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Motivation and Changes in Depression

Article  in  Cognitive Therapy and Research · April 2012

DOI: 10.1007/s10608-012-9458-3

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Cogn Ther Res
DOI 10.1007/s10608-012-9458-3
ORIGINAL ARTICLE
Motivation and Changes in Depression
David Burns • Henny Westra • Mickey Trockel •
Aaron Fisher
Ó Springer Science+Business Media, LLC 2012
Abstract This study evaluated the capacity of the Will-
ingness Scale (WS) to predict changes in depression over
the course of a brief inpatient admission. Two cohorts
(N = 160) of adult inpatients completed the Willingness
Scale along with a measure of depression following
admission. Depression severity was assessed approxi-
mately 4 days later, prior to discharge. Data were evaluated
using structural equation modeling. Higher WS scores
predicted greater reductions in depression in both cohorts,
and the magnitude of this effect was large. The fits of the
models were outstanding, with no significant differences in
any parameter estimates across the two cohorts. The WS
predicts changes in depression, even within a brief inpa-
tient admission where the treatment is predominantly bio-
logical. These results replicate results of previous studies in
outpatient populations where CBT was the primary treat-
ment and suggest motivational factors may play an
important role in causation and recovery from depression.
D. Burns  M. Trockel (&)
Department of Psychiatry and Behavior Sciences, Stanford
University, 401 Quarry Road, Stanford, CA 94305, USA
e-mail: trockel@stanford.edu
D. Burns
e-mail: david@feelinggood.com
H. Westra
Department of Psychology, York University, Toronto,
ON, Canada
e-mail: hwestra@yorku.ca
A. Fisher
Department of Psychology, The Pennsylvania State University,
University Park, PA, USA
e-mail: aaron@psu.edu
Keywords Motivation  Willingness  Depression 
Inpatients  Structural equation modeling
Introduction
Despite high levels of disability associated with mental
health problems such as depression (Judd et al. 2000), non-
adherence with recommended treatment procedures is a
formidable problem in multiple settings and populations. For
example, in their analysis of over 740,000 new prescriptions
for Selective Serotonin Reuptake Inhibitors (SSRIs), Eaddy
and Regan (as cited in Keene 2005) reported that nearly 50 %
of patients failed to adhere for a minimum of 60 days and a
mere 28 % were compliant at 6 months. In fact, poor
adherence with treatment regimens is the primary cause for
readmission and relapse in a number of psychological dis-
orders, including bipolar mood disorder (Svarstad et al.
2001) and schizophrenia (Weiden et al. 2004).
Psychotherapy homework (HW) assignments are fre-
quently recommended across various types of psychotherapy
(Kazantzis and Ronan 2006) and are widely hypothesized
to be essential to the efficacy of empirically supported
treatments such as Cognitive Behavioral Therapy (CBT;
Kazantzis et al. 2005). Nonetheless, HW non-adherence is a
commonly acknowledged problem limiting the efficacy of
treatment (for a review see Kazantzis et al. 2000). For
example, Helbig and Fehm (2004) surveyed practicing CBT
therapists regarding their clients’ HW adherence. Therapists
reported that 74.5 % of clients expressed doubts about their
ability to complete HW tasks and only 38.9 % of clients were
identified as totally compliant. Resistance in therapy is
consistently associated with poorer outcomes (for a review
see Beutler et al. 2001), whereas HW adherence in CBT
is associated with more positive outcomes (Burns and
123

