Attributional Style, Hope, and Initial Response to Selective Serotonin Reuptake Inhibitors in Youth Psychiatric Inpatients

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1 Cognitive Therapy and Research, Vol. 29, No. 6, December 2005 ( C 2006), pp DOI: /s x Attributional Style, Hope, and Initial Response to Selective Serotonin Reuptake Inhibitors in Youth Psychiatric Inpatients Thomas E. Joiner Jr., 1,3 Jessica S. Brown, 1 Kathryn H. Gordon, 1 Mark R. Rouleau, 2 and Karen Dineen Wagner 2 We investigated the role of attributional style in inpatients initial response to treatment, particularly to SSRIs, and explored possible psychological factors implicated in response to SSRIs. One hundred youth psychiatric inpatients completed questionnaires at admission and discharge on attributional style, hopelessness, self-esteem, and depressive symptoms; medication status was recorded. Change in depressive symptoms from admission to discharge varied depending on negative attributional style status and treatment group status. Patients with a relatively positive attributional style and who were on SSRI medicines experienced the largest decreases in depression from admission to discharge, as well as the lowest absolute depression level at discharge. Depression changes were less pronounced in other patients, including those on SSRIs with a negative attributional style. Psychological processes corresponding to these changes appeared to involve increased hope, not enhanced self-esteem. Attributional style may moderate initial SSRI treatment response, an effect that appears to correspond with increased hope. KEY WORDS: SSRIs; attributional style; hopelessness; youth. Cognitive variables (e.g., pessimism, hopelessness, self-esteem) are associated with depression onset and risk in children (Joiner & Wagner, 1995; Wagner, Rouleau, & Joiner, 2000) and adolescents (Lewinsohn, Joiner, & Rohde, 2001; Wagner, Berenson, Harding, & Joiner, 1998). They are also associated with course of disorder (Lewinsohn, Rohde, & Seely, 1998) and treatment response in children and adolescents (Brent et al., 1998). In their study of adolescents with major depression, Brent et al. (1998) found that cognitive distortions and hopelessness at intake 1 Department of Psychology, Florida State University, Tallahassee, Florida. 2 Division of Child & Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch at Galveston, Galveston, Texas. 3 Correspondence should be directed to Thomas Joiner, Department of Psychology, Florida State University, Tallahassee, Florida, ; joiner@psy.fsu.edu /05/ /0 C 2006 Springer Science+Business Media, Inc.

2 692 Joiner, Brown, Gordon, Rouleau, and Wagner predicted later psychotherapeutic response, and reported that lack of treatment response was accounted for, in part, by continued hopelessness. Joiner (2000) found that youth inpatients with a negative cognitive style at admission and who experienced negative life events in the interval between discharge and 2-month followup were likely to experience recurrence of depressive symptoms. These symptoms appeared to recur as a function of increased hopelessness, not of decreased selfesteem. In the general treatment literature, there is growing consensus that the combination of antidepressant medicines and specific forms of psychotherapy represents the maximally effective therapeutic modality (e.g., see Pettit, Voelz, & Joiner, 2001). This issue has been studied much more so with adults than with children. In one of the most compelling studies to date on this issue, Keller et al. (2000) studied several hundred chronically depressed adult patients, a third of whom were randomized to treatment with nefazodone, a third of whom were randomized to treatment with cognitive-behavioral analysis system psychotherapy, and a third of whom received both nefazodone and the therapy. Around 55% of patients on nefazodone remitted; approximately 55% of patients treated with the therapy remitted; but remission rate of those receiving both drug and therapy approached 90%. This study, as well as others (e.g., Reynolds et al., 1999), suggests that targeting psychological variables, including negative cognitions, in combination with antidepressant medicines, may maximize chances of recovery. One may speculate that this is particularly true for those with negative attributional styles (e.g., tendency to view causes of negative events as pervasive and permanent). Such patients may be in particular need of cognitive therapy added to pharmacotherapy (Miller, Norman, & Keitner, 1990, although not all studies have supported this; e.g., Spangler, Simons, Monroe, & Thase, 1997), and pharmacotherapy alone for such patients may not lead to maximally positive outcomes. One purpose of the present study was to empirically assess this possibility. Another purpose was to assess the psychological processes that may be associated with initial response to SSRI antidepressants. Several anecdotal and other reports suggest that antidepressants may enhance self-esteem, which, in turn, contributes to recovery (Deakin, 1996; Kramer, 1993). This view