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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Behav Ther. 2019 Nov 27;51(5):739–752. doi: 10.1016/j.beth.2019.10.008

Do Cognitive Therapy Skills Neutralize Lifetime Stress to Improve Treatment Outcomes in Recurrent Depression?

Jeffrey R Vittengl 1, Sonja Stutzman 2, Aparna Atluru 3, Robin B Jarrett 4
PMCID: PMC7431681  NIHMSID: NIHMS1544705  PMID: 32800302

Abstract

Cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but not all patients respond. Past research suggests that stressful life events (SLE; e.g., childhood maltreatment, emotional and physical abuse, relationship discord, physical illness) sometimes reduce the efficacy of depression treatment, whereas greater acquisition and use of CT skills may improve patient outcomes. In a sample of 276 outpatient participants with recurrent MDD, we tested the hypothesis that patients with more SLE benefit more from CT skills in attaining response and remaining free of relapse/recurrence. Patients with more pre-treatment SLE did not develop weaker CT skills, on average, but were significantly less likely to respond to CT. However, SLE predicted non-response only for patients with relatively weak skills, and not for those with stronger, CT skills. Similarly, among acute-phase responders, SLE increased risk for MDD relapse/recurrence among patients with weaker CT skills. Thus, the combination of more SLE and weaker CT skills forecasted negative outcomes. These novel findings are discussed in the context of improving CT for depression among patients with greater lifetime history of SLE and require replication before clinical application.

Keywords: depression, cognitive therapy, stressful life events, skills, response, relapse

Cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) that produces benefits comparable to antidepressant medication (Cuijpers et al., 2013; Weitz et al., 2015) and can be delivered through traditional and technological modalities (Cuijpers et al., 2019). Even so, not all patients respond to CT and remain free of depressive relapse or recurrence. Consequently, efforts to improve outcomes include augmenting or modifying CT to focus on core depression symptoms such as insomnia (Cunningham & Shapiro, 2018) and anhedonia (Dunn et al., 2019), and clarifying risks and mechanisms that may produce distinct CT outcomes. For example, stressful life events (SLE) such as childhood maltreatment, relationship discord, unemployment, emotional or physical abuse, and criminal convictions have predicted poor depression treatment response and increased risk for relapse/recurrence in past studies (Colman & Ataullahjan, 2010; Wojnarowski et al, 2019), whereas acquiring and using skills taught during CT have predicted better outcomes (Jarrett et al., 2001; Strunk et al., 2007). These CT skills include scheduling and participating in reinforcing activities, as well as identifying and changing unrealistically negative thoughts, and testing new behavioral patterns. In this context, the current study evaluated the extent to which pre-treatment SLE and CT skills may interact to predict outcomes in CT for adults with recurrent MDD.

Modern theories of depression etiology emphasize SLE. For example, Beck and Bredemeier (2016) suggested that SLE that produce perceived loss of social or tangible resources activate cognitive and biological vulnerabilities that lead to depression. Cognitive vulnerabilities include negatively biased attention and memory, whereas biological risks include genetic and neurochemical factors. This theory is consistent with research revealing changes in the hippocampus (Zaletel et al., 2016) and increased mortality (Russ et al., 2012) associated with stress. Similarly, Barlow et al. (2014) proposed that SLE contribute to both psychological and biological risks for depression reflected in the trait dimension of neuroticism. In this model, psychological risks include cognitive structures producing a sense that life events are unpredictable and uncontrollable, and biological risks include gene-environment interactions producing HPA axis dysregulation. Finally, Kendler et al. (Kendler & Gardner, 2011; Kendler, Gardner, & Prescott, 2002, 2006) proposed that SLE both during childhood and adulthood increase risk for onset and recurrence of depression. Kendler et al. suggest that SLE may increase depression risk non-linearly after reaching a threshold and interact with other risk factors, including genetics and personality.

Consistent with these theories, SLE have often (but not always) predicted depression onset and poor treatment outcomes. In past research, SLE correlated with onset of MDD (Bebbington et al., 1988; Colman & Ataullahjan, 2010). Severe SLE may be more important for first depressive episodes whereas chronic stressors are more relevant for recurrent episodes (Monroe et al., 2007). Previous research has also shown that persons predisposed to depression, or with depression, often have parents with mood or other mental health disorders, choose risky environments and affected partners, and behave in ways that increase SLE incidence and severity (Flynn, Kecmanovic, & Alloy, 2010; Hammen & Shih, 2010; Nordsletten et al., 2016; Rasic et al., 2014). Consequently, SLE and depression may be linked through complex social, behavioral, and biological processes.