Nolen-Hoeksema 1991; Burns and Spangler 2000; Kazantzis
et al. 2000). More broadly, the quality of the client’s engage-
ment with treatment is critical to treatment outcomes
(Orlinsky et al. 1994).
Resistance and non-adherence may be secondary to, or
reflective of, low motivation or ambivalence about change
(Burns 2005a; Engle and Arkowitz 2006). Most existing
measures of motivation reliably predict treatment dropout
(Brogan et al. 1999; Dozois et al. 2004; Keijsers et al.
2001; Soler et al. 2008) but not outcome. Some investi-
gators have reported significant relationships between
measures of motivation and outcome (e.g., de Haan et al.
1997; Keijsers et al. 1994a, b) but others have not (e.g.,
Dozois et al. 2004; Kampman et al. 2008; Vogel et al.
2006). Consequently, despite the widespread recognition of
the importance of motivation and resistance in common
disorders such as anxiety and depression, adequate self-
report measures of motivation are lacking.
Most studies of motivation have been conducted with
anxiety disorders, with surprisingly few investigators
examining motivation as a predictor of dropout or outcome
in depression. Zuroff et al. (2007) reported that high scores
on a measure of autonomous motivation were associated
with increased rates of improvement in three different
types of psychotherapy for depression. In three studies of
depressed outpatients receiving CBT, willingness to try
various coping activities predicted subsequent changes in
depression (Burns and Nolen-Hoeksema 1991; Burns and
Spangler 2000; Neimeyer et al. 2008). In addition, patients’
subsequent adherence with HW assignments mediated the
effects of willingness on clinical improvement (Burns and
Nolen-Hoeksema 1991; Burns and Spangler 2000). Such
findings are also consistent other models of adherence and
illness coping behavior such as Leventhal et al.’s self-
regulatory model (1992), which has been applied to
depression (Brown et al. 2007) and specifies a key role for
perceived controllability in initiating coping behaviors.
The Self-Help Inventory (SHI) used in the Burns (Burns
and Nolen-Hoeksema 1991; Burns and Spangler 2000) and
the Neimeyer et al. (2008) studies required patients to rate
45 coping strategies in three dimensions: 1. How often do
you use this coping strategy when you’re feeling depres-
sed? 2. How helpful do you think this coping strategy
would be? 3. How willing would be to use this coping
strategy if suggested by a therapist or trusted friend? Thus,
the SHI included a behavioral scale, a cognitive scale, and
a motivational scale. In a cross sectional pilot study of
depressed women, all three subscales were correlated with
initial depression severity (Burns et al. 1987). Women who
were more severely depressed engaged in fewer coping
strategies, were less optimistic that coping strategies would
be helpful, and were less willing to try coping strategies
when depressed. However, in three subsequent longitudinal
123
Cogn Ther Res
studies, only the motivational scale predicted subsequent
changes in depression (Burns and Nolen-Hoeksema 1991;
Burns and Spangler 2000; Neimeyer et al. 2008). Although
these results were promising and robust across three stud-
ies, the length of the SHI reduced its usefulness in clinical
settings, since 135 ratings of coping strategies are required.
The goal of the present study was to examine the
capacity of the brief Willingness Scale (WS) to predict
changes in depression in psychiatric inpatients over short
time periods. Existing research has focused on outpatients
during the first 12 weeks of treatment. In addition, we
wished to examine the value of the scale in a naturalistic
treatment setting, where patients are struggling with a wide
variety of disorders, since the findings might be more likely
to generalize to other clinical settings. Based on previous
studies with the SHI, we expected that patients’ willingness
to engage in recommended coping strategies would predict
subsequent changes in depression.
Methods
Patients
The study included two cohorts of admitted patients to the
psychiatric unit of Stanford University Hospital. The first
cohort consisted of 69 patients who were recruited between
2004 and 2006. The second cohort consisted of 91 patients
who were recruited between 2006 and 2008. The study was
approved for ethical conduct in research by both Stanford
University and the Pacific Graduate School of Psychology.
Patients who were incapable of giving informed consent,
younger than 18 years of age, illiterate, unable to speak
English, intoxicated, or delirious were excluded from the
study. In addition, the inpatient team considered individu-
als who were currently in seclusion or restraints, those with
significant dementia, and those who were too symptomatic
to complete questionnaires to be inappropriate to include in
the study.
Measures
Motivation
Motivation was assessed with the Willingness Scale (WS),
which was adapted from the willingness subscale of the
SHI (Burns et al. 1987). The internal reliability of the
original subscale was 0.95 (Burns and Nolen-Hoeksema
1991; Burns and Spangler 2000), and previous research
with depressed outpatients supported its construct and
predictive validity (Burns et al. 1987; Burns and Nolen-
Hoeksema 1991; Burns and Spangler 2000; Neimeyer et al.
2008). For this analysis, the author of the original WS
Cogn Ther Res
selected eight items from the WS that were relevant to
behavioral and interpersonal coping strategies. The abbre-
viated WS asks respondents whether they’d be willing to
try each of eight coping activities such as, ‘‘Try new ways
of relating to other people,’’ ‘‘Get started on a task I’ve
been putting off,’’ and ‘‘(F2) Face a problem I’ve been
avoiding.’’ The expanded response options range from
‘‘Definitely not’’ (0) to ‘‘Extremely willing’’ (4).
Depression
Symptoms of self-reported depression were assessed with
the Burns Depression Checklist (BDC; Burns 1997, 2006).
The BDC was selected because it is has excellent internal
consistency and is brief and user-friendly, and focuses on the
specific symptoms of depression, rather than the more non-
specific symptoms such as insomnia or changes in appetite.
The BDC asks participants to rate the intensity of five car-
dinal symptoms of depression: (1) sad or down in the dumps,
(2) discouraged or hopeless, (3) low self-esteem, worth-
lessness, or inferiority, (4) a loss of motivation, and (5) a loss
of pleasure or satisfaction in life. Response options for each
item range from ‘‘Not at all true’’ (0) to ‘‘Completely true’’
(4). The BDC correlates highly with other commonly used
depression self-report scales including the Beck Depression
Inventory (r = 0.85 to r = 0.92), the Zung depression test
(r = 0.87) and the SCL-90 Depression Scale (r = 0.89)
(Hargrave and Sells 1997; Sekirnjak and Beal 1999; Marr
2000). BDC scores are significantly correlated with mea-
sures of dysfunctional attitudes and hopelessness and are
sensitive indicators of change in depression during treatment
with CBT (Westra et al. 2002).
For this study, the motivation item was eliminated from
the BDC to prevent any possible item overlap with the
WS.1 The internal consistency (reliability) of the 4-item
BDC scale was estimated in Structural equation modeling
(SEM) using confirmatory factor analysis. The values were
0.96 at both time points in cohort 1 and 0.94 at both times
in cohort 2. Total scores on the BDC were normalized to
range from 0 to 100 % to facilitate interpretation.2
Diagnoses
The EASY Diagnostic Survey (Burns 2005b; Burnett 2008)
consists of self-assessment tests for numerous Axis I and
Axis II disorders. Burnett (2008) has reported that the
EASY subscales for depression and mania demonstrate
1
All the analyses reported in this paper were repeated using the full
BDC, and the results were virtually identical to those reported here.
2
In addition, this scoring system facilitates a rough comparison with
other comparable tests. For example, the 21-item beck depression
inventory (BDI) ranges from 0 to 63. A score of 70 % on the BDC
would correspond approximately to a score of 43 on the BDI.
strong internal reliability, convergent validity, sensitivity
and specificity, with a kappa value of 0.91 for the Mood
Disorder diagnostic variable when compared with the
diagnoses based on the SCID.
Procedures
All patients referred to the study by the inpatient treat-
ment team were contacted by a student researcher who
explained the purpose of the study and obtained consent.
In the first cohort, diagnoses were determined using the
EASY Diagnostic Survey (Burns 2005b; Burnett 2008)
followed by a systematic diagnostic interview. A subset
of 29 patients in that cohort also received a structured
clinical interview for Axis I and II DSM-IV disorders
(SCID-I and SCID-II; First et al. 1997, 2002) in order to
validate the EASY diagnoses. The SCID and EASY
interviews were conducted independently by different
student researchers who were unaware of the diagnoses
assigned by the other interviewer.
In the second cohort, patients completed a revised and
condensed version of the EASY Diagnostic Survey (Burns
2007). Research students reviewed the results of the
survey and briefly interviewed each patient to ensure that
the data were complete and reported accurately. Diagno-
ses were assigned according to the responses on the
EASY Diagnostic Survey and were summarized for the
inpatient treatment team who were encouraged to finalize
the diagnoses based on their clinical knowledge of each
patient as well as the DSM-IV diagnostic criteria.
Patients in both cohorts completed the EASY Diag-
nostic Survey along with the BDC and WS shortly after
admission. Patients were encouraged to complete the
BDC again prior to discharge. Fifty-one percent of the
patients in both cohorts completed the brief follow-up
surveys. In most cases, failure to complete the follow-up
surveys was not due to a lack of cooperation but rather
the abrupt nature of discharge from the inpatient unit and
the fact that student researchers were only available on
the unit to administer the surveys several times per week.
The times from initial to follow-up assessments in the
first and second cohorts were 3.88 days (SE = 0.52) and
4.45 days (SE = 0.49), respectively.
Treatment
The psychiatric inpatient unit at the Stanford Hospital
includes a voluntary and an involuntary unit. In both
cohorts, 20 % of the patients were hospitalized involun-
tarily. Length of stay is brief with the major focus on
biological interventions, such as medications. In addition,
123

