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From the American Psychiatric Association’s (2000)Practice Guidelines for Major Depressive Disorder in Adults:
From the American Psychiatric Association’s (2000)Practice Guidelines for Major Depressive Disorder in Adults:
• “Antidepressant medications should be provided for moderate to severe depressive disorders unless ECT is planned.”
• “For example, although some data suggest that cognitive behavioral therapy alone may be effective for patients with moderate to severe major depressive disorder, most such patients will require medication.”
• “Antidepressant medications should be provided for moderate to severe depressive disorders unless ECT is planned.”
• “For example, although some data suggest that cognitive behavioral therapy alone may be effective for patients with moderate to severe major depressive disorder, most such patients will require medication.”
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CPT II
Acute Phase (16 weeks) Continuation Phase (12 months) Follow-up Phase (12 months)
CT
ADM
PLACEBO
Prior CT
(N=34)
ADM
(N=34)
PLACEBO
(N=34)
(N= 60)
(N= 120)
(N= 60)
3 booster sessions
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Major Entry Criteria Major Entry Criteria• Principal Diagnosis of Major Depressive Disorder
• Two consecutive (at least one week apart) scores of 20 or more on a modified 17-item Hamilton Rating Scale for Depression
• No Psychosis or Bipolar Disorder
• No Borderline, Antisocial, or Schizotypal PD
• No marked Substance Abuse or Dependence in previous 6 months
• Principal Diagnosis of Major Depressive Disorder
• Two consecutive (at least one week apart) scores of 20 or more on a modified 17-item Hamilton Rating Scale for Depression
• No Psychosis or Bipolar Disorder
• No Borderline, Antisocial, or Schizotypal PD
• No marked Substance Abuse or Dependence in previous 6 months
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Reasons Interested Patients Were Screened Out of the TrialReasons Interested Patients
Were Screened Out of the Trial
4
83
5
1112
13
19
25
29
38
45
63
67
106
129
240
0 20 40 60 80 100 120 140 160 180 200 220 240
Number of Patients
Primary eating disorder
Imminent suicide risk
Schizotypal PD
Antisocial PD
Borderline PD
Outside age limits
Primary anxiety disorder
Recent paroxetine failure
Would not stop current meds
Psychosis
Refused meds
Medical condition
Substance Abuse or Dependence
Bipolar
No Major Depressive Episode
Low severity
Randomized to Treatment
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81
82
33
33
89
75
64
53
0 20 40 60 80 100
Percentage
Employed
Married orCohabiting
Caucasian
Female
PennVanderbilt
Demographic InformationDemographic Information
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Depressive Subtype and History InformationDepressive Subtype and History Information
12
209
2933
9786
8267
75
4941
9
5843
2810
0 10 20 30 40 50 60 70 80 90 100
Percentage
Bipolar II
Atypical
Melancholic
Chronic, Dysthymic, or Recurrent
Recurrent
Chronic or Dysthymic
Dysthymic
Chronic
Ever Hospitalized
Penn
Vanderbilt
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Comorbidity IComorbidity I
3734
249
24
63
239
197
1313
285
6541
8363
0 10 20 30 40 50 60 70 80 90 100
Percentage
Substance Abuse or Dependence
Eating Disorder
Anxiety Disorder NOS
OCD
Specific Phobia
Panic Disorder
GAD
PTSD
Any Anxiety Disorder
Any Axis I Comorbidity
Penn
Vanderbilt
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Comorbidity IIComorbidity II
1318
422
000
444
222
1322
756
3891
76
0 10 20 30 40 50 60 70 80 90 100
Percentage
PD NOS
Narcissistic PD
Histrionic PD