When treating depression with antidepressant medication, poorer acute and longer-term outcomes have been associated with pre-treatment SLE from both childhood and adulthood (Buckman et al., 2018; Buhler & Pagels, 2003; Mazure et al, 2000; Nanni, Uher & Danese, 2012). Moreover, SLE may reduce the efficacy of antidepressants relative to pill placebo (Lewis et al., 2010). However, relations of SLE with antidepressant medication outcomes may be complex. For example, pre-treatment SLE have been shown to interact with specific genetic variants during pharmacotherapy (for a review, see Kovacs et al., 2014). Further, mild pre-treatment SLE predicted better outcomes, whereas severe SLE before or during treatment predicted poorer outcomes (Bulmash et al., 2009).

Similarly, in CT for depression, SLE have often predicted poorer treatment outcomes but relations have sometimes been complex. For example, among both adolescents and adults, patients with more SLE before or during treatment had poorer outcomes in acute-phase CT for depression (Carney et al., 2016; Shirk, Kaplinski, & Gudmundsen, 2009). In addition, SLE after response to acute-phase CT or other depression-specific treatments predicted recurrence (Harkness et al., 2014). Similarly, daily hassles during continuation CT predicted recurrence (Bockting et al., 2006). However, pre-treatment SLE may reduce the efficacy of acute-phase CT less than SLE reduce the efficacy of pharmacotherapy (Fournier et al., 2009; Nemeroff et al., 2003). Moreover, adults with more pre-treatment SLE may derive greater benefit from acute-phase CT (Niciu et al., 2015) and continuation-phase CT (Williams et al., 2014). These past findings suggest that a specific “active ingredient” of CT may be especially important for patients with more SLE, a possibility tested in the current study.

Both theory and research suggest that skills that patients learn and use during CT are a likely active ingredient (Adler et al., 2015; Hundt et al., 2013; Jarrett et al., 2018). Skills taught in CT are designed to help patients recognize and change relations among behavior, thought, and emotion to reduce depressive symptoms, and thereby can reduce the impact of stressors (Beck et al., 1979). For example, CT patients learn to identify and test the validity of negative thoughts, replace unsupported negative thoughts with more realistic ones, engage in reinforcing activities to decrease negative and increase positive affect, and solve problems effectively, regulate emotions, and behave in new ways. Research has shown that patients with greater CT skills are more likely to respond to CT and less likely to experience subsequent depressive relapse or recurrence (Jarrett, Vittengl, Clark, & Thase, 2011; Strunk, DeRubeis, Chiu, & Alvarez, 2007).

We aimed to extend the literature on pre-treatment SLE and CT skills in treatment for depression, utilizing available data from a randomized clinical trial (RCT; Jarrett & Thase, 2010). In this multi-phase RCT, all patients had opportunity to learn CT skills during acute-phase CT. Acute-phase responders were then randomized to one of three continuation treatments (continuation CT, or clinical management with fluoxetine or pill placebo). We predicted outcomes, including acute-phase response and post-acute relapse/recurrence, from SLE over the lifetime (measured before acute-phase CT) and the interaction of SLE with CT skills. Because past research suggests that patients with more SLE are at greater risk for poorer treatment outcomes and so have more to gain, we tested the hypothesis that patients with more pre-treatment SLE benefit more from CT skills in attaining response and remaining free of relapse/recurrence. Although we did not make a directional hypothesis, we also tested whether continuation treatment moderated relations between SLE and post-acute outcomes.

Method

Data analyzed here were collected at the Psychosocial Research and Depression Clinic at The University of Texas Southwestern Medical Center (Dallas) during a multi-phase, two-center RCT (Jarrett & Thase; 2010; Jarrett et al., 2013). Study procedures were approved by the Institutional Review Board and the trial’s Data Safety and Monitoring Board. Participants analyzed here constituted the intent-to-treat sample at the Dallas site. Participants at the University of Pittsburgh site were excluded because SLE coding was not available. Figure 1 shows the flow of patients through the RCT at the Dallas site.

Figure 1.

Figure 1.

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Patient flow through the RCT at the University of Texas Southwestern Medical Center (Dallas) site.

Participants

Participants were recruited through newspaper advertisements, fliers, and self- and practitioner-referrals in the Dallas-Fort Worth area. Patients provided written and verbal informed consent for evaluation and treatment. Included participants met criteria for recurrent MDD (American Psychiatric Association, 2000) as diagnosed with the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996), either remitted between major depressive episodes (MDE; i.e., had periods of ≥ 2 months with minimal or absent symptoms) or had dysthymic disorder preceding the onset of MDD, and scored ≥ 14 on the 17-item Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) at both initial and second diagnostic evaluations. (Two patients erroneously entered CT with HRSD = 13 at one of two diagnostic visits. During CT, one of these patients responded and one dropped out. As recommended by the Data Safety and Monitoring Board, the two patients are analyzed here as they were treated during data collection.) Exclusion criteria were severe or poorly controlled medical disorders that could cause depression; psychotic, bipolar, or organic mental disorders, active substance dependence, or primary obsessive-compulsive or eating disorders; unable to complete questionnaires in English; active suicide risk; age < 18 or > 70 years; history of non-response to ≥ 8 weeks of CT or 6 weeks of fluoxetine; pregnant or pregnancy planned during the first 11 months of the study. On average, participants (N = 276) were 42.6 (SD = 12.2) years old and had completed 15.3 (SD = 2.8) years of education; 69.6% were women, and 74.5% were of non-Hispanic white ethnicity. Participants’ average age of onset of MDD was 19.7 (SD = 9.9) years, and they had experienced a median of 3 (minimum 2) MDEs.

