AJOR DEPRESSION, A DISorder with early onset and often chronic course, imposes a high individual burden of pain, suffering, and disability. 1 Ethnic minority patients are less likely to obtain care for depression than white patients 2 and are less likely to receive appropriate treatment when they do seek care. 3,4 These disparities are partially due to minorities being less likely to be insured, 2 which results in poor access to care. In this study, we evaluated whether interventions that promote guidelineconcordant treatments for depression among young, predominantly minority women would improve rates of appropriate care and clinical and functional outcomes.Effective treatments for major depression include antidepressant medications and psychotherapies. 5,6 Most US psychiatrists favor the selective serotonin reuptake inhibitors for first-line treatment. 7 Two brief, structured psychotherapies, cognitive behavioral therapy (CBT) 8 and interpersonal psychotherapy, 9 have demonstrated effectiveness in treating psychiatric pa-tients. 10-14 However, efficacy trials have been conducted on predominantly white patients in academic psychiatric settings. According to a review conducted as part of a surgeon general's report, 2 the studies forming the evi-

The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome.

At the end of primary treatment for breast cancer, women in all treatment groups report good emotional functioning but report decreased physical functioning, particularly among women who have a mastectomy or receive chemotherapy. Clinical interventions to address common symptoms associated with treatment should be considered to improve physical and emotional functioning at the end of primary treatment for breast cancer.

Most studies ignore prior trauma exposure when evaluating outcomes of target events. This study explored symptom severity associated with different types of traumatic experiences occurring alone and with multiple exposure. The Stressful Life Events Screening Questionnaire categorized 1,909 sophomore women into groups including no trauma exposure, exposure to a serious non-Criterion A event only, exposure to several unique noninterpersonal and interpersonal events, and exposure to multiple interpersonal events. Women with noninterpersonal trauma did not differ from those without trauma on the Trauma Symptom Inventory. Only interpersonal trauma and non-Criterion A events were associated with elevated symptoms; multiple-exposure participants had significantly higher symptoms than all other groups. Complex trauma histories should be accounted for, even in studies of one target event.

Prior analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program indicated that patients' expectancies of treatment effectiveness (S. M. Sotsky et al., 1991) and the quality of the therapeutic alliance (J. L. Krupnick et al., 1996) predicted clinical improvement. These data were reanalyzed to examine the hypothesis that the link between treatment expectancies and outcome would be mediated by patients' contribution to the alliance. Among 151 patients who completed treatment, this hypothesis was supported, suggesting that patients who expect treatment to be effective tend to engage more constructively in session, which helps bring about symptom reduction. Therapists' expectancies for patient improvement also predicted outcome, although this association was not mediated by the alliance. None of the expectancy scales interacted with alliance ratings in the prediction of clinical improvement.