findings also provided further information on the nature of depression change as a complement to Keller et al. but more time is needed to reap their benefits in naturalistically occurring relationships.. Schneider. Thus. We also examined the quadratic term. Again. patients receiving combined treatment had significantly lower depression levels and rate of depression change at the midpoint of therapy compared to patients in CBASP alone. It will be important for future research to examine interpersonal styles and impacts in relation to clinical constructs other than just depression. Secondarily. though. Change in CBASP alone involved a fairly uniform deceleration. and multi-method/multi-perspective replication is required for greater confidence. & . Finally. it is possible that even more changes in assertiveness were present than detected by the clinicians. For the full modified ITT sample. the findings based on our subsample essentially paralleled those of Keller et al.and posttreatment ( Grosse Holtforth. that the present findings were quite similar to those in a study of depressed outpatients whose significant others rated their interpersonal impact messages at both pre. the current treatment length might be sufficient to learn these skills. was not statistically significant from Week 4 to Week 12. a steeper deceleration in depression earlier in treatment.

Fourth. decreases in submissiveness and hostile–submissiveness were associated with greater depression reduction. This scenario was predominantly a function of patients dropping out prior to the late IMI assessment. submissive. we were restricted to just one early and one late treatment assessment. it is difficult to know if the changes that we did capture in interpersonal impacts were specific to CBASP versus more generally related to having 12 weeks of contact with a psychosocial or pharmacological treatment provider. and more dominant and friendly–dominant after treatment. These complexities might play a role in how depression change occurs. though non-causal. In this study. perhaps especially for the FD scale. this debilitating condition will no longer require the ―understudied‖ designation. including likely ebbs and flows as the dyad engages in novel exchanges that disrupt the patient's maladaptive transaction cycles. Second. In future studies. Fifth. interrater reliability on the HRSD was not assessed in the parent trial from which the current data derive. Finally. Sixth. the present study provides further support for McCullough's (2000) theory of chronic depression and therapeutic change. it is unclear how the IMI change trajectories might have continued for these dropout cases. given that patients included in our subsample were more symptomatic than patients excluded because of no IMI ratings. thus limiting our ability to measure more complex change patterns. Moreover. it also provides preliminary. and how these specific trajectories might have differentially related to depression. thus limiting our ability to assess fully the temporal direction of the change.Caspar. patients were perceived by their significant others as less friendly– submissive. a large portion of cases in our effective sample had only one IMI rating (with change scores being estimated using characteristics of the entire sample). . given the absence of a control condition. the IMI was measured on just two occasions. Interpersonal change might unfold more complexly in the context of the patient–psychotherapist relationship. it is unclear if our findings would generalize to patients with less severe chronic depression. Thus. It is plausible that such difficulty contributed to the lack of association between FD change and outcome. evidence for the promise of CBASP influencing processes and outcomes in its intended manner. it is possible that the IMI items. were difficult for the rating therapists to apply to the therapy setting. some converging findings across rating perspectives already exist. Having just the two IMI occasions also allowed us to examine only the concurrent relation of interpersonal change and depression change. and they might also interact with other relational processes such as alliance ruptures and potential subsequent repairs. and hostile–submissive. it will be important to have more frequent and reliable IMI assessment to understand more fully (with less missing data and more data points when imputation is required) how IMI change relates to therapeutic change. Thus. With continued focus on the nature of chronic depression and its related treatment processes and outcomes. Third. Seventh. With these limitations in mind. Although using HLM to create change scores helped us to remove measurement error. it is possible that IMI changes were at least partly attributable to statistical regression to the mean or to repeated administration. 2011).