is consistent with studies from the animal literature showing that social dominance rank (cf. self-esteem) is correlated with levels of serotonin metabolites, and that changes in social rank are associated with changes in metabolites (Higley et al., 1996). On the other hand, cognitive theories of depression (Abramson, Metalsky, & Alloy, 1989) view increased hope as one key to recovery, and the empirical results of Brent et al. (1998) and Joiner (2000) supported this view. In the latter study, the roles of hopelessness and self-esteem in recovery were directly compared, and it was found that hopelessness, but not self-esteem, accounted, in part, for symptom improvement. To our knowledge, this question has not been thoroughly addressed with regard to response to SSRIs; in the current study, we will evaluate whether the psychological processes associated with initial SSRI-related symptom resolutions are characterized by increased hope versus enhanced self-esteem. We studied depressive symptoms at admission and discharge in 100 youth psychiatric inpatients, 31 of whom were treated with SSRI antidepressants in the

3 Attributional Style, Hope, Treatment Response 693 hospital. We assessed whether patients with a negative attributional style benefited less than other patients from SSRI antidepressants. A secondary aim of this study was to determine whether this effect showed specificity to SSRIs versus other treatments, lending strength to the idea that SSRIs induce different effects on mood and emotion than other medications. Moreover, we determined whether any effects of negative attributional style on initial SSRI response were associated with continued hopelessness versus continued self-esteem problems. Results of the study may inform both clinical decision-making and theoretical models of depression recovery. METHOD Participants Based upon consecutive admissions and willingness to participate, a total of 100 participants were obtained from admissions to the child and adolescent inpatient units at the University of Texas Medical Branch (the internal review board of which approved this study). Written informed consent was given from the parent and assent from the minors for participation in the study. Participants (51 boys, 49 girls) ranged in age from 7 to 17 years (mean = 13.38, SD = 1.49). The majority of the subjects were Caucasian (64%) followed by African- American (24%), Hispanic (10%), and Asian (1%); one participant s race was not recorded. Participants inpatient medication status was established by detailed chart review. Thirty-one patients were taking one or more of the SSRIs fluoxetine, paroxetine, sertraline, or fluvoxamine, and these 31 form the SSRI group for the analyses reported later. Of the 31 patients in the SSRI group, eight were also on one or more additional medicines, as follows: Two were also taking valproate; one was also taking valproate and trazodone; one was also taking valproate, risperidone, and lorazepam; one was also taking valproate, carbamazepine, and haloperidol; one was also taking carbamazepine; one was also taking carbamazepine and dextroamphetamine; and one was also taking carbamazepine and methylphenidate. Analyses were repeated excluding these eight patients from the SSRI group, with no substantive impact on the results. We thus included them in the SSRI group. All patients not included in the SSRI group (n = 69) were assigned to an Other treatments group. This Other treatments group is heterogeneous with regard to treatments and diagnoses (in addition to descriptions provided next, we will return to this point in the Discussion Section). Of the 69 patients in this group, 25 patients were taking no psychiatric medicines. Thirty-four were on monotherapy, as follows: 15 were on valproate alone; six were on methyphenidate alone; four on lithium alone; two on dextroamphetamine alone; two on risperidone alone; two on imipramine alone; two on carbamazepine alone; and one on lorazepam alone. Of the 69 patients in the Other treatments group, 10 were on combination treatments, as follows: four were taking valproate and risperidone (one of

4 694 Joiner, Brown, Gordon, Rouleau, and Wagner these four was also taking dextroamphetamine); three were taking valproate and lithium (one of these three was also taking dextroamphetamine and trazodone); one was taking carbamazepine and pemoline; one was taking valproate, dextroamphetamine, and chlorpromazine; and one was taking lithium, risperidone, and doxepin. Of course, medication status and diagnostic status are interrelated. Diagnoses were made using DSM-IV criteria based on direct interviews of the child and parent using the Lifetime Schedule for Affective Disorders and Schizophrenia (Puig- Antich, Chambers, & Klein, 1993), which assesses both current and lifetime psychiatric disorders in youth. Diagnoses were made by the fourth and fifth authors, who were initially blind to chart diagnoses, based on the K-SADS-L. After the K-SADS-L was completed, chart diagnoses were consulted. In a very small minority of cases, discrepancies were found, the treating