6.2 % of patients in the first cohort, and 7.8 % in the
second cohort, were receiving electroconvulsive therapy.
All patients were also encouraged to participate in daily
cognitive therapy groups as well as occupational therapy
and other activities.3
Approach to Data Analyses
SEM with the Analysis of Moment Structures (AMOS;
Arbuckle 1994), Version 19.0, was used because of its
ability to compare competing models using nested tests,
incorporate confirmatory factor structures, compare
parameter estimates across groups, and estimate missing
data models using Full-Information Maximum Likelihood
(direct FIML; Arbuckle 1996; Burns and Spangler 2001;
Wothke 2000).4 Only the v2 statistic was used to evaluate
model fit, as suggested by Barrett (2007). Changes in v2
values relative to changes in degrees of freedom (v2 dif-
ference tests) were used to compare nested models.5 The
significance of model parameters was determined by
examining the critical ratios (cr). LISREL 8.80 (Jöreskog
and Sörbom 2006) was used for confirmatory factors
analysis, to allow for analyses involving polychoric
correlations.
Because causal models are not yet very highly refined in
the behavioral sciences, some investigators have recom-
mended sensitivity testing in model evaluation (Burns and
Spangler 2000; Leamer 1985). Sensitivity testing involves
introducing theoretically relevant variables into a model to
assess changes in parameter estimates. The rationale is to
determine whether the inclusion or exclusion of these other
variables will influence the parameter estimates.
That’s because willingness could be a proxy for some
other variable with strong causal effects on recovery from
depression. To test this, a wide variety of demographic and
diagnostic variables were included in the final model to
3
We do not have any empirical data on the extent of participation in
the CBT groups.
4 model with a confirmatory factor analysis, stipulating two
This method provides efficient and consistent estimates for missing
data, even when the data are not missing completely at random. Three
alternative methods of estimating models with missing data include
mean substitution, listwise deletion, and pairwise deletion. These
methods provide efficient and consistent estimates only under the
stronger assumption that the data are missing completely at random.
5 each factor. This resulted in a significantly improved fit, v2
A nested test is a powerful and flexible method for comparing any
group of parameter estimates within groups or across groups. For
example, an investigator might wish to compare factor structures in
two independent samples by declaring the parameter estimates to be
identical. A statistically significant increase in the Chi-square for the
nested model indicates that the hypothesis can be rejected, and that
the factor structures are not the same. In contrast, a negligible increase
in the Chi-square indicates the hypothesis can be accepted.
123
Cogn Ther Res
evaluate the stability of SEM estimates of the relationship
between willingness and changes in depression.
Results
Demographic and Diagnostic Profiles
As shown in Table 1, the mean age of the patients in both
cohorts was around 40. Approximately 70 % were female
and 41 % were married. Most patients were of modest
income with some post-secondary education. There were
no statistically significant differences between the two
cohorts on any demographic variables. Ethnic composi-
tions in the first and second cohorts were: Caucasian: 68.9
and 77.8 %; African-American: 9.8 and 3.3 %; Hispanic:
8.2 and 4.4 %; Asian: 9.7 and 7.8 %; and other ethnicities:
8.1 and 6.6 %. Table 1 also indicates that there was sub-
stantial diagnostic co-morbidity in both samples. The
majority of the patients had mood and/or anxiety disorders
and the diagnostic profiles in the two cohorts were similar.
The diagnostic profiles of the two cohorts can be seen in
Table 2. There were no significant differences in the means
(point prevalence rates) of the EASY versus SCID diag-
noses in cohort 1, where both instruments were adminis-
tered. The kappa values for most of the SCID versus EASY
diagnoses indicated adequate therapeutic convergence
(Landis and Koch 1977). However, kappa values for GAD
and Drug Abuse or Dependence were low, due to the
higher values when diagnosed with the EASY system.
Cronbach’s coefficient alpha for the EASY screening tests
varied from a low of 0.89 and 0.87 for Bulimia Nervosa in
cohorts 1 and 2, respectively, to a high of 0.98 and 0.97 for
panic disorder in the two cohorts, indicating good internal
consistencies.
Mood and Motivation Variables
Since four of the WS items reflected interpersonal coping
strategies and four reflected behavioral coping strategies,
we hypothesized a two-factor structure. We tested this
correlated factors and no correlations among the error
terms for the observed variables. The model fit was not
satisfactory, v2 (19, N = 160) = 54.03, p \ .001. There-
fore, we removed one item with the lowest loading from
(8, N = 160) = 15.87, p = .04. However, the modification
indices suggested that one behavioral item (‘‘Get started on
a task I have been avoiding or putting off’’) shared a sig-
nificant cross-loading with the interpersonal factor. This
modification resulted in an excellent fit v2 (7, N = 160) =
6.86, p = .44.
Cogn Ther Res