Schizoid PD
Paranoid PD
Dependent PD
Avoidant PD
Obsessive Compulsive PD
Any Personality Disorder
Any Comorbidity (Axis I or II)
Penn
Vanderbilt
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Acute Phase
CT(N= 60)
ADM(N= 120)
PLACEBO (N= 60)
0 2 4 6 8 10 12 14 16Weeks
(Triple blind)
Un-blinding for pill patients
R a n d o m i z a t i
o n
(Single blind)
Augmented (41%)
Not Augmented (59%)
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2%3%
0%0%
1%0%0%
1%0%0%
1%0%
7%1%
0%7%
3%3%
0%0%
7%0%
1%3%
15%10%
13%
0% 2% 4% 6% 8% 10% 12% 14% 16%
Percentage
Unknown
Suicide
Suicide Risk
Hospitalized
Too busy
SEs / Did not like treatment
Dissatisfied w/progress
Refused Tx
All reasons
PlaceboADMCT
Dropouts in First 8 WeeksDropouts in First 8 Weeks
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13%
23%
5%12%
26%
35%
75%
51%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Pe
rce
nta
ge
Remission (0-7) Response (8-12) Nonresponse (13 and up)
HRSD Score Categories
PlaceboADMCT
Degrees of Response at 8 WeeksDegrees of Response at 8 Weeks
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16.0
14.4
13.4
12
14
16
18
20
22
24
26
Intake 0 2 4 6 8
Week
Mo
dif
ied
17-
item
Ham
ilto
n R
atin
g S
cale
fo
r D
epre
ssio
n
PlaceboCTADM
Mean HRSD Scores Over 8 WeeksMean HRSD Scores Over 8 Weeks
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Change in Depressive Symptomsfrom Intake to Week 8 (HRSD)
Change in Depressive Symptomsfrom Intake to Week 8 (HRSD)
Contrast Mean HRSD Difference Effect Size (d)
Effect Size Descriptora
ADM vs. Placebo
2.3 .73** medium
CT vs. Placebo
1.7 .54# medium
ADM vs. CT
0.6 .19 --
**p < .01 #p < .10 a From Cohen
Contrast Mean HRSD Difference Effect Size (d)
Effect Size Descriptora
ADM vs. Placebo
2.3 .73** medium
CT vs. Placebo
1.7 .54# medium
ADM vs. CT
0.6 .19 --
**p < .01 #p < .10 a From Cohen
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Dropouts in ADM and CTover 16 Weeks
Dropouts in ADM and CTover 16 Weeks
2%3%
0%1%
0%1%
0%1%
7%2%
7%8%
0%0%
0%1%
15%16%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Percentage
Unknown
Suicide
Suicide Risk
Hospitalized
Too busy
SEs / Did not like treatment
Dissatisfied w/progress
Refused Tx
All reasons
ADM
CT
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25%
49%
40%
57% 58%
0%
10%
20%
30%
40%
50%
60%
Pe
rce
nta
ge
8 Weeks 16 Weeks
Placebo (n=60)
ADM (n=120)
CT (n=60)
Percent Responders (HRSD < 12) amongAll Assigned, Across Sites
Percent Responders (HRSD < 12) amongAll Assigned, Across Sites
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Degrees of Response after 16 WeeksDegrees of Response after 16 Weeks
45%
37%
12%
21%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Per
cen
tag
e
Remission (HRSD = 0 -- 7) Response (HRSD = 8 -- 12)
ADM CT
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Percent Response (HRSD < 12) by Site (16 Weeks)
Percent Response (HRSD < 12) by Site (16 Weeks)
47%
63%67%
53%
0%
10%
20%
30%
40%
50%
60%
70%
Pe
rce
nta
ge
ADM CT ADM CT
Penn Vanderbilt
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Sample Characteristics on Potential Predictors of Response
Demographics History/SubtypeAge 40+12 Ever Hospitalized 19%Female 59% Chronic 50%Minority 18% Recurrent 75%Married 33% Melancholic 31%Employed 82% Atypical 15%
Axis I Comorbidity (73%) Axis II Comorbidity (47%)PTSD 17% Cluster A 3%GAD 13% Cluster B 4%Panic Dis. 13% Avoidant 18%Eating Dis. 17% OCPD 15%Subs. Use 36% PD NOS 16%
Predicts response across ADM and CT (Prognostic)
Predicts differential response to ADM vs. CT (Prescriptive)
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Chronicity Predicts Poor Response (Prognostic)