Acute phase

Before entering acute phase cognitive therapy (A-CT), patients were withdrawn from any psychotropic medications. The A-CT protocol (Beck et al., 1979) lasted 12 weeks with 2 additional weeks allowed for rescheduling. Patients received 2 CT sessions per week for 4 weeks. Thereafter, patients with ≥ 40% decreases in HRSD scores received 8 weekly sessions (16 total sessions), whereas patients with less early symptom reduction received 8 twice-weekly and then 4 weekly sessions (20 total sessions). Patients with less early improvement received more sessions to increase their chance of response and eligibility to enter the continuation phase focused on relapse prevention, as specified in the RCT design (Jarrett & Thase, 2010). Goals of A-CT include reducing depressive symptoms, re/engaging patients with sources of reinforcement, improving functioning, and identifying and restructuring negative automatic thoughts and broader negative assumptions (schema) about the world, self, and future. The cognitive therapists (N = 16) had completed at least 1 year of supervised CT training and maintained average Cognitive Therapy Scale (Young & Beck, 1980) scores ≥ 40, demonstrating competence. Across the RCT, therapy supervisors and teams rated 368 randomly selected sessions, and 93% of sessions had Cognitive Therapy Scale scores ≥ 40 (see Jarrett & Thase, 2010, and Jarrett et al., 2013, for details). Cognitive therapists received weekly group supervision and consultation, including feedback on strengths and weaknesses observed in session videotapes.

Continuation phase

Non-responders to A-CT were referred for non-protocol treatment and are not analyzed further here. Responders to A-CT (no MDE and HRSD ≤ 12 at the end of A-CT) who met a priori criteria for high risk of relapse (≥ 1 of the last 7 acute-phase HRSD scores ≥ 7) were offered 8 months of continuation treatment. Higher-risk responders were randomized to continuation phase cognitive therapy (C-CT; n = 48), fluoxetine with clinical management (FLX; n = 46), or pill placebo with clinical management (PBO; n = 38). Responders to A-CT at lower risk of relapse (all of the last 7 acute-phase HRSD scores ≤ 6; n = 20) completed only assessments after the acute phase and over 32 months.

The C-CT protocol included 10 sessions (4 biweekly and then 6 monthly) of about 60 minutes each (Jarrett, 1989; Jarrett, Vittengl & Clark, 2008). In C-CT, patients learned to apply compensatory skills to residual and emergent depressive symptoms, restructure depressive assumptions, generalize therapeutic skills (e.g., across problems, time, and situations), cope preemptively with cognitive and behavioral risks for depression, and maintain new behavioral patterns. Patients worked with the same therapists as in A-CT, with a few exceptions (e.g., due to a therapist’s maternity leave).

The double-blinded FLX and PBO protocol (Fawcett et al., 1987) included 10 sessions on the same schedule as C-CT. Experienced pharmacotherapists conducted an initial session of up to 45 minutes and subsequent sessions of up to 30 minutes. Clinical management included supportive contact involving discussion of the signs and symptoms of depression, beneficial and unwanted medication effects, and information about depression to facilitate high-quality pharmacotherapy. Pharmacotherapists were prohibited from using CT methods or providing other psychosocial treatments. Research pharmacies dispensed active fluoxetine or visually identical pill placebo capsules. Patients received 10 mg/day for 2 weeks, then 20 mg/day for 2 weeks, and finally 40 mg/day. Pharmacotherapists were permitted to decrease doses to lessen side effects (Jarrett et al., 2013).

Independent evaluators assessed MDD with the SCID (First et al., 1996) and the Longitudinal Interval Follow-up Evaluation (Keller et al., 1987) at the end of months 4 and 8 (and interim, if relapse was suspected). Patients who relapsed were referred for additional non-research treatment.

Follow-up phase

Patients who completed the 8-month continuation phase discontinued any protocol treatment and entered the 24-month follow-up. As in the continuation phase, evaluators blinded to continuation arm assignment assessed patients every 4 months. If patients experienced depressive symptoms, they were encouraged to contact study personnel for interim evaluation. Patients who relapsed or recurred were referred out for non-research treatment.