Table 1 Patient characteristics in the two cohorts

Cohort 1 (N = 69) Cohort 2 (N = 91)
Mean SE Mean SE

Age (years) 42.49 1.97 39.84 1.68

Female (%) 69 6 71 5
Married or cohabitating (%) 41 6 41 5
Involuntary admission (%) 20 5 20 4
Education 3.75 0.16 3.79 0.14
Family’s annual income 4.68 0.50 5.01 0.41
Admission BDC 0.65 0.04 0.73 0.03
Discharge BDC 0.36 0.05 0.43 0.03
Willing Scale 1 0.73 0.03 0.73 0.02
Willing Scale 2 0.71 0.03 0.74 0.02
There were no statistically significant differences in any of the means of the demographic variables in the two cohorts
Education was assessed with the following categories: 0 = no formal education; 1 = grammar school; 2 = high school; 3 = some college or
technical training; 4 = college degree; 5 = some graduate school; and 6 = graduate degree
Income was assessed with the following categories: 0 = \$10,000; 1 = 10,001–20,000; 2 = 10,001–20,000; 3 = 20,001–30,000;
4 = 30,001–40,000; 5 = 40,001–50,000; 6 = 60,001–70,000; 6 = 70,001–80,000; 7 = 80,001–100,000; 7 = 100,001–150,000;
7 = 150,001–200,000; and 8 = [200,000
* p \ .001