physician was informed, and a conference regarding the case arranged, at which a consensus diagnosis was decided. This procedure is consistent with the complete intended process of the K-SADS-L, which encourages information from as many sources as possible. As in most inpatient settings, comorbidity was common, but is not emphasized here because the number of patients experiencing any particular pattern of comorbidity was so low as to preclude meaningful statistical analyses. Principal diagnoses were defined as those occasioning inpatient admission. The principal diagnoses were bipolar disorder (26%), major depression (22%), depressive disorder NOS (10%), ADHD (14%), conduct disorder (8%), psychotic disorder NOS (5%), substance-use disorder (2%), organic mood disorder (2%), PTSD (2%), acute adjustment disorder (2%), intermittent explosive disorder (2%), oppositional defiant disorder (1%), schizoaffective disorder (1%), anxiety disorder NOS (1%), OCD (1%), and undifferentiated somatoform disorder (1%). In general, the SSRI group included more patients with non-bipolar mood disorders, whereas the Other treatments group included more patients with bipolar disorder and externalizing behavior syndromes. Nevertheless, each group contained substantial diagnostic heterogeneity. For the SSRI group, 39% had major depression; 10%, depressive disorder NOS; 23%, bipolar disorder; 6% substanceuse disorder; and 3% each of ADHD, psychotic disorder NOS, oppositional defiant disorder, acute adjustment disorder, OCD, schizoaffective disorder, and organic mood disorder. For the Other treatments group, 14% had major depression; 10%, depressive disorder NOS; 27%, bipolar disorder; 18%, ADHD; 10%, conduct disorder; 5% psychotic disorder NOS, 4% each of PTSD and intermittent explosive disorder; and 2% each of acute adjustment disorder, undifferentiated somatoform disorder, organic mood disorder, and anxiety disorder NOS. No specific form of individual psychotherapy was routinely rendered during hospitalization. Patients attended at least one family meeting, and received occupational and recreational therapy. The average length of hospitalization was 8.68 days (SD = 5.72). When used as a covariate, length of hospitalization did not affect results (and was not related to the study s main predictor variable, negative attributional style), therefore it will not be discussed further.

5 Attributional Style, Hope, Treatment Response 695 Procedure Written informed consent from the parent or legal guardian and child assent was obtained. A set of questionnaires was administered upon admission to the psychiatric unit, and the same questionnaires were re-administered at the time of discharge. Measures Children s Attributional Style Questionnaire (CASQ) The CASQ (Kaslow, Tanenbaum, & Seligman, 1978) is a widely used (Joiner & Wagner, 1995) 48-item forced choice measure of causal explanations for 24 positive and 24 negative events. Hypothetical events are presented and participants are requested to select the response that explains why the event happened to them. Sixteen questions pertain to each of the three attributional dimensions of internality, stability, and globality. A score of 1 is assigned to each internal, stable, or global response and a score of 0 to each external, unstable, or specific response. Adequate reliability and validity data for the measure have been reported (Kaslow et al., 1978; but also see Abela, 2001; Abela & Sarin, 2002; Nolen-Hoeksema, Girgus, & Seligman, 1992; Seligman et al., 1984 (where αs =.50.55); and see also Hankin, Abramson, & Siler, 2001, who reported an alpha of.40). For the purposes of the present study, consistent with the hopelessness theory of depression (Abramson et al., 1989) and with empirical work showing that stability and globality reflect the same factor but internality does not (Joiner & Rudd, 1996), analyses using the CASQ were limited to the negative attributional components of stability and globality. The resulting combination of negative stability and negative globality is referred to as negative generality. Those who scored in the top third on baseline negative generality were assigned to the negative attributional style group; all others were assigned to the positive style group. The measure was dichotomized so that it could be used in our repeated-measures ANOVA framework as an independent variable. Using the top third also identifies a reasonably large group with clear negative attributional styles. Children s Hopelessness Scale (CHS; Kazdin, French, Unis, Esveldt-Dawson, & Sherick, 1983) This 17-item, true false scale was modeled after a similar scale for adults (Beck, Weissman, Lester, & Trexler, 1974). Kazdin et al. reported adequate internal consistency, and reasonable validity data (e.g., substantial correlations with depression and suicidal ideation; see also Joiner, 2000). Rosenberg Self-Esteem Questionnaire (SEQ; Rosenberg, 1965) The SEQ is a 10-item scale that assesses global self-esteem. Coefficient alpha has been estimated in the range from.85 to.95, and validity data are adequate (Rosenberg, 1965).