Chronicity Predicts Poor Response (Prognostic)
9.8 10.511.8
13.0
0
2
4
6
8
10
12
14
Ter
min
atio
n H
amil
ton
Sco
re
ADM(N=63)
CT(N=28)
ADM(N=57)
CT(N=32)
Non Chronic Patients Chronic patients
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Being Unemployed Predicts Poor Response (Prognostic)
Being Unemployed Predicts Poor Response (Prognostic)
8.69.8
11.4 11.6
0
2
4
6
8
10
12
Ter
min
atio
n H
amil
ton
Sco
re
ADM(N=103)
CT(N=47)
ADM(N=17)
CT(N=13)
Employed Unemployed
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Cluster A Predicts Poor Response (Prognostic)
Cluster A Predicts Poor Response (Prognostic)
10.8 11.1
16.318.2
02468
101214161820
Ter
min
atio
n H
amil
ton
Sco
re
ADM(N=116)
CT(N=58)
ADM(N=4)
CT (N=2)
No Cluster A Cluster A
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PTSD Predicts Poor Response(Prognostic)
PTSD Predicts Poor Response(Prognostic)
9.811.4
14.9
12.5
0
2
4
6
8
10
12
14
16
Ter
min
atio
n H
amil
ton
Sco
re
ADM(N=104)
CT(N=47)
ADM(N=16)
CT(N=13)
Non PTSD Patients PTSD Patients
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GAD Predicts Differential Response (Prescriptive)
GAD Predicts Differential Response (Prescriptive)
11.4 11.2
7.5
15.7
0
2
4
6
8
10
12
14
16
Ter
min
atio
n H
amil
ton
Sco
re
ADM(N=105)
CT(N=54)
ADM(N=15)
CT (N=6)
Non GAD Patients GAD Patients
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CPT II
Acute Phase (16 weeks) Continuation Phase (12 months) Follow-up Phase (12 months)
CT
ADM
PLACEBO
Prior CT
(N=34)
ADM
(N=34)
PLACEBO
(N=34)
(N= 60)
(N= 120)
(N= 60)
3 booster sessions
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75%
60%
19%
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Sample Characteristics on Potential Predictors of Relapse
Demographics History/SubtypeAge: 40+12 Early Onset: 49%Female: 58% Dysthymic: 34%Minority: 13% Recurrent: 75%Married: 37% Melancholic: 34%Employed: 89% Atypical: 24%
Axis I Comorbidity (69%) Axis II Comorbidity (49%)PTSD:10% Cluster A: 1%GAD: 11% Cluster B: 1%Panic Dis. 12% Avoidant: 18%Eating Dis. 18% OCPD: 13%Subs. Use 31% PD NOS: 19%
Predicts risk for relapse
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16%
30%
39%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
ADM followed byPlacebo
ADM followed by ADM CT followed by 3additional sessions
Sustained Improvementfor All Assigned to Treatment
Sustained Improvementfor All Assigned to Treatment
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0
500
1000
1500
2000
2500
3000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Months in Treatment
Co
st
in D
olla
rs
CT
ADM
Cumulative Direct Costs of ADM and CT
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16% 15%
31%29%
47%
31%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
ADM followed byPlacebo
ADM followed by ADM CT followed by 3additional sessions
Penn Vandy
Sustained Improvement Rates by SiteSustained Improvement Rates by Site
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Treatment Response as a Function of Site and GenderTreatment Response as a Function of Site and Gender
64%
40%
60%
67%
76%71%
37%
57%
0
10
20
30
40
50
60
70
80
% R
es
po
ns
e
Vandy Penn Vandy Penn
CT ADM
male
female
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Response to CT as a Function of PTSD by SiteResponse to CT as a Function of PTSD by Site
60%
53%
63% 62%
33% 33%
0
10
20
30
40
50
60
70
% R
esp
on
se
Overall No PTSD PTSD
Penn (10%)
Vandy (29%)
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Therapist Competence as a Function of Experience in the Trial (Vandy)
Therapist Competence as a Function of Experience in the Trial (Vandy)
