In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between-sessions interval. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were less depressed than the other patients at posttreatment, and they remained so 18 months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains. Improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation-->critical session/sudden gain-->upward spiral.

Background High neuroticism is a personality risk factor that captures much of the genetic vulnerability to Major Depressive Disorder (MDD), and low extraversion may increase risk as well. Both have been linked to the serotonin system. Objectives To test whether MDD patients in selective serotonin reuptake inhibitors (SSRIs) treatment report greater changes in neuroticism and extraversion than patients receiving inert-placebo; and to examine the state-effect hypothesis, that self-reported personality change during SSRI treatment is merely a change of depression-related measurement bias. Design/Setting Personality was measured during a placebo-controlled trial in research clinics. Patients Adult moderate-to-severe MDD patients randomized to receive paroxetine (n=120), placebo (n=60), or cognitive therapy (CT) (n=60). Outcome Measures NEO Five-Factor Inventory; Hamilton Rating Scale for Depression. Results Paroxetine patients reported greater personality change than did placebo patients, even after controlling for depression improvement (p≤.002). The advantage of paroxetine over placebo in antidepressant efficacy was no longer significant after controlling for change in personality (p≥.14). Paroxetine patients reported 6.8 times as much change on neuroticism and 3.5 times as much change on extraversion as placebo patients matched for depression improvement. Although placebo patients exhibited substantial depression improvement (−1.2 SD, p<.001), they reported little change on neuroticism (−0.18 SD, p=.08) or extraversion (0.08 SD, p=.50). CT produced greater personality change than placebo (p≤.01); but its advantage on neuroticism was no longer significant after controlling for depression (p=.14). Neuroticism reduction during treatment predicted lower relapse rates among paroxetine responders (p=.003), but not among CT responders (p=.86). Conclusion Paroxetine appears to have a specific pharmacological effect on personality that is distinct from its effect on depression. If replicated, this pattern would disconfirm the state-effect hypothesis and instead support the notion that SSRIs’ effects on personality go beyond and perhaps contribute to their antidepressant effects.

Using an independent cognitive-behavioral therapy (CBT) data set, the authors replicated T. Z. Tang and R. J. DeRubeis' (1999) discovery of sudden gains--sudden and large decreases in depression severity in a single between-session interval. By incorporating therapy session transcripts, the authors of this study improved the reliability of the Patient Cognitive Change Scale to .75 and found that these CBT sudden gains were also preceded by substantial cognitive changes in the pregain sessions.

Following T. Z. Tang and R. J. DeRubeis's (1999) report of sudden gains (a sudden and substantial improvement in depression symptoms in one between-session interval) in cognitive-behavioral therapy (CBT) for depression, this study explored sudden gains in supportive-expressive (SE) psychotherapy. Studies suggested that CBT sudden gains are caused by cognitive changes, which is a factor specific to CBT. Thus, sudden gains might not be expected in SE psychotherapy. Contrary to that expectation, sudden gains in SE psychotherapy were found, and they showed similar magnitude, affected a similar percentage of patients, and occurred at about the same time in treatment as CBT sudden gains. However, the symptom gains from the SE psychotherapy sudden gains were much less stable than the CBT sudden gains and showed a much higher rate of reversal before treatment ended. The long-term benefits of SE psychotherapy sudden gains also appear less robust than CBT sudden gains.

Cognitive therapy (CT) may have significant advantages over antidepressants in preventing depression relapses. Many CT patients experience sudden gains: large symptom improvement in 1 between-session interval. Past studies have associated CT sudden gains with in-session cognitive changes but not with life events. This study examined sudden gains and depression relapse/recurrence among 60 CT clinical-trial patients. Survival analyses showed that only one third of sudden-gain-responders relapsed in 2 years, and they had 74% lower relapse risks than did non-sudden-gain-responders. Among patients with sustained responses, 73% experienced sudden gains. The authors also replicated J. R. Vittengl, L. A. Clark, and R. B. Jarrett's finding that sudden gains identified with their unique criteria did not predict relapse. The current authors' findings suggest that CT sudden gains are not measurement artifacts, and that sudden gains and their causes and consequences might be important in preventing relapses.

llardi and Craighead (1994) observed that 6020% of symptom improvement in cognitive behavioral therapy (CBT) occurs in the first 4 weeks, and they assumed that cognitive modification techniques are not extensively applied in these week. They thus concluded that Beck's cognitive hypothesis of CBT cannot explain this early improvement. However, studies have shown that cognitive modification techniques am applied extensively in early sessions. Also, in most CBT studies there have been two sessions per week for the first 4 weeks and 1 session per week thereafter. Thus, 4040% of CBT sessions in studies occur in the first 4 weeks, which aguably is enough therapeutic time for cognitive techniques t o have a substantial effect on symptoms.Finally, llardi and Craighead's method assumes homogeneity among the patients' time courses, which is inconsistent wRh empirical data. We conclude that symptom change time course data do not contradict Beck's cognitive hypothesis.

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