Measures

Stressful life events

The SLE measure developed for this study assessed (a) which events occurred, (b) to whom (the patient and/or close family/friend; friends/family data not presented in this report), and (c) when in the patient’s lifespan (i.e., birth to age 18, age 18 to the past year, or the past year) relative to study intake. The 35 target events were selected from literature review focused on extant measure of life stressors (Brugha & Cragg, 1990; Gray et al., 2004; Greenwald & Rubin, 1999; Holmes & Rahe, 1967) and clinical experience of the investigative team who assessed and/or treated depressed patients. Supplement 1 lists the SLE items and their sources.

Clinicians, experienced in diagnostic evaluation, reviewed the baseline chart and completed the SLE measure. In particular, they reviewed data from structured interviews (SCID-I/P for DSM-IV-TR, including major depressive and post-traumatic stress disorders; First et al., 1996), a patient-report questionnaire (List of Threatening Experiences; Brugha & Cragg, 1990), and narrative clinical reports compiled at diagnostic intake (including lifetime history of depressive episodes and accompanying psychosocial stressors). Past research supports the inter-rater reliability of the List of Threatening Experiences (median kappa = .75; Brugha & Cragg, 1990) and SCID (median kappa = .71; Lobbestael, Leurgans, & Arntz, 2011). After training on practice materials, clinicians scored the presence or absence of each event for the patient. To estimate inter-rater reliability, two independent coders completed the SLE for 18 patients. Inter-rater reliability for the lifetime total number of SLEs was high (intraclass correlation = .92 for estimated single-rater reliability). The same two coders also provided SLE for the full sample of patients. We analyzed the total number SLE over the lifetime because our hypotheses did not differentiate particular time periods for events, and events were relatively infrequent in shorter time periods.

Cognitive therapy skills

Therapists and their patients completed the 8-item Skills of Cognitive Therapy scale (SoCT; Jarrett et al., 2011) at approximately weeks 7 and 12 in CT. Items were rated on a 5-point frequency scale to assess CT skill acquisition and use. Reliability and validity of the SoCT have been supported by convergence of therapist, patient, and external observer ratings, and prediction of CT response (Brown et al., 2016; Jarrett et al., 2011). Patient and therapist ratings from mid and late in CT were averaged for the current analyses. Alpha internal consistency for the aggregate CT skills measure was moderate (alpha = .78).

Depressive symptom severity

Clinicians completed the 17-item HRSD to assess symptom severity. Clinicians received initial and regular training throughout the RCT to complete the HRSD reliably (see Jarrett & Thase, 2010 for details). The HRSD demonstrated acceptable internal consistency (median alpha = .82) and inter-rater (ICC = .91) reliability, as well as strong convergence with patient reports of symptom severity (Vittengl, Clark, Thase, & Jarrett, 2013). Patients completed the Inventory of Depressive Symptomatology--Self-Report (Rush, Gullion, Basco, Jarrett, & Trivedi, 1996) and the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). We also standardized the HRSD and patient-report measures using their distributions at study intake and averaged them to form a robust composite. In analyses using the depressive symptom composite, the pattern of results was similar to that reported below for the HRSD alone.

Treatment outcomes

Outcomes were defined a priori (Jarrett & Thase, 2010; Jarrett et al., 2013). Patients who completed A-CT missed no more than 2 sessions (i.e., attend at least 14/16 or 18/20 sessions). Patients who responded to A-CT no longer met criteria for MDE and had a HRSD score ≤ 12 at exit. (This higher symptom threshold was used because the parent RCT focused on relapse prevention among participants with elevated relapse risk due to partial or unstable response [Jarrett & Thase, 2010; Jarrett et al., 2013]). Acute-phase responders who relapsed or recurred met criteria for MDE before or after, respectively, an 8 month period of minimal or absent depressive symptoms, as measured by the Longitudinal Interval Follow-Up Evaluation (Keller et al., 1987). The 8 month period of minimal or absent symptoms represented a rigorous definition of recovery and matched the duration of continuation treatment in the RCT (Jarrett & Thase, 2010; Rush et al., 2006). Independent evaluators completed this semi-structured retrospective interview every 4 months after A-CT, when patients, therapists, or follow-up evaluators suspected relapse or recurrence, and at study exit.

Statistical Analyses

Most of the acute-phase sample (83.7%), and all of the post-acute-phase sample of consenting responders (100%), had complete data for the measures analyzed in this report. Some acute-phase CT skills and depressive symptom severity data were missing due to attrition (see Table 1). The primary analyses presented in this report used complete cases without missing data. For acute-phase models where some data were missing, we also analyzed data after multiple imputation of missing data. In particular, we multiply imputed missing data using the Markov chain Monte Carlo method in PROC MI, computed standard analyses on each of 10 complete datasets, and pooled the results via PROC MIANALYZE (SAS Institute Inc., Cary, NC, USA). Analyses with multiply imputed data produced results similar to the primary analyses presented in this report. When modeling time to post-acute relapse or recurrence, patients were censored at the earliest of the end of the study, dropping out of the study, relapse, or recurrence. An alpha level of .05, two-tailed, was used in hypothesis tests.