47 45
36
45
36
45
0
10
20
30
40
50
CT
Sco
re
Therapist 1 Therapist 2 Therapist 3
1st half
2nd half
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Response to Treatmentas a Function of Time in Trial
Response to Treatmentas a Function of Time in Trial
57%63%
47%
60% 57% 57%
0%
10%
20%
30%
40%
50%
60%
70%
% R
es
po
ns
e
Penn CT Vandy CT ADM
1st half
2nd half
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0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Week
Do
sag
e (m
g)
Vandy
Penn
Weekly Paxil Dosage By Site
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0
5
10
15
20
25
30
35
40
45
50
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Week
Do
sag
e (m
g)
Vandy (Aug)
Vandy (No Aug)
Penn (Aug)
Penn (No Aug)
Weekly Paroxetine Dosage by Site and Augmentation
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-10
-5
0
5
10
15
20
25
30
Least to Most Responsive Patients
HR
SD
Ch
ang
e
PlaceboADMCT
Response to Treatment as a Function of Ordinal Rank within Group (Vandy)
Response to Treatment as a Function of Ordinal Rank within Group (Vandy)
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-10
-5
0
5
10
15
20
25
30
Least to Most Responsive Patients
HR
SD
Ch
an
ge
PlaceboADMCT
Response to Treatment as a Function of Ordinal Rank within Group (Penn)
Response to Treatment as a Function of Ordinal Rank within Group (Penn)
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‘Normalcy’
Symptoms
Syndrome
Treatment phases
progression
to disorder
RelapseRelapseRelapseRelapse RecurrenceRecurrenceRecurrenceRecurrence
RemissionRemissionRemissionRemission RecoveryRecoveryRecoveryRecovery
Acute Continuation Maintenance
X
Incompleterecovery
Chronicity
Response, Remission, Recovery, Relapse, Recurrence & Chronicity
adapted from Kupfer & Frank 2001
ResponseResponseResponseResponse
Time
Sev
erit
y
RX
16 wks 12 mo 12 mo
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Prevention of Relapse Following Successful Treatment
0
0.2
0.4
0.6
0.8
1
0 1 2 3 4 5 6 7 8 9 10 11 12
Months (following active treatment)
% S
urv
ival Placebo (n=35)
Drug (n=34)
Compliant (n=30)
Prior CT (n=35)
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Prevention of Recurrence in Recovered Patients Following Successful Treatment
0
0.2
0.4
0.6
0.8
1
Months (following end of continuation)
% S
urv
ival
Drug (n=14)CT (n=20)
25% ITT25% ITT
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Prevention of Relapse and Recurrence Following Successful Treatment
0
0.2
0.4
0.6
0.8
1
Months (following active treatment)
% S
urv
ival
Placebo (n=35)
Drug (n=34)
Compliant (n=30)
Prior CT (n=35)
ContinuationContinuation FollowupFollowup
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ADM and CT
(N=225)
ADM(N=225)
ADM(N=90+)
No ADM(N=90+)
1st
R a n d o
m i z a t i o n
Acute Treatment(3-12 months)
Continuation (6-18 months)
Maintenance/Follow-up(36 months)
CPT III
No ADM(N=90+)
ADM(N=90+)
2nd
R a n d o m i z a t i o n
Remission Recovery
Response Relapse Recurrence
(twice weekly/weekly)
(monthly)
(weekly/biweekly) (monthly)
(monthly/quarterly)
(monthly/quarterly)
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Medication SequenceMedication Sequence
SNRI MAOITCA
SNRI or SSRI
Augment Augment Augment Augment
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Acute Remission Recovery Normal
Symptoms Elevated Normal Normal Normal
Mechanisms Elevated Elevated Normal Normal
Traits Elevated Elevated Elevated Normal
Acute Remission Recovery Normal
Symptoms Elevated Normal Normal Normal
Mechanisms Elevated Elevated Normal Normal
Traits Elevated Elevated Elevated Normal
Using Longitudinal Data to Disentangle Cause from Consequence