Table 2 Diagnostic profiles in

Cohort 1 Cohort 2
the two cohorts
EASY SCID Kappa EASY
% (SE) % (SE) % (SE)

Mood disorders
Unipolar mood disordera 52 (6) 53 (8) .70 81 (4)***
b
Bipolar mood disorder 32 (6) 40 (8) .70 11 (3)**
Anxiety disorders
Generalized anxiety disorder 41 (6) 22 (8) .43 75 (5)***
Panic disorder w or w/o agoraphobia 30 (6) 43 (8) .69 39 (5)
Agoraphobia w or w/o panic disorder 24 (5) 26 (7) .73 26 (5)
There were no significant Simple phobia 29 (6) 14 (6) .54 34 (5)
differences in the means of the Social phobia 41 (6) 29 (8) .70 46 (5)
EASY versus SCID diagnoses Obsessive-compulsive disorder 22 (5) 15 (6) .62 30 (5)
in cohort 1. The EASY means in
cohort 2 were compared with Substance abuse
the EASY means in cohort 1 Alcohol abuse or dependence 29 (6) 29 (7) .57 18 (4)
a Drug abuse or dependence 38 (6) 26 (7) .47 24 (5)
Major depressive disorder or
dysthymic disorder Eating disorders
b
Bipolar I or II disorder Anorexia nervosa 9 (4) 14 (7) 1.00 9 (3)
c
No patients were diagnosed Bulimia nervosa 8 (3) 5 (4) .64 10 (3)
with schizophrenia using the
Binge eating disorder 12 (4) 5 (7) .61 16 (4)
SCID, so the inpatient treatment
team’s schizophrenia diagnoses Psychotic disorders
were used for comparison with Schizophrenia 8 (3) 4 (2)c .73 6 (2)
the EASY Personality disorders
* p \ .05; ** p \ .01; Borderline personality disorder 18 (5) 11 (5) – 35 (5)*
*** p \ .001

Given that the response options for these items consisted nature. Therefore, we re-ran the model using a polychoric
of five-point Likert scales, it could be argued that the covariance matrix, which assumes bivariate normal distri-
response data are ordinal—as opposed to continuous—in butions for each pair of observed variables. This model also

