Effects of antidepressants on thinking styles in depressed inpatients

Effects of antidepressants on thinking styles in depressed inpatients

Prog. Neuro-Psychophormocol. 8 Biol. Psychiat. Printed in Great Britain. All rights reserved 1988. Vol. 12, pp. 277-284 Copyright 0 027fL5846188 $0...

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Prog. Neuro-Psychophormocol. 8 Biol. Psychiat. Printed in Great Britain. All rights reserved

1988. Vol. 12, pp. 277-284 Copyright


027fL5846188 $0.00 + .50 1988 Pergamon Press plc



Departments of Psychology and Psychiatry Royal Ottawa Hospital, Ottawa, Canada

(Final form, October 1987)

Abstract Telner, J.I., W.R.P. Surphlis, Y.D. Lapierre and G. Mehta: Effects of antidepressantson thinking styles in depressed inpatients. Prog. Neuro-Psychopharmacol.Biol. Psychiat. 1988, 2:277-284 1. 2.



Clinical and empirical evidence point to distorted negative thinking during depressive episodes. The present study, utilizing the Cognitions Questionnaire, examined the thinking styles in depressed inpatients prior to antidepressant pharmacotherapy and again 3 - 4 weeks after treatment. Across the 5 dimensions of thinking assessed, only generalization across situation changed significantly in the drug-respondent group. While clinically, short-term antidepressant treatment was shown to be efficacious, it only changed cognitions in a limited way.

Keywords: antidepressants,cognitions, depression

Introduction Cognitive therapy espouses that the characteristic set of symptoms of depression stem from errors or deficits in thinking (Beck, 1967; 1976). Numerous studies have demonstrated the efficacy of both cognitive therapy and drug therapy in alleviating the symptoms of unipolar depression (e.g. Rush et al. 1977; Blackburn et al. 1981). Thus, although both psychotherapy and pharmacotherapy are effective in reducing depressive symptoms, few studies have documented the differences in symptom reduction between the two forms of treatment. Although rationally both forms of treatment should ameliorate the mood component of depressive illness, psychotherapy should be more selective in reducing cognitive distortions while pharmacotherapy should primarily affect vegetative symptoms such as sleep and appetite. An early report (DiMascio -*a et al 1979) comparing short-term interpersonalpsychotherapy with amitriptyline revealed that psychotherapy affected mood, suicidal ideation, work and interests while amitriptyline mainly ameliorated sleep and appetite disturbances. Rush et al. (1982) found that cognitive therapy induced greater 277


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improvement in hopelessness and self-concept than treatment with imipramine. More recently, however, Simmons et al. (1984) challenged this basic assumption of differential effects of psychotherapy and pharmacotherapy by showing that both therapies were similar in alleviating thinking styles, suggesting that cognitive change may be seen as part of improvement rather than the primary cause of improvement. The aim of the present study was to assess the effects of short-term pharmacotherapy on the thinking styles of severely depressed, hospitalized patients, with the aid of a novel instrument. While numerous questionnaireshave been designed to measure cognitive style (eg. Dysfunctional Attitude Scale: Weissman and Beck, 1978; Automatic Thoughts Questionnaire: Hollon and Kendall, 1980; Attributional Style Questionnaire: Seligman et al. 1979), they are designed to assess either single dimensions of depressive thinking or a global tendency to interpret events in a distorted, negative way.

The instrument utilized

in the present study, the Cognitions Questionnaire (CQ: Fennel1 and Campbell, 1984) was designed to measure the specification of particular thinking errors as well as a global assessment of depressive cognitive styles in response to negative, positive and neutral events. Furthermore, the CQ utilizes dimensions of thinking based on the revised helplessness model (Abramson et al., 1978) but applies not to the causes of hypothetical situations but rather to their consequences, partitioned into five dimensions of thinking.