Using Longitudinal Data to Disentangle Cause from Consequence
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0%
10%
20%
30%
40%
50%
60%
Psychotherapy and Medications in the Treatment of Unipolar Depression
(AHCPR)
Dynamic
IPT
CT
BT
Medications
Placebos
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0%
10%
20%
30%
40%
50%
60%
70%
MAOIs TCAs SSRIs Heteros
Response to Different Medication Classes and Placebo Controls (AHCPR)
% Response
Comp Drug
Placebo
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0%
10%
20%
30%
40%
50%
60%
Jarrett (Atypical) DeRubeis (8weeks)
DeRubeis (16weeks)
CT in Placebo-controlled Trials
CBTDrugPlacebo
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0%
10%
20%
30%
40%
50%
60%
70%
80%
Kovacs Blackb Simons Evans Shea
Relapse Following Treatment Termination: CT versus Medications
CT
Drug
Comb
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Evans Hollon
Relapse following Successful Treatment: Prior CT versus Medications
CTDrugDrug-CComb
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Paykel Fava #1 Fava #2 Teasdale
Relapse/Recurrence Following CT for Residual Symptoms
CBTDrug
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0%
10%
20%
30%
40%
50%
60%
70%
80%
Blackbrn Murphy Hollon Keller
Response to Combined Treatment with CT and Medications in Adult Outpatients
CBTDrugComb
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Combined Treatment with CBASP and Nefazodone (Keller et al., 2000)
0
5
10
15
20
25
30
0 1 2 3 4 5 6 7 8 9 10 11 12
Weeks in Treatment
HR
SD
DrugCBASPComb
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0%
10%
20%
30%
40%
50%
60%
Post HRSD 6 or below
Less Severe More Severe
Pre HRSD 20 or above
Patients in Full Remission at Posttreatment in TDCRP (ITT)
CBTIPTTCAPlacebo
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0
2
4
6
8
10
12
14
16
Post HRSD
Treatment Condition (CT by Site)
Site Differences in the TDCRP (High Severity Completers N=42)
Placebo (n=13)
Drug (n=15)
CT (n=14)
CT by Site:
Site 1 (n=3)
Site 2 (n=6)
Site 3 (n=5)
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Post-treatment HRSD Scores forSeverely Depressed Patients (Intake HRSD > 20)
Post-treatment HRSD Scores forSeverely Depressed Patients (Intake HRSD > 20)
10.79.9
11.5
15.2
12.714.0
4.5
12.113.1
12.1
02468
1012141618
Elkin (N=53)
Rush (N=26)
Murphy (N=22)
Hollon (N=68)
Pooled (N=169)
Po
sttr
ea
tme
nt H
RS
D (
lea
st s
qu
are
s m
ea
n)
ADM CT
10.79.9
11.5
15.2
12.714.0
4.5
12.113.1
12.1
02468
1012141618
Elkin (N=53)
Rush (N=26)
Murphy (N=22)
Hollon (N=68)
Pooled (N=169)
Po
sttr
ea
tme
nt H
RS
D (
lea
st s
qu
are
s m
ea
n)
ADM CT
(From DeRubeis et al., 1999, Am J of Psychiatry)
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Attributional Styles as a Function of Treatment Condition (CPT II)
Attributional Styles as a Function of Treatment Condition (CPT II)
-1
-0.5
0
0.5
1
1.5
2
0 2 4 6 8 10 12 14 16
Weeks in Treatment
AS
Q P
os-
Neg
(ad
j)
Placebo
Drug
CBT
-1
-0.5
0
0.5
1
1.5
2
0 2 4 6 8 10 12 14 16
Weeks in Treatment
AS
Q P
os-
Neg
(ad
j)
Placebo
Drug
CBT** **
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ASQ and Relapse as a Function of Treatment Condition
ASQ and Relapse as a Function of Treatment Condition
ASQ and Relapse
-4
-2
0
2
4
6
8
10
0 2 4 6 8 10 12 14
Months Survived without Relapse Following Successful Treatment
AS
Q P
os-
Neg
(ad
j)
Drug
CBT
ASQ and Relapse
-4
-2
0
2
4
6
8
10
0 2 4 6 8 10 12 14
Months Survived without Relapse Following Successful Treatment
AS
Q P
os-
Neg
(ad
j)
Drug
CBT
R2=.18R2=.18
R2=.05R2=.05
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