Table 1.

Characteristics of Patients with Recurrent Depression Treated with Cognitive Therapy (CT)

Variables N M or % SD
Pre-treatment
 Stressful life events: Lifetime 276 5.37 2.33
 Hamilton Rating Scale for Depression 276 20.45 4.09
During treatment
 CT skill acquisition and use 231 3.32 0.55
Post-treatment
 CT completion 276 80.8%
 CT response 276 60.9%
 Hamilton Rating Scale for Depression 226 9.77 6.22
Among patients completing and responding to CT
 Relapse or recurrence within 32 months 152 32.2%
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Results

How frequent were stressful life events?

Before CT, participants had experienced an average of about 5 of 33 measured SLE at any point during their lifetimes (see Table 1). Relatively common SLE (≥ 25%) included relationship discord, job loss, financial crisis, change in residence, divorce, substance abuse, verbal abuse, and change in physical health (see Table 2).

Table 2.

Proportions of Patients with Stressful Life Events before Cognitive Therapy

Event Lifetime Happened to Patient
 Past year
Birth to Age 18 Age 18 to past year
Relationship discord .68 .04 .52 .35
Loss of job/stressful retirement .51 .00 .31 .38
Financial crisis .47 .00 .20 .42
Change in residence .47 .24 .27 .06
Divorce .36 .01 .33 .03
Drug/alcohol abuse .35 .05 .32 .05
Verbal abuse .30 .18 .17 .03
Change in physical health .25 .04 .21 .06
Sexual assault/sexual abuse/rape .24 .17 .10 .01
Physical abuse .24 .16 .10 .02
Suicide attempt .17 .06 .12 .02
Change in schools .16 .08 .08 .00
Serious accident .13 .02 .11 .01
Change in mental health .13 .05 .09 .05
Marital separation .12 .00 .06 .08
Problems with the law/court appearance .11 .03 .05 .04
Serious hospitalization .08 .01 .07 .01
Unwanted pregnancy .07 .03 .05 .00
Assault with a deadly weapon .07 .01 .05 .01
Additional person in household .06 .01 .03 .03
Threatened or bullied .06 .05 .02 .00
Being robbed .06 .01 .04 .01
Serious injury .05 .01 .04 .02
Death of spouse/partner .04 .00 .04 .00
Natural disaster .04 .02 .03 .00
Miscarriage .03 .00 .02 .01
Abortion .03 .01 .02 .00
Jail term .03 .01 .01 .00
Abandonment .02 .02 .00 .00
Combat or exposure to war zone .02 .00 .01 .01
Sexual harassment .01 .00 .01 .00
Neglect .01 .01 .00 .00
Fire .01 .01 .01 .00
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Note. N = 276.

Do SLE correlate with pre-CT symptom severity, CT skill development, at CT outcomes?

Patients with more lifetime SLE had greater pre-treatment depressive symptom severity measured with the HRSD, rs = .14, p = .03, but did not develop significantly weaker CT skills, rs = .00, p = .99. (With multiple imputation of missing data, the correlation of SLE with CT skills was also non-significant, rs = −.05, p = .46.) Among the 276 patients, 223 (81%) completed and 168 (61%) responded to CT. Most responders completed the CT protocol (n = 156), but because these outcomes were defined for the intent-to-treat sample, a few responders were also non-completers (n = 12). Patients with more SLE were less likely to complete, rs = −.16, p = .006, and respond, rs = −.15, p = .01, to CT. The odds of CT completion were about 40% lower (OR = 0.60), and response about 29% lower (OR = 0.71), per 1 SD increase in SLE.

Do patients with more SLE benefit more from CT skills during A-CT?

In a logistic regression model, we predicted acute phase CT response from lifetime SLE, CT skills, and the SLE by CT skills interaction, while controlling pre-treatment depressive symptom severity. Skills have been shown to predict response in the current RCT, as reported previously (Jarrett et al., 2011). The interaction of SLE with CT skills (i.e., the moderator effect) was of primary interest here. As shown in Table 3, this interaction was significant.

Table 3.