Method Subiects Subjects were 23 inpatients (8 males and 15 females) with a mean


of 41 years who met DSM III criteria for major affective disorder, unipolar type. All patients were free of organic brain syndromes, delusions and psychosis. Two patients had received ECT 3-6 months prior to inclusion into the study while two subjects were hypothyroid but stabilized prior to hospitalization. All patients had a Hamilton Rating Scale for Depression (RAM-D) score of at least 18 (17 item scale) and were of inpatient status on the same ward for the duration of the study. After a 4-7 day placebo washout phase, patients who were placebo responders were excluded from the study. The remaining subjects were partitioned into responders and non-responders at the end of the study, defined by at least a 50% fall in total HAM-D score or a score below 18. All patients were administered the CQ both during

Antidepressants and thinking styles indepressed inpatients

placebo washout (4-7 days) and again after 3-4 weeks of active drug (imipramine, fluoxetine or trazodone). Sixteen of the patients were involved in a double-blind clinical trial of fluoxetine vs trazodone and dosage was determined by the study schedule. The remaining five patients were involved in a single-blind imipramine predictor study and dosage was determined by the treating psychiatrist based on clinical judgment. Patients on the fluoxetine-trazodonestudy were allowed chloral hydrate, flurazepam and diazepam on a p.r.n. basis, while the imipramine subjects were allowed chloral hydrate and lorazepam on a p.r.n. basis. Sleep medication (chloral hydrate and flurazepam) were not administered the night before ratings (HAM-D and CQ). No other psychotropic medications were administered. Measures The following components of the CQ were examined in three types of scenarios (negative, neutral, positive). 1.

Emotional Impact (EI) - the felt aversiveness of negative situations and the pleasantness of positive situations.

2. Attribution of Causality (AC) - the individual's tendency to attribute negative outcomes to the self and positive outcomes to external factors. 3.

Generalization Across Time (GT) - the individual's expectation that negative outcomes will extend into the future while positive outcomes will be short-lived.


GeneralizationAcross Situations (GS) - the individual's expectation that negative situations are typical of their lives while positive outcomes are atypical.


Perceived Uncontrollability (PU) - the individual's belief that events (positive and negative) are beyond personal control.

Results CQ and HAM-D. During placebo washout, there was no correlation between total CQ score and HAM-D (z-=0.11,p>O.OS). At the end of treatment, these two measures correlated (r=0.47, pO.OS).


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ReSpO”*er Non-Responder








Fig 1. Pre-drug responses of responders and non-responders on five dimensions of thinking (means 2 S.E.M.). EI = Emotional Impact; AC = Attribution of causality; GT = Generalization across time; GS = Generalization across situation; PU = Perceived uncontrollability. Figure 2 shows the mean score for each dimension for responder and non-responder groups following 3-4 weeks of drug treatment. Analysis of variance for each dimension revealed a significant group by drug interaction for GS, F (1,15)=5.27, pO.OS; Neutral event: F (1,18)=0.59, p>O.OS; Positive event: F (1,14)=3.00,p>O.O5. At the post-drug phase, there were no significant differences between drug responders and drug non-responders for all three event types (Negative event: F (1.16)=3.78,p>O.O5; Neutral event: F (1,18)=3.02, p>O.OS; Positive event: F (1,14)=2.25,p>O.OS).

Antidepressants and thinking styles indepressed inpatients

POST-DRUG Non-Responder






Fig 2. Post-drug responses of respo6ders and non-responders on five dimensions of thinking (means 2 S.E.M.). EI = Emotional Impact; AC = Attribution of causality; GT = Generalization across time; GS = Generalization across situation; PU = Perceived uncontrollability. * Significantly different from non-responder group at ~(0.04.

I)iscussion The results of this study indicated that short-term antidepressant treatment, while clearly therapeutic in alleviating the clinical symptoms of depression in approximately 50% of the sample within 3-4 weeks, only altered cognitions in a limited way. However, it is interesting to note that in the original study on the CQ, Fennel1 and Campbell (1984) found that both currently depressed and never depressed groups differed significantly on all 5 dimensions, with the largest difference on GS.

More importantly, further analysis revealed that the

currently depressed group differed significantly from both past depressed and never depressed groups, whereas the past and never depressed groups did not differ. It thus appears that these authors were able to demonstrate a return to "normal cognitions" in recovered depressives. In our study, patients who responded clinically to drug treatment only showed a normalization in GS, corresponding to the heavy loading on GS in the original study on the CQ.

Two factors appear to emerge in

explaining the limited findings in our study. Firstly, Fennel1 and


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Neutral Event


Fig 3. Pre-drug and post-drug responses of responders and non-responders on event type (mean + S.E.M.).