6 696 Joiner, Brown, Gordon, Rouleau, and Wagner Children s Depression Inventory (CDI; Kovacs, 1992) The CDI is a reliable and well-validated 27-item self-report measure of depressive symptoms. Kovacs (1992) reported adequate internal consistency and 1-month test retest reliabilities (.86 and.72, respectively) for the scale as a whole. The scale has been adequately validated (e.g., correlates significantly [r =.55] with clinician-rated depression). The scale was administered at admission and at discharge, and will be used here as an index of initial treatment response. RESULTS The SSRI treatment and Other treatment groups were compared on number of prior hospitalization and suicide attempts in an attempt to determine if one group was more chronic or severe than the other. However, there were no differences on prior hospitalization (F[1, 98] = 1.37, p = ns) or on suicide attempts (F[1, 98] = 0.17, p = ns). Means, standard deviations, and correlations are presented in Table I. The correlations in Table I further support the view that group status was not associated with symptom severity (i.e., group status did not correlate significantly with any symptom index). As can also be seen there, the baseline mean for the CDI was elevated (raw score of 17.87; SD = 10.37; corresponds to a T-score of approximately 60; Kovacs, 1992), as would be expected in inpatients, some but not all of whom experienced considerable depression. As would also be expected in a sample undergoing inpatient treatment, CDI scores at discharge dropped substantially (mean raw score of 13.51, SD = 9.30; corresponds to a T-score of approximately 53). Similarly, mean Table I. Means and Standard Deviations of, and Intercorrelations Between, All Variables SSRI group vs. Other treatment group 2. Positive vs. negative.01 attibutional style group 3. Hopelessness-admission (3.74) 4. Hopelessness-discharge (3.25) 5. Self-esteem-admission (2.83) 6. Self-esteem-discharge (2.58) 7. Depression-admission (10.37) 8. Depression-discharge (9.30) Note. Means on diagonal; standard deviations in parentheses. For SSRI Group Status Variable, 0: Other treatments group ; 1: SSRI group. For attributional style group variable, 0: relatively positive attributional style; 1: negative attributional style. p <.05.

7 Attributional Style, Hope, Treatment Response 697 hopelessness scores decreased from admission to discharge, and mean self-esteem scores increased. Intercorrelations were also consistent with expectations. The categorical variable reflecting negative attributional style status at admission was significantly correlated with hopelessness, self-esteem, and depressive symptoms, at admission and at discharge. The direction of these correlations was such that those with a negative attributional style endorsed more hopelessness and depression, and less self-esteem, as compared to those with a more positive attributional style. Test retest correlations of self-esteem, depressive symptoms, and hopelessness were in line with past work (e.g., Joiner, 2000). Hopelessness is the most state-like of these three variables, and thus it is not surprising that hopelessness displayed the lowest test retest coefficient. With one exception, age and gender were not correlated with any variable (these correlations are thus not shown in Table I). The one exception was that SSRI group status correlated with age, such that older patients were more likely to be in the SSRI group than the Other treatments group (r =.30, p <.05; SSRI group mean was 14.70, SD = 2.27; Other treatments group mean was 12.90, SD = 2.66). Accordingly, all statistical analyses were corrected for age, and in no case were results affected. Therefore, uncorrected analyses will be reported. Did Negative Attributional Style Moderate Initial Response to SSRI Medications? To evaluate whether negative attributional style moderated initial response to SSRI medications (and whether this effect applied specifically to the SSRI group or applied as well to the Other treatments group ), we conducted a repeatedmeasures analysis of variance, with CDI depressive symptoms at admission and discharge as the repeated measure. The two between-subjects factors were SSRI group status (1: SSRI group ; 0: Other treatments group ) and negative attributional style status (1: negative attributional style; 0: relatively positive attributional style). If negative attributional style indeed moderated initial treatment response, and if it specifically moderated initial response to SSRIs versus other treatments, then the Time SSRI group status Negative attributional group status interaction will achieve statistical significance. Results indicated a main effect for time (F[1, 96] = 19.35, p <.001, partial eta squared =.17), indicating that CDI depression scores decreased significantly from admission to discharge in patients in general. Crucial in the present context, no other effect was significant (ps >.43), with the key exception of the Time SSRI group status Negative attributional group status interaction (F[1, 96] = 4.14, p <.05, partial eta squared =.04). The means displayed in Table II indicate the nature of this significant interaction. As can be seen there, the largest decrease in depression scores from admission to baseline occurred among participants on SSRI medications with a relatively positive attributional style. These patients also achieved the lowest absolute depression score at discharge. All other patients, including those on SS- RIs with a negative attributional style, experienced minimal or modest depression decreases. This overall pattern of findings indicates that attributional style moderated initial treatment response those with a relatively positive attributional style

