Elsevier

Psychiatry Research

Volume 161, Issue 3, 15 December 2008, Pages 302-308
Psychiatry Research

Dysfunctional attitudes and perceived stress predict depressive symptoms severity following antidepressant treatment in patients with chronic depression

https://doi.org/10.1016/j.psychres.2007.08.004Get rights and content

Abstract

Many patients continue to experience depressive symptoms after optimal pharmacological treatment. The aim of this study was to investigate whether Beck's cognitive diathesis stress model of depression would help predict the degree of improvement in the depressive symptoms of patients with chronic depression receiving antidepressant treatment. The study investigated the dysfunctional attitudes, perceived stress, and depressive symptoms of 117 patients with chronic depression before and after they were treated with an 8-week course of fluoxetine. A hierarchical multiple regression analysis showed a significant effect for the interaction between dysfunctional attitudes and perceived stress explaining severity of depressive symptom following antidepressant treatment. Patients with both high perceived stress and high dysfunctional attitudes prior to treatment reported more depressive symptoms at the end of treatment than patients with high perceived stress and lower dysfunctional attitudes. Surprisingly, in the presence of low perceived stress, patients with higher dysfunctional attitudes experienced less depressive symptoms at the end of treatment than patients with lower dysfunctional attitudes. Results suggest the value of taking into consideration both patients' perceived stress and dysfunctional attitudes when assessing treatment for depressive symptoms.

Introduction

Depression is one of the most prevalent mental health disorders and is associated with profound personal and societal costs. According to the National Comorbidity Study (NCS; Kessler et al., 2003) 16.9% or 32.6 to 35.1 million US adults meet criteria for Major Depression Disorder (MDD) at some point in their lifetime and the World Health Organization reports that in the year 2020 depression will be the second most disabling disorder (Murray and Lopez, 1996). Although pharmacological interventions have been shown to be effective in ameliorating symptoms of depression for a large number of patients (Katon et al., 1995, Steffens et al., 1997, MacGillivray et al., 2003, Constant et al., 2005), 31% to 57% of patients continue to experience residual symptoms even after optimal pharmacological treatment (Keller et al., 2000, Kornstein et al., 2000, DeRubeis et al., 2005). The aim of the current study was to apply Beck's cognitive diathesis stress model of depression (Clark and Beck, 1999) to identify predictors of improvement following antidepressant medications. Beck's cognitive diathesis stress model of depression postulates that individuals who are prone to develop depression have latent dysfunctional attitudes that in the presence of life stress emerge and influence individuals' perceptions and views. Dysfunctional attitudes have been described as negative schemas about the self, the world, and the future that maintain depressive symptoms by leading to negative interpretations of information, and by selecting information supporting their negative content (Beck et al., 1979).

There has been considerable empirical support for the cognitive diathesis stress model of depression across studies employing both cross-sectional and longitudinal designs (Scher et al., 2005). However, only a few studies have investigated the role played by the constructs described by the cognitive diathesis stress model in pharmacotherapy. Two studies found that dysfunctional attitudes decrease in patients with depression following pharmacotherapy (Peselow et al., 1990, Fava et al., 1994). Peselow et al. (1990) showed that 112 patients with depression experienced a significant decrease in dysfunctional attitudes after three to six weeks of treatment with antidepressant medications. Similarly, Fava et al. (1994) found that dysfunctional attitudes in 67 patients diagnosed with MDD decreased after receiving eight weeks of fluoxetine. In Fava et al.'s (1994) study the degree of change in dysfunctional attitudes was associated with the degree of change in depressive symptoms. However, findings are mixed as to whether severity of dysfunctional attitudes predicts treatment outcome. Peselow et al. (1990) found that higher dysfunctional attitudes predicted poorer outcome of antidepressant treatment. Similarly, Sotsky et al. (1991) in the National Mental Health (NIMH) Treatment of Depression Collaborative Research Program, found that lower dysfunctional attitudes predicted better response to imipramine and Cognitive Behavioral Therapy (CBT). However, unlike Peselow's and Sotsky's studies, Fava et al. (1994) did not observe that the severity of dysfunctional attitudes prior to treatment was predictive of improvement of depressive symptoms following treatment with fluoxetine. These studies may show mixed results because they do not account for the role of stress, a critical component of the cognitive vulnerability model. In the current study we aimed to investigate whether the interaction between dysfunctional attitudes and perceived stress predicted improvement of depressive symptoms in patients with MDD who received antidepressant treatment. We hypothesized that higher dysfunctional attitudes and higher perceived stress would be associated with worse outcome following antidepressant treatment.

Section snippets

Participants

The current investigation was carried out on a subsample of participants enrolled in a clinical trial assessing the effectiveness of fluoxetine in patients with chronic MDD conducted at the Depression and Clinical Research Program of the Massachusetts General Hospital (Fava et al., 2000). Inclusion criteria were: meeting DSM-III-R criteria for a current episode of MDD, and a 17-item Hamilton Depression Rating Scale (HAM-D-17; Hamilton, 1960) score ≥ 16. Participants were also required to meet at

Results

A series of t-tests showed that in the current sample women and men did not differ on levels of perceived stress, symptom severity and dysfunctional attitudes. Therefore, we did not control for gender in our analyses.

Participants experienced a significant decrease of depressive symptoms following 8 weeks of antidepressant treatment (t(1, 116) = 19.28; P < 0.001). The majority of the patients responded to treatment (62.4%), defined as a 50% decrease in depressive symptoms as measured by the

Discussion

We examined whether dysfunctional attitudes and perceived stress predicted changes in depressed symptoms following treatment with antidepressant medications among patients with MDD. Consistent with our hypothesis, results suggest that, during periods of increased stress, patients with higher dysfunctional attitudes prior to starting treatment benefit less from the administration of fluoxetine than patients with low dysfunctional attitudes. Such results are consistent with the cognitive

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