Campbell (1984) used the Beck Depression Inventory (BDI) which, under inspection, is more weighted on the cognitive components of depression, while we used the HAM-D which concentrates more strongly on the vegetative and affective components of depression, as compared to the BDI.

Secondly, and more importantly,we measured changes in depression

in patients after short-term antidepressant treatment, while the original work examined a fully remitted group of depressives. Concomitant with this line of reasoning is'the severity factor. Studies which have shown specific cognitive changes after psychotherapeuticand/or pharmacotherapeuticinterventionsutilized subjects who were moderately depressed (as rated by the BAM-D and BDI). Cur sample consisted of severely depressed inpatients with a mean HAM-D


score of 28. Because of the rather short treatment period assessed, it may very well be that the changes in "thinking styles" observed in other studies may have only started to emerge in our patients. We are currently examining this possibility by looking at patients at a later point in their treatment regimen. Positive results in this investigationwould lend support for Akiskal and McKinney's (1975) "final conrmOnpathway" hypothesis as well as Simmons et al.'s (1984) suggestion that psychotherapy and pharmacotherapyserve as different points of entry into the constellation of emotional, cognitive, behavioral and physiological processes involved in depression.

Conclusion Although short-term antidepressant treatment was able to significantly lower the clinical severity of depression in one half of patients sampled, it only changed cognitive styles in a limited way. These residual errors in thinking may be further reduced as the patient continues in the course of recovery. Further work is being carried out to examine this hypothesis.

Acknowledgements Imipramine (Tofranil) was graciously supplied by Ciba-Geigy while fluoxetine and traaodone were supplied by Eli Lilly. This research was funded in part by an NRRDP Grant from Health and Welfare, Canada.

References ABRAMSON, L.Y., SELIGMAN, M/E.P. and TEASDALE, J.T. (1978) Learned helplessness in humans: Critique and reformulation. J. Abnor. Psychology, 87, 49-74. AKISKAL, H.S. and McKINNEY, W-T. (1975) Overview of recent research in depression. Arch. Gen. Psychiatry, 32, 285-305. BECK, A.T. (1967) Depression: Clinical, Experimental and Theoretical Aspects. New York: Harper and Row. BECK, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: InternationalUniversity Press. BLACKBURN, I.M., BISHOP, S., GLEN, I.M., WRALLEY, L.J. and CHRISTIE, J.E. (1981) The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy,each alone and in combination. Br. J. Psychiatry, 139, 181-189. DiMASCIO, A., WEISSMAN, M.M., PRUSOFP, B.A., NEU, C., ZWILLING, M. and KLERMAN, G.L. (1979) Differential symptom reduction by drugs and psychotherapy in acute depression. Arch. Gen. Psychiatry, a, 1450-1456. FENNELL, M.J. and CAMPBELL, E.A. (1984) The Cognitions questionnaire; Specific thinking errors in depression. Br. J. Clin. Psychology, 23, 81-92.

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HOLLON, S.D. and KENDALL, P.C. (1980) Cognitive self-statements in depression. Development of an Automatic Thoughts Questionnaire. Cog. Ther. Res., 4, 383-395. RUSH, A.J., BECK, A.T., KOVACS, M. and HOLLON, S. (1977) Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cog. Ther. Res., 1, 17-37. RUSH, A.J., BECK, A.T., KOVACS, M., WEISSENBURGRR, M.A. and HOLLON, S.D. (1982). Comparison of the effects of cognitive therapy and pharmacotherapyon hopelessness and self-concept. Am. J. Psychiatry, 139, 862-866. SELIGMAN, M.E.P., ABRAMSON, L.Y., SRMMRL, A. and VON BARYRR, C. (1979) Depressive attributional style. J. Abnor. Psychology, a, 242-247. WEISSMAN, M.M. and BECK, A.T. (1978) Development and Validation of the DAS: A preliminary investigation. Paper presented at the Annual Meeting of the American Education Research Association, Toronto.

Inquiries and reprint requests should be addressed to: Dr. J.I. Telner Royal Ottawa Hospital 1145 Carling Avenue Ottawa, Ontario, KlZ 7K4 Canada