8 698 Joiner, Brown, Gordon, Rouleau, and Wagner Table II. Means Within the Eight Cells of the Time SSRI Group Status Negative Attributional Group Status Interaction Admission CDI Score Discharge CDI Score Positive attributional style group SSRI group (n = 17) Other treatments group (n = 46) Negative attributional style group SSRI group (n = 10) Other treatments group (n = 27) Note. CDI: Children s Depression Inventory. benefited more and furthermore, that this effect was not applicable to treatments in general, but rather the effect was specific to SSRI antidepressants. Which Psychological Processes Correspond to Initial SSRI Treatment Response Among Those with Relatively Positive Attributional Styles? To evaluate this question, we conducted two separate repeated-measures analyses of variance, again with CDI depressive symptoms at admission and discharge as the repeated measure, and again with SSRI group status and negative attributional style status as between-subjects factors. We tested whether self-esteem or hope were the mechanisms (i.e., mediating variables) by which relatively positive attributional style increases initial SSRI treatment response (as reflected in CDI scores). In order for it to be said that a variable mediates the relationship between the independent variable (IV) and dependent variable (DV), the correlation between the IV and DV must be examined both with and without controlling for the variance accounted for by the proposed mediating variables. If the proposed variable (e.g., hope) mediates the relationship between the IV (relatively positive attributional style) and the DV (SSRI treatment response), then the correlation between the IV and DV should decrease when the mediating variable is accounted for in the equation. In the first of these analyses, we covaried changes from intake to discharge in levels of hopelessness; in the second of these analyses, we covaried changes from intake to discharge in levels of self-esteem. If increased hope is one process by which the initial effects of SSRIs on depressive symptoms occur among those with a relatively positive attributional style, covariance of changes in hope should substantially reduce the previously significant effect of the Time SSRI group status Negative attributional group status interaction (reported above as F[1, 96] = 4.14, p <.05, partial eta squared =.04). Similarly, if self-esteem is a process by which the initial effects of SSRIs on depressive symptoms occur among those with a relatively positive attributional style, covariance of self-esteem changes should substantially reduce the previously significant effect of the Time SSRI group status Negative attributional group status interaction (cf. Kraemer, Wilson, Fairburn, & Agras, 2002). 4 4 We are unaware of formal statistical significance tests within the framework of repeated measures ANOVA. However, using a regression framework that approximated repeated measures ANOVA, the

9 Attributional Style, Hope, Treatment Response 699 Results were at odds with the view that self-esteem is implicated in the initial effects of SSRIs on depressive symptoms among those with a relatively positive attributional style. When self-esteem changes were covaried, the effect of the Time SSRI group status Negative attributional group status interaction (reported above as F[1, 96] = 4.14, p <.05, partial eta squared =.04) was slightly increased not decreased (F[1, 95] = 4.19, p <.05, partial eta squared =.05). By contrast, results were consistent with the view that increased hope is a psychological process by which the initial effects of SSRIs on depressive symptoms occur among those with a relatively positive attributional style. When changes in hope were covaried, the effect of the Time SSRI group status Negative attributional group status interaction (reported above as F[1, 96] = 4.14, p <.05, partial eta squared =.04) was no longer statistically significant (F[1, 95] = 3.42, p <.10, partial eta squared =.03). The decrease in effect from F = 4.14 to F = 3.42 is modest; accordingly, we concluded that, although hope overshadows self-esteem as a process implicated in initial SSRI effects among those with a relatively positive attributional style, hope is just one of many variables (psychological and otherwise) that are implicated in initial response to SSRIs. 5 DISCUSSION We investigated the role of attributional style in inpatients initial response to treatment, particularly to SSRIs. Furthermore, we explored psychological processes implicated in initial response to SSRIs, at least among certain patients (i.e., those with a relatively positive attributional style). Three findings were particularly noteworthy. First, although not directly pertinent to our main emphases, it is worth reiterating that there was a main effect of Time on depressive symptoms from admission to discharge. In general, patients depressive symptoms were substantially lower at discharge than at admission. It is possible that this effect could be due to simple regression to the mean in this sample. However, the second finding argues against this point. The second main finding qualifies the first, in that change in depressive symptoms from admission to discharge varied depending on negative attributional style status and treatment group status. Patients with a relatively positive attributional style and who were on SSRI medicines experienced the largest decreases in depression from admission to discharge, as well as the lowest absolute depression level at discharge. Depression changes were less pronounced in other patients, including those on SSRIs with a negative attributional style. Regression to the mean does not explain this pattern of differential changes across the groups. mediational role for hopelessness approached significance (p <.10), and was over twice as large as the mediational effect for self-esteem. 5 As a supplemental analysis that is potentially clearer, we re-ran analyses just comparing those on SSRIs to those who received no psychopharmacologic treatment. Though somewhat weakened by diminished power, all results were very similar to those reported above, without exception.