123

Table 3 Correlations among the depression and motivation scales in the two cohorts
Cohort 1
Initial Final Willing
BDC BDC Scale 1
Initial BDC 1.00
Final BDC .55*** 1.00
Willing Scale 1 -.15 -.40** 1.00
Willing Scale 2 -.15 -.46*** .57***
* p \ .05; ** p \ .01; *** p \ .001
provided an adequate fit to the data, v2 (7, N = 160) =
11.29, p = .13.
Based on this analysis, two Willingness Scales, called
Willing Scale 1 and Willing Scale 2, were created, with
total scores normalized to range from 0 to 100 %. There
were no statistically significant differences in the means or
variances of the two motivation scales at the initial eval-
uation in the two cohorts, v2 (4, N = 160) = 3.03,
p = .55. In addition, there were no significant differences
in the means or variances of the 4-item BDC at the initial
evaluation or at discharge in the two cohorts, v2 (4,
N = 160) = 4.05, p = .40. However, the mean depression
score at discharge (40.7, SE = 2.7, p \ .0001) in both
cohorts was significantly lower than the mean depression
score at the initial evaluation (70.0, SE = 2.4, p \ .0001),
v2 (1, N = 160) = 76.62, p \ .0001, with an average
reduction of depression severity of 42 %. The correlations
among the depression and motivation scales in the two
groups did not differ as a function of cohort v2 (6,
N = 160) = 8.11, p = .23 (see Table 3).
Measurement Model
In a measurement model, the relationships among the
variables of theoretical interest are represented by corre-
lations. If the measurement model is successful, a variety
of causal models can be evaluated in order to test the
hypotheses about the variables of interest. The measure-
ment model in Fig. 1 was estimated in both cohorts
simultaneously. Circles represent unobserved variables
(factors and error terms) and rectangles represent observed
variables (scale scores). One-headed arrows represent
causal effects, and two-headed arrows represent
correlations.
The two willingness scales load on the Willing Factor,
and e1–e4 are the error terms for the observed measures.
The Willing Factor was identified by setting one regression
coefficient to 1.0. The Initial and Final Depression Factors
were identified by specifying their error variances so that
their R-square values would be identical to their estimated
reliabilities (0.96 and 0.94 in cohorts 1 and 2, respectively).
123
Cogn Ther Res
Cohort 2
Willing Initial Final Willing Willing
Scale 2 BDC BDC Scale 1 Scale 2
1.00
.61*** 1.00
.06 -.22 1.00
1.00 -.09 -.27* .72*** 1.00
The unstandardized factor loadings for the error terms were
also set to 1.0 in both groups.
The fit of the measurement model was excellent in both
cohorts, v2 (4, N = 160) = 4.56, p = .47.6 In a nested test,
the four intercepts were set to be the same in the two
groups, along with the three factor variances and covari-
ances. In addition, the error variances for the two indicators
for the Willing Factor were set to be the same within each
group to determine whether this factor had a parallel
structure in each group.7 The increase in Chi-square was
not significant, v2 (12 N = 160) = 8.53, p = .74, indi-
cating that these additional restrictions were acceptable.
The fit of the final measurement model was excellent, v2
(16, N = 160) = 12.30, p = .72.
These results indicated that the Willing Factor was
parallel in both groups. The Willing Factor was not sig-
nificantly correlated with depression at admission in either
group but was negatively correlated with depression at
discharge in both groups, r(160) = -0.44, p \ .0001. This
meant that patients with higher WS scores at the initial
evaluation had significantly lower depression scores at the
second evaluation. In addition, the initial and final BDC
scores were positively correlated, as expected and
r(160) = 0.65, p \ .0001, indicating that patients with
higher initial depression scores were more likely to have
higher final depression scores.
The R-square values for Willing Scales were 0.59 in
cohort 1 and 0.70 in cohort 2. The Willing Factor repre-
sents the variance shared by two Willingness Scales in each
group, and the two error terms represent errors of mea-
surement as well as systematic variance that is not shared
by the other Willing Scale. The outstanding model fit
indicated that only the variance by the two Willing Scales
6
These values represent the sum of the Chi-squares values and
degrees of freedom in both groups, which were estimated
simultaneously.
7
A tau-equivalent factor has identical unstandardized factor load-
ings. A parallel factor also has identical error terms for all the
indicators. In a super parallel factor, all the indicators also have
identical intercept terms.
Cogn Ther Res

Fig. 1 In this measurement

model, observed variables (e.g.
scale scores) are rectangles, and
unobserved variables are ovals
or circles. Two-headed arrows
represent correlations and one-
headed arrows represent causal
effects, and e1–e4 are error
terms. Standardized output
values are shown. The values
above the four observed
variables are R-square values.
The parameter estimates in the
second cohort were similar. The
correlation between the willing
and initial depression factors
was not significant in either
group. All other values were
significant at p \ .0001 in both
groups

(e.g. the Willing Factor) was correlated with Final
Depression Factor in each group.
Causal Model
In order to learn more about the causal structure that might
account for the relationships among the Willing Factor and
the two depression scales, the structural equation model in
Fig. 2 was estimated. In this model, the correlations linking
the Willing Factor with the initial and final depression
factors were replaced with two causal arrows in both
cohorts. In addition, the correlation between the Willing
Factor and the initial depression factor was set to zero in
both cohorts. This model allowed estimation of the effect
of the Willing Factor on changes in depression, by con-
trolling for the effect of initial depression on final

Fig. 2 In this causal model, the

correlation between the
willingness and initial
depression factor has been set to
zero in both groups. The values
above each observed variable
are the means of the scales. The
means of the unobserved
variables have been set to 0.
Path (regression) coefficients
are unstandardized estimates.
The value above the final dep
factor is the R-square. The
parameter estimates in the
second cohort were similar. All
parameter estimates were
significant at p \ .0001 in both
groups