Prediction of Cognitive Therapy (CT) Outcomes from Stressful Life Events and CT Skills

Predictors B SE p
Model 1: Logistic regression predicting CT response
Intercept 0.82 0.16
Pre-CT HRSD −0.39 0.16 .02
Stressful life events −0.13 0.18 .48
CT Skills 0.89 0.19 <.001
Stressful life events x CT skills 0.58 0.19 .002
Model 2: Linear regression predicting post-CT depressive symptom severity (HRSD)
Intercept 0.04 0.06
Pre-CT HRSD 0.25 0.06 <.001
Stressful life events 0.11 0.06 .08
CT Skills −0.37 0.06 <.001
Stressful life events x CT skills −0.18 0.06 .004
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Note. Model 1 n = 231, model 2 n = 226. HRSD = Hamilton Rating Scale for Depression. Predictors and post-CT HRSD variables were standardized. With multiple imputation of missing data, the interaction of SLE and CT skills was also significant when predicting response, beta = 0.52, SE = 0.15, p = .001, and post-CT depressive symptom severity, beta = −0.15, SE = 0.06, p = .02.

Within the regression solution, we estimated simple slopes and response probabilities at selected values of the continuous SLE and CT skills variables to clarify the form of the interaction. In support of the hypothesis, the significant interaction suggested that patients with more SLE may have benefited more from CT skills than did patients with fewer SLE. Follow-up tests showed that more SLE (1 SD difference) predicted significantly lower odds of response (beta = −0.71, SE = 0.24, p = .003, OR = 0.49) for patients with poorer CT skills (1 SD below the mean). However, for patients with better CT skills (1 SD above the mean), SLE did not predict response significantly (beta = 0.45, SE = 0.29, p = .12, OR = 1.57). Figure 2 shows estimated response probabilities for patients with lower (1 SD below the mean) versus higher (1 SD above the mean) numbers of SLE and skills. Patients’ estimated probability of response was 66% (CI.95 = 52–77%) with lower skill and lower SLE, 31% (CI.95 = 18–48%) with lower skill and higher SLE, 78% (CI.95 = 65–87%) with higher skill and lower SLE, and 90% (CI.95 = 78–96%) with higher skill and higher SLE.

Figure 2.

Figure 2.

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The interaction of lifetime stressful life events before cognitive therapy with skills developed during acute-phase cognitive therapy predicted the probability of acute treatment response. Fewer/lower or more/higher events or skills are 1 SD below or above the sample mean, respectively.

In parallel, a linear model predicting post-CT depressive symptom severity (HRSD score) also showed that patients with more SLE may have benefited more from CT skills than did patients with fewer SLE. Again, the interaction of SLE with CT skills (i.e., the moderator effect) was significant (see Table 3). Follow-up analyses identified regions of significance for the interaction in the linear model (Preacher, Curran, & Bauer, 2006): More SLE predicted significantly (p < .05) higher post-CT depressive symptoms for patients with poorer CT skills more than 0.07 SD below the mean (47% of patients, CI.95 = 40–54%). Fewer SLE predicted higher post-CT symptoms only for patients with CT skills more than 2.38 SD above the mean, which was rare (<1% of patients, CI.95 = 0–2%).

Do patients with more SLE benefit more from CT skills after acute-phase CT response?

Among the 152 patients who completed and responded to acute-phase CT, and who consented to the continuation and follow-up phases, 49 (32%) experienced a major depressive relapse or recurrence within 32 months after acute-phase CT. We predicted time to relapse/recurrence in a Cox regression model. The model controlled depressive symptoms after response to acute-phase CT and included the main effects of continuation arm (C-CT, FLX, PBO, or assessment only), CT skills, SLE, and their two-way interactions. (The three-way interaction was not hypothesized, not statistically significant, and trimmed from the final model.)

The main effects of SLE and CT skills were not statistically significant, but the interaction was (see Table 4). We again estimated simple slopes and relapse/recurrence probabilities at selected values of the continuous SLE and CT skills variables to clarify the form of the interaction. The relapse/recurrence interaction paralleled the interaction observed for acute-phase response and supported the hypothesis. In particular, more SLE (1 SD difference) predicted significantly greater risk of relapse/recurrence (beta = 0.69, SE = 0.26, p = .008, HR = 1.99) for patients with poorer CT skills (1 SD below the mean). However, for patients with better CT skills (1 SD above the mean), SLE did not predict relapse/recurrence significantly (beta = − 0.47, SE = 0.29, p = .11, HR = 0.63). Patients’ estimated probability of relapse/recurrence within 32 months was 24% (CI.95 = 6–39%) with lower skill and lower SLE, 66% (CI.95 = 34–83%) with lower skill and higher SLE, 46% (CI.95 = 13–67%) with higher skill and lower SLE, and 22% (CI.95 = 5–35%) with higher skill and higher SLE (see Figure 3).

Table 4.