10 700 Joiner, Brown, Gordon, Rouleau, and Wagner Our third main finding suggests psychological processes that might be associated with the second main finding. Among patients with a relatively positive attributional style on SSRI medications, self-esteem changes were not clearly implicated in SSRI-related depression decreases; rather, increased hope seemed involved. In the following sections, we summarize some scientific and clinical implications of our findings, and then note some limitations of the study that should be considered in interpreting our results. Scientific Implications Needles and Abramson (1990) proposed, and empirically supported, a model of recovery from depression, in which people with a positive attributional style who experienced positive life events became more hopeful, and as a function thereof, less depressed. Our results complement those of Needles and Abramson (1990) youth inpatients on SSRIs with a relatively positive attributional style became less depressed, an effect that was associated with increased hope. Perhaps SSRIs reduce depression symptoms by initiating behavioral activation, which then interacts with a positive attributional style to increase hope. These speculations dovetail with Fredrickson s (2001) broaden-and-build theory of positive emotions, which posits that an individual is able to generate and execute a greater number of problemsolving skills when she or he is in a positive mood state than when she or he in a negative mood state. Future research investigating this speculation could increase the understanding of the mechanisms by which SSRIs reduce depression symptoms, particularly in individuals with a relatively positive attributional style. Our findings are also relevant regarding psychological processes associated with initial SSRI response. In contrast to the view that self-esteem boosts comprise SSRIs psychological mechanism of action, our results suggest that enhanced selfesteem is less important than increased hope. This conclusion is consistent with the empirical findings of Brent et al. (1998) and Joiner (2000). Moreover, it squares with the hopelessness theory s relegation of the internality dimension of attributional style to a secondary role (Abramson et al., 1989). In the hopelessness theory, the stability and globality dimensions (which together make up the construct of generality) are central in the presence of negative events, those who attribute negative events to stable and global causes will become hopeless and thus depressed. Those who also attribute negative events to internal causes will develop decreased selfesteem as a feature of their depressive reaction. From this perspective, self-esteem is a frequent but not necessary aspect of depressive reactions, and plays no causal or mediational role in the onset of depression. By contrast, negative attributional style and hopelessness play modest causal and mediational roles, respectively, in the hopelessness theory, and our empirical findings from the present study were consistent with this general view. Clinical Implications Our results may inform clinical decision-making, in three ways. First, the findings may have implications for treatment choice depressed youth with relatively

11 Attributional Style, Hope, Treatment Response 701 positive attributional styles may experience remission of symptoms on SSRIs alone. However, for depressed youth with a negative attributional style, SSRIs alone may not be sufficient. Because they have a negative attributional style, and in light of the impressive results of Keller et al. (2000) among adults on combined drug + cognitive behavioral analysis system of psychotherapy (McCullough, 2000), combined SSRI + cognitive therapy might be indicated among youths with negative attributional styles (although there is some ambiguity regarding the minimum appropriate age for cognitive therapy). 6 Therefore, it may be worthwhile to assess attributional style in depressed youth prior to initiation of treatment. Development of a therapeutic technique designed to retrain attributional styles in youth may be beneficial for those with a negative attributional style. This type of therapy would likely show some positive effects on their mood, as well as maximize their chances for response to SSRIs. Second, at least among youth with relatively positive attributional styles (but perhaps not limited to them), a potential marker for initial treatment response is increased hope (more so than enhanced self-esteem). Third, in context of current controversy surrounding SSRIs and suicidality in youth, our findings are consistent with the view that SSRIs can facilitate initial treatment response; to the degree that this response is associated with increased hope a suicide buffer treatment response may be enhanced and suicidality reduced. Limitations In closing, we note some important cautions. First, the Other treatments group was heterogeneous in terms of treatments received some received no medicines; others, mood stabilizers; others, combinations of medicines; and so on. Importantly, however, our formation of this group was not intended as a basis for inferences about their treatment responses; rather, the purpose of including this group was to evaluate whether results on attributional style and hopelessness/self-esteem applied to any treatment whatsoever, or rather, displayed some specificity to SSRIs (the latter view was supported). Second, because SSRIs are associated with relatively fewer side effects than many other pharmacologic agents, SSRIs are often first line treatments. After poor response to an SSRI, trials with medication from other classes may be initiated. Therefore, it is possible that the Other treatments group is a more treatmentresistant group, and that treatment resistance is responsible for a lack of overall change in depression for the Other treatments group. We have no way of empirically testing this possibility, and it should be considered when interpreting our findings. Third, diagnostic heterogeneity within both the SSRI group and the Other treatments group deserves comment. In an important sense, diagnostic heterogeneity worked to our advantage, because if treatment group and diagnostic status were 6 Based on the capitalization hypothesis (i.e., that those with cognitive strengths do better with cognitive therapy than those with cognitive weaknesses; cf. Longabaugh, Wirtz, DiClemente, & Litt, 1994), one could argue that negative attributional style children might fare best on the combination of SSRIs and a non-cognitive psychotherapy, such as interpersonal psychotherapy (for adaptation to adolescents, see Mufson, Moreau, Weissman, & Klerman, 1993).

