The ability of several process variables to predict therapy outcome was tested with 30 depressed clients who received cognitive therapy with or without medication. Two types of process variables were studied: 1 variable that is unique to cognitive therapy and 2 variables that this approach is assumed to share with other forms of treatment. The client's improvement was found to be predicted by the 2 common factors measured: the therapeutic alliance and the client's emotional involvement (experiencing). The results also indicated, however, that a unique aspect of cognitive therapy (i.e., therapist's focus on the impact of distorted cognitions on depressive symptoms) correlated negatively with outcome at the end of treatment. Descriptive analyses that were conducted to understand this negative correlation suggest that therapists sometimes increased their adherence to cognitive rationales and techniques to correct problems in the therapeutic alliance. Such increased focus, however, seems to worsen alliance strains, thereby interfering with therapeutic change.Despite support for the effectiveness of cognitive therapy for depression, researchers are still confronted with a high degree of uncertainty about its underlying processes of change (Whisman, 1993). As recently noted by Beck and Haaga (1992), the refinement of our understanding of the mechanisms of action in the treatment of depression will take a predominant place in the future of cognitive therapy. The present study is an attempt to better understand the process of change in cognitive therapy for depression.As recommended by several workers in the field (e.g., Kazdin, 1986;Lambert, Shapiro, & Bergin, 1986), two types of processes were investigated: variables that are unique to cognitive

Patients' perceptions of stigma at the start of treatment influence their subsequent treatment behavior. Stigma is an appropriate target for intervention aimed at improving treatment adherence and outcomes.

Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients.

Objective-The PROSPECT Study evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period.Method-The subjects (N=599) were older (>=60 years) patients with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months. Results-Intervention patients had a higher likelihood to receive antidepressants and or psychotherapy (84.9-89% vs. 49-59%) and a 2.2 times greater decline in suicidal ideation than usual care patients over 24 months. Treatment response occurred earlier in intervention patients and continued to increase from the 18 th to the 24 th month, while there was no appreciable increase in usual care patients during the same period. Among patients with major depression, a greater number achieved remission in the intervention than the usual care group at 4 (26.6 vs. 15.2%), 8 (36% vs. 22.5%), and 24 (45.4% vs. 31.5%) months. Patients with minor depression had favorable outcomes regardless of treatment assignment.Conclusions-Sustained collaborative care maintains high utilization of antidepressant treatment, reduces suicidal ideation, and improves the outcomes of major depression over two years. These observations suggest that sustained collaborative care increases depression-free days.

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