Prediction of Post-acute Relapse or Recurrence from Stressful Life Events and CT Skills

Predictors B SE p
Post-acute HRSD −0.01 0.17 .95
Continuation arm X2(3) = 3.59, p = .31
 Higher risk: C-CT −0.20 0.28 .47
 Higher risk: FLX 0.18 0.24 .46
 Higher risk: PBO 0.17 0.24 .49
 Lower risk: Assessment only --- --- ---
Stressful life events (SLE) 0.11 0.18 .53
Cognitive therapy (CT) skills −0.17 0.18 .34
Continuation arm * SLE X2(3) = 9.77, p = .02
 C-CT * SLE 0.53 0.26 .04
 FLX * SLE −0.04 0.23 .87
 PBO * SLE −0.15 0.25 .54
 Assessment only * SLE --- --- ---
Continuation arm * CT skills X2 (3) = 4.90, p = .18
 C-CT * skills −0.12 0.29 .68
 FLX * skills 0.02 0.26 .94
 PBO * skills −0.37 0.27 .17
 Assessment only * CT skills --- --- ---
SLE * CT skills −0.58 0.21 .006
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Note. N = 152. The Cox regression model predicted time to relapse/recurrence (over 32 months) after response to acute-phase cognitive therapy. Predictors were standardized. HRSD = Hamilton Rating Scale for Depression. C-CT = continuation cognitive therapy. FLX = continuation fluoxetine plus clinical management. PBO = continuation pill placebo plus clinical management.

Figure 3.

Figure 3.

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The interaction of lifetime stressful life events (SLE) before cognitive therapy with skills developed during acute-phase cognitive therapy predicted the probability of major depressive relapse or recurrence. Fewer/lower or more/higher events or skills are 1 SD below or above the sample mean, respectively.

The interaction of lifetime SLE with continuation arm was also significant. Follow-up tests showed that more SLE (1 SD difference) predicted relapse/recurrence in the C-CT arm (beta = 0.99, SE = 0.36, p = .006, HR = 2.70) but not in the FLX (beta = −0.22, SE = 0.27, p = .66, HR = 0.80), PBO (beta = −0.48, SE = 0.38, p = .20, HR = 0.62), or lower-risk (beta = −0.13, SE = 0.43, p = .76, HR = 0.88) arms.

Discussion

The current analyses supported the hypothesis that adults who recalled more SLE prior to CT derived greater benefit from skills taught in CT for depression. Stated another way, among outpatients with MDD treated with CT, strong CT skills may have “neutralized” risks for poor treatment outcomes attributable to SLE. In this multi-phase RCT, all patients received CT during the acute phase and thus had opportunity to learn CT skills. Among patients with recurrent MDD treated with A-CT, patients who reported more SLE at baseline also had higher baseline depressive symptom severity and lower odds of treatment completion and response, overall. However, a likely active ingredient of CT, acquisition and use of CT skills, was especially valuable for patients with a greater number of SLE; patients with weaker CT skills were at increased risk for non-response from SLE. Similarly, among A-CT responders, SLE predicted major depressive relapse/recurrence only among patients with weaker CT skills.

These novel findings require replication but suggest possible clinical strategies for patients with a history of more SLE to be tested in future research. In particular, testing whether additional assessment of SLE and CT skills, and focus on development of patients’ CT skills, improve treatment outcomes will be an important topic for future research. Further, we note that patient with more SLEs also were more likely to drop from acute phase CT, which makes such patients prime candidates for additional treatment engagement strategies. In treatment settings where assessment of CT skills and SLE is not routine, integrating brief, valid, low-cost measures can facilitate improvement in patient care. The CT skills measure used in the current analyses consists of only 8 items and is available at no cost for noncommercial research and clinical practice (when patients are not charged for administering the measure) in patient, clinician, and observer versions (Jarrett et al., 2011).

The chart-review measure of SLE designed for this study may also have some advantages. The current SLE measure did not increase the assessment burden on patients. Instead, the chart-review method drew from diagnostic interview data, narrative clinical reports, and a brief questionnaire. In addition, although the current SLE measure required review and rating of existing data sources by research personnel, it may be more cost effective than alternative measures such as the high quality but time-intensive Life Events and Difficulties semi-structured interview (Brown & Harris, 1978; Monroe, & Simons, 1991).

The current SLE measure has important limitations. For example, the measure did not differentiate independent and dependent life events. The depressive symptoms of affected adults can increase the likelihood of SLE such as unemployment and divorce (Hammen & Shih, 2010). In other words, such dependent (versus independent) life events may be more strongly related to depressive symptoms (Flynn, Kecmanovic, & Alloy, 2010) and possibly treatment outcomes, as well. Personality, such as high neuroticism, may also color patients’ experience, recall, and reporting of SLE. In addition, the current SLE measure assessed a number of common and important events, but some patients may have experienced SLE not captured by the current instrument but relevant to treatment outcomes. Moreover, the current SLE measure could not attempt to scale the objective or subjective severity of events, whereas some research suggests that the subjective impact of life events is the most depressogenic component of SLE (Marquett et al., 2013). Finally, our measurement and analyses focused on history of SLE before starting acute-phase CT and did not address events that happened during or after treatment. Whether CT skills also moderate relations between new SLE and treatment outcomes is an important question for future research.