12 702 Joiner, Brown, Gordon, Rouleau, and Wagner completely confounded, our inferences would be more ambiguous. For example, if all patients in the SSRI group experienced a non-bipolar mood disorder, and no or very few patients in the Other treatments group did, we could not discern whether effects were a function of treatment status or mood disorder status. However, less than half of SSRI group patients experienced a non-bipolar mood disorder, and a substantial portion of the Other treatments group experienced a non-bipolar mood disorder. On the other hand, the SSRI group included 49% with some depressive disorder, as compared to 24% in the Other treatments group. The outcome measure of CDI depression (versus a more general outcome measure) is more relevant to the SSRI group. Because the SSRI group included more depressed patients and because the study s outcome measure was a depression index, this might have biased the study in favor of finding effects for the SSRI group. Because there was no main effect for group status, we do not view this issue as critical, but nonetheless it should be kept in mind when interpreting our findings. Fourth, some may be concerned that the SSRI group included youth with bipolar disorder, as SSRIs by themselves are generally not recommended for use in patients with bipolar disorder. However, two points are key in this regard: (1) in addition to receiving SSRIs, patients with bipolar disorder also received mood stabilizers; (2) analyses excluding these patients were very similar to analyses including them. Fifth, we did not fully assess such variables as comorbid diagnostic status, previous treatments and adherence thereto, and poor family support, which may affect treatment outcomes, and which represent important areas for future research. Additionally, it could be argued that the 1 2-week hospital stay for this sample was not long enough for SSRIs to show effects. Actually, however, initial (i.e., partial) responses do occur relatively soon after treatment initiation (Nierenberg et al., 2000). Initial response is important because it facilitates discharge into continued care on an outpatient basis, and it is a favorable prognostic indicator regarding future course of the disorder. In this context, our findings suggest that targeting hopelessness early in treatment could augment SSRI response and set patients on a positive trajectory of change. Sixth, we reiterate that the partial mediational effect of changes in hope on initial treatment response was small. Finally, we note that results were obtained within the context of a youth psychiatric inpatient unit not necessarily representative of the usual mental health setting. Caution should be exercised in generalizing to other clinical settings and populations. We look forward to research in other settings and populations evaluating the view, supported here, that attributional style may moderate initial SSRI treatment response, an effect associated with increased hope, not self-esteem. ACKNOWLEDGMENTS Portions of this work were supported by a fellowship to Dr. Joiner from the J. S. Guggenheim Memorial Foundation and a grant to Dr. Wagner from the American Foundation for Suicide Prevention.