123

depression. Finally, all the parameter values were set to be
identical in the two groups.
The fit of this model was very good, v2 (17,
N = 160) = 13.98, p = .67. Together, the Willing Factor
and initial depression factor accounted for 55 % of the
variance in the final depression factor in both cohorts,
indicating good predictive validity.
As expected, patients who were more depressed initially
were more likely to be depressed at discharge, b
(N = 160) = 0.58 (SE = 0.08), p \ .0001. The effect of the
Willing Factor on changes in depression was also large b
(N = 160) = -0.55, SE = 0.15, p \ .0001. The negative
value of the regression coefficient meant that patients with
higher scores on the Willing Factor improved substantially
more than individuals with lower scores. Surprisingly, the size
of the effect of the Willing Factor on changes in depression
was similar to the size of the effect of initial depression on the
final depression when controlling for willingness.
To confirm these results, the effect of the Willing Factor
on changes in Depression was set to zero in both groups.
The large increase in the Chi-square value indicated that
this model could be rejected, v2 (1, N = 160) = 14.80,
p = .0001. Then the effect of Initial Depression on Final
Depression was set to zero. The large increase in the Chi-
square value indicated that this model could also be
rejected, v2 (1, N = 160) = 39.62, p \ .0001.
These findings indicated that the Willing Factor and the
Initial Depression Factors made strong additive and inde-
pendent contributions to the prediction of the final depres-
sion scale. To illustrate the magnitude of the effect of the
Willing Factor on changes in depression, consider two
individuals who are admitted to the inpatient unit with scores
of 70 on the depression scale, which was the mean for the
patients in both cohorts. This score indicates moderate to
severe depression. However, their scores on the Willing
Factor differ by 50 (90 and 40, respectively). This means that
one patient is willing to try a variety of coping activities, but
the second patient is reluctant. Their predicted discharge
BDC scores can be calculated by this equation:
Final BDC ¼ 41  ð0:55ÞðWilling Scale ScoreÞ
þ ð0:58ÞðAdmission BDCÞ
The patient with the high initial willingness score will be
only minimally depressed at the second evaluation, with a
predicted depression score of 30, while the patient with the
low willingness score will have a predicted depression
score of 57, indicating very little improvement.
For the sensitivity analyses, a wide variety of demo-
graphic and diagnostic variables were introduced into the
model as correlates of willingness and depression variables
at the initial evaluation. In all of these tests, the parameter
estimates for the effects of the Willing Factor on changes in
123
Cogn Ther Res
depression were very similar to or even larger than the
results reported above.
Missing Data Testing
SEM can produce consistent parameter estimates even
when missing data are not missing completely at random.
For example, if the patients with missing data were sig-
nificantly more or less depressed or motivated at intake, the
estimates for the means and variances of the final BDC in
both cohorts, as well as the causal effects of the Willing
Factor on changes in depression, would still be unbiased. In
fact, the means and variances of the depression scale and
the two willing scales at the initial evaluation were not
significantly different in the patients with and without
follow-up data in either cohort, and there were no signifi-
cant differences in demographic variables such as age,
gender, marital status, income, education or voluntary
versus involuntary status in patients with and without fol-
low-up data in either cohort. Nevertheless, the causal
model in Fig. 2 was estimated using only patients with data
at both time points. The fit of the model was superb (v2 (17,
N = 81) = 11.25, p = .85) and all of the parameter esti-
mates were similar to those reported above using the
complete data set. The result of this analysis is consistent
with missing data that are missing completely at random.
Subgroup Analysis
We included the entire sample in this analysis because we
wanted the greatest possible range on the Willingness and
Depression scales so as to avoid range restriction problems.
Furthermore, our theory suggests that the relative presence or
absence of willingness predicts changes in depression
symptoms in all patients, whether or not they have a diag-
nosable mood disorder. However, we also did a subgroup
analysis with only those patients with a with a Mood Dis-
order diagnosis such as Major Depressive Disorder, Dys-
thymic Disorder, Bipolar Disorder in the depressed phase,
and so forth. The model fit [v2 (17, N = 117) = 18.00,
p = .39] was excellent and the parameter estimates were
similar to the values for the full sample. For example, the
unstandardized parameter estimate for the effect of the
Willing Factor on subsequent changes in depression was b
(N = 117) = -0.67, SE = 0.21, p = .001, in both groups.
Discussion
The current study indicated that the revised WS had
excellent predictive validity and suggests that patients’
willingness to engage in specific coping strategies may
have strong effects on changes in depression, even over a
Cogn Ther Res
brief course of inpatient treatment. High scores on the WS
predicted greater improvement in depression, as predicted.
The measurement and causal models produced excellent
fits to the data in both cohorts, with no significant differ-
ences in the parameter estimates in either cohort, sug-
gesting that the findings were robust. Since there are very
few variables in the world literature which have consis-
tently predicted changes in depression in inpatient and
outpatient settings, these findings could have significant
implications for our understanding and treatment of this
disorder.
The WS was designed to capture a type of resistance
that Burns (2005a) has called Process Resistance. This
means that the patient may desire to recover but is reluctant