Other limitations of the current study include the nature of the sample, treatment, and research design. Whether the current results obtained from adults with carefully-diagnosed recurrent MDD treated by trained and supervised cognitive therapists working a research protocol generalize to other patient populations, treatments, and settings is unknown. Our methods do not allow comment on the effects of preferential recall of negative memories characterizing depression (Gotlib & Joormann, 2010). Our analyses focused on CT skills as a possible active ingredient in CT, but did not address or control for other potentially important processes such as therapist and expectancy effects. Thus, our hypothesis that CT skills “neutralize” risk from SLE is only one possible interpretation of the current results. In addition, the CT skills measure was administered during and after, but not before, acute-phase treatment. Thus, the possibility that some measured skills represented pre-treatment individual differences cannot be ruled out. Similarly, the potential confounding or overlap of patient CT skills with treatment elements (e.g., therapist skills, sessions attended, medication dosage) may warrant attention in future research. Finally, the RCT was not designed to test mechanisms (e.g., behavioral, cognitive, genetic, and their interactions) connecting SLE and CT skills with response and relapse/recurrence, and limited sample size may have led to missed effects, especially in the smaller post-acute sample. Future research designed and statistically powered to test specific mechanisms is indicated.

An interaction of SLE with continuation-phase arm was also detected in the current analyses but not hypothesized. That is, continuation arm moderated relations of SLE with outcomes after response to acute-phase CT. We found that SLE predicted relapse/recurrence more strongly among higher-risk responders randomized to C-CT than to other continuation treatments (FLX or PBO) or among lower-risk responders who were only assessed. This finding may represent Type I error and was separate from the interaction of SLE with CT skills (i.e., the three-way interaction of SLE * skills * arm was not statistically significant). Alternatively, this finding may represent an important difference between acute- and continuation-phase treatments, because previous research suggested that SLE might inhibit patients’ progress less during acute-phase CT than during pharmacotherapy (Fournier et al., 2009; Nemeroff et al., 2003). Research on SLE in the context of continuation and maintenance treatments for depression is especially sparse and an important area for future research. For example, sequential treatment involving switching treatment modalities between acute and continuation phases is an active area of research for relapse prevention (e.g., Dunlop et al, 2019). Our data suggest that exploring whether SLE moderate the benefits of sequential treatment may be of interest in future research.

In this study, we found that outpatients with recurrent MDD and a lifetime history of SLE, as reported during a depressive episode, can and often do improve substantively with CT. However, patients with greater incidence of SLE need to develop and use strong CT skills to maximize their chances of short-term treatment response and longer-term freedom from relapse or recurrence. Fortunately, SLE did not appear to limit development of CT skills, although more SLE do appear to increase the risk of attrition. The current findings are novel and require replication before clinical application. If future studies replicate these novel findings, then screening patients for SLE and assessing CT skills may provide additional tools to improve outcomes for an important sub-population of adults with recurrent MDD.

Supplementary Material

1

Highlights for.

Patients with depression vary in lifetime exposure to stressful life events (SLE). Cognitive therapy (CT) patients also vary in the strength of CT skills they develop. We found that SLE predicted poorer CT outcomes for patients with weaker skills. SLE did not predict treatment outcomes for CT patients with stronger skills. Developing strong CT skills may be especially important for patients with more SLE.

Acknowledgments

This report was supported by Grants Number K24 MH001571, R01 MH58397, R01 MH69619 (Robin B. Jarrett, Ph.D.) and R01 MH58356 from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH.

We appreciate the careful review by the trial’s Data Safety and Monitoring Board. We are indebted to our patients, research teams, and our colleagues at The University of Texas Southwestern Medical Center. We appreciate the participation of colleagues, previously named, and study participants. We appreciate the careful coding of stressful life events from Nancy Cravens, LVN, and data management by Abu Minhajuddin, Ph.D. We are grateful to Carol Tamminga, M.D., Lou and Ellen McGinley Distinguished Chair in Psychiatric Research and Communities Foundation of Texas Chair in Brain Sciences and the University of Texas Southwestern Medical Center Department of Psychiatry for support of research.

Dr. Vittengl and Dr. Jarrett are paid reviewers for UpToDate. Dr. Jarrett is a paid consultant to the National Institutes of Health. Dr. Jarrett’s medical center collects the payments from the cognitive therapy she provides to patients. Dr. Atluru and Dr. Stutzman have no financial conflicts of interests to disclose.

Footnotes

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Contributor Information

Jeffrey R. Vittengl, Truman State University

Sonja Stutzman, University of Texas Southwestern Medical Center.

Aparna Atluru, University of Texas Southwestern Medical Center.

Robin B. Jarrett, University of Texas Southwestern Medical Center

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