13 Attributional Style, Hope, Treatment Response 703 REFERENCES Abela, J. R. Z. (2001). The hopelessness theory of depression: A test of the diathesis-stress and causal mediation components in third and seventh grade children. Journal of Abnormal Child Psychology, 29, Abela, J. R. Z., & Sarin, S. (2002). Cognitive vulnerability to hopelessness depression: A chain is only as strong as its weakest link. Cognitive Therapy and Research, 26, Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42, Brent, D. A., Kolko, D. J., Birmaher, B., Baugher, M., Bridge, J., Roth, C., et al. (1998). Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 37, Deakin, J. F. W. (1996). 5-HT, antidepressant drugs and the psychosocial origins of depression. Journal of Psychopharmacology, 10, Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56(3), Hankin, B. L., Abramson, L. Y., & Siler, M. (2001). A prospective test of the hopelessness theory of depression in adolescence. Cognitive Therapy and Research, 25, Higley, J. D., King, S. T., Jr., Hasert, M. F., Champoux, M., Suomi, S. J., & Linnoila, M. (1996). Stability of interindividual differences in serotonin function and its relationship to severe aggression and competent social behavior in rhesus macaque females. Neuropsychopharmacology, 14, Joiner, T. E., Jr. (2000). A test of the hopelessness theory of depression among youth psychiatric inpatients. Journal of Clinical Child Psychology, 29, Joiner, T. E., & Rudd, M. D. (1996). Toward a categorization of depression-related psychological constructs. Cognitive Therapy and Research, 20, Joiner, T. E., Jr., & Wagner, K. D. (1995). Attributional style and depression in children and adolescents: A meta-analytic review. Clinical Psychology Review, 8, Kaslow, N. J., Tanenbaum, R. L., & Seligman, M. E. P. (1978). The Kastan-R: A children s attributional style questionnaire. Pennsylvania: University of Pennsylvania. Kazdin, A. E., French, N. H., Unis, A. S., Esveldt-Dawson, K., & Sherick, R. B. (1983). Hopelessness, depression, and suicidal intent among psychiatrically disturbed inpatient children. Journal of Consulting and Clinical Psychology, 51, Keller, M., McCullough, J., Klein, D., Arnow, B., Dunner, D., Gelenberg, A. J., et al. (2000). A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine, 342, Kovacs, M. (1992). Children s depression inventory manual. Los Angeles: Western Psychological Services. Kraemer, H. C., Wilson, T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59, Kramer, P. (1993). Listening to prozac. New York: Penguin. Lewinsohn, P. M., Joiner, T., & Rohde, P. (2001). Evaluation of cognitive diathesis-stress models in predicting major depressive disorder in adolescents. Journal of Abnormal Psychology, 110, Lewinsohn, P. M., Rohde, P., & Seely, J. R. (1998). Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review, 18, Longabaugh, R., Wirtz, P. W., DiClemente, C. C., & Litt, M. (1994). Issues in the development of clienttreatment matching hypotheses. Journal of Studies on Alcohol, 12(Suppl), McCullough, J. P., Jr. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy (CBASP). New York: Guilford. Miller, I. W., Norman, W. H., & Keitner, G. I. (1990). Treatment response of high cognitive dysfunction depressed inpatients. Comprehensive Psychiatry, 31, Mufson, L. H., Moreau, D., Weissman, M. M., & Klerman, G. L. (1993). Interpersonal psychotherapy for adolescent depression. In G. Klerman and M. Weissman (Eds.), New applications of interpersonal psychotherapy (pp ). Washington, DC: American Psychiatric Press. Needles, D., & Abramson, L. Y. (1990). Positive life events, attributional style, and hopefulness: Testing a model of recovery from depression. Journal of Abnormal Psychology, 99, Nierenberg, A., Farabaugh, A., Alpert, J., Gordon, J., Worthington, J., Rosenbaum, J., et al. (2000). Timing of onset of antidepressant response with fluoxetine treatment. American Journal of Psychiatry, 157,

14 704 Joiner, Brown, Gordon, Rouleau, and Wagner Nolen-Hoeksema, S., Girgus, J. S., & Seligman, M. E. P. (1992). Predictors and consequences of childhood depressive symptoms: A 5-year longitudinal study. Journal of Abnormal Psychology, 101, Pettit, J., Voelz, Z., & Joiner, T. (2001). Combined treatments for depression. In M. Sammons & N. B. Schmidt (Eds.), Combined treatments for mental disorders (pp ). Washington, DC: American Psychological Association. Puig-Antich, J., Chambers, W. J., & Klein, R. G. (1993). Lifetime schedule for affective disorders and schizophrenia for adolescents. Pittsburgh, PA: University of Pittsburgh. Reynolds, C. F., III, Frank, E., Perel, J. M., Imber, S. D., Cornes, C., Miller, M. D., et al. (1999). Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 281, Rosenberg, S. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Seligman, M. E. P., Peterson, C., Kaslow, N. J., Tanenbaum, R. L., Alloy, L. B., & Abramson, L. Y. (1984). Attributional style and depressive symptoms among children. Journal of Abnormal Child Psychology, 93, Spangler, D. L., Simons, A. D., Monroe, S. M., & Thase, M. E. (1997). Response to cognitive-behavioral therapy in depression: Effects of pretreatment cognitive dysfunction and life stress. Journal of Consulting and Clinical Psychology, 65, Wagner, K. D., Berenson, A., Harding, O., & Joiner, T. E., Jr. (1998). Attributional style and depression in pregnant teenagers. American Journal of Psychiatry, 155, Wagner, K. D., Rouleau, M., & Joiner, T. E., Jr. (2000). Cognitive factors related to suicidal ideation and resolution in psychiatrically hospitalized children and adolescents. American Journal of Psychiatry, 157,