to engage in the process that will be required for successful
treatment. Process Resistance appears to be common
among depressed individuals. For example, most CBT
therapists regard psychotherapy HW as an essential part of
the treatment of depression, and research suggests that
completion of psychotherapy HW assignments greatly
facilitates recovery (Burns and Nolen-Hoeksema 1991;
Burns and Spangler 2000). In spite of this, depressed
patients are often reluctant to complete HW assignments
(Helbig and Fehm 2004; Kazantzis et al. 2000). As noted
previously, studies with outpatients have indicated that the
effects of the WS on changes in depression are, in fact,
mediated by HW adherence (Burns and Nolen-Hoeksema
1991; Burns and Spangler 2000).
However, it is unclear why willingness would be asso-
ciated with rapid changes in depressive symptoms over the
course of a brief inpatient admission, given the biological
orientation of the inpatient unit, and the sensitivity testing
did not provide any hints that would help to answer this
question. It is possible that depressed patients with high
scores on the WS were more likely to attend the daily CBT
groups, which were voluntary, and that the CBT triggered
the improvement. Since the data on group participation was
not available to the investigators, this would be an
important area for future research. However, it is also
possible that the WS captures something that is crucial and
basic to recovery, regardless of the setting or treatment
methods. One additional implication of the current findings
is that the rather dramatic and rapid improvement in
depressed patients with high WS scores was probably not
the result of the biological treatments the patients received,
which presumably require several weeks to become
effective, but rather powerful and unrecognized psycho-
social factors which may be captured, in part, by the WS. It
was of interest in this regard that the ECT that 8 % of the
patients received was not associated with more rapid
improvement.
In the current study, willingness was represented by a
single factor. The excellent fit of the model indicated that
there was nothing unique about either willingness sub-scale
(i.e., willingness to address relationship vs. personal
problems) that predicted changes in depression—rather,
what was important was the shared variance. Indeed, both
willingness scales predicted change in depression equally
well when they were included separately in the model in
place of the Willing Factor. This means that the specific
types of coping strategies on the WS may not be important
for symptom change. Instead, it may be that the willingness
to engage in any potentially meaningful coping strategy
triggers improvement.
Future studies should investigate how willingness
influences outcome. While much of the improvement in
depression could have resulted from a number of non-
specific factors such as regression to the mean or respite
from stressful circumstances, the scores on the WS still
differentiated those who improved the most from those
who remained the most symptomatic. Higher willingness
appears to be associated with higher HW adherence in
outpatient settings (Burns and Spangler 2000) and may be
associated with a more collaborative therapeutic alliance.
Simply committing oneself to change may trigger some
degree of clinical improvement, perhaps through promot-
ing positive expectations or hope for change (Frank and
Frank 1991).
In addition, further research may elucidate variables that
are associated with increased willingness which may be
important in understanding how to help patients increase
their willingness to take active steps toward recovery from
depression. It is possible that other variables not included
in this study, such as perceived controllability (Leventhal
et al. 1992) or self-efficacy (Bandura 1997), may be
associated with willingness. Also, given that sudden gains
in the treatment of depression are often preceded by sub-
stantial cognitive changes and are associated with superior
recovery (Tang et al. 2005), studying such changes in the
context of motivational variables would be of interest.
Given its brevity and capacity to predict symptom
change in depression, the revised WS could be used early
in treatment to assess client motivation and identify indi-
viduals who may benefit from motivational interventions at
the onset of treatment. In addition, the development of
clinical methods to boost willingness during the initial
phases of treatment for depression could be extremely
useful, as described by Burns (2005a). In addition, while
Motivational Interviewing (MI: Miller and Rollnick 2002)
has not yet been examined in the treatment of depression, it
has garnered empirical support in the treatment of sub-
stance abuse and health behavior change (for a review see
Hettema et al. 2005). MI is also being investigated in a
wide range of mental health problems beyond addictions
(Arkowitz et al. 2008), including anxiety (Westra et al.
2009; Westra and Dozois 2006).
123

The current study had several important strengths and
limitations. In terms of strengths, all available newly-
admitted psychiatric inpatients were studied, not only those
with a mood disorder diagnosis. Depression was also
measured as a dimensional construct, using a reliable self-
assessment instrument, rather than as a categorical con-
struct. The inclusion of continuous measures of depression
is important because it resembles how these constructs are
assessed in clinical settings. Moreover, the diversity of
patients and the high level of comorbidity of the sample, as
well as the naturalistic setting, suggest that these findings
will probably generalize to real world populations,
including severely distressed patients.
Nevertheless, patients who were incapable of giving
informed consent, younger than 18, illiterate, unable to
speak English, intoxicated, delirious, or whom the inpatient
team deemed inappropriate for participation in the studies
were excluded from this study. Additional research would
be needed to test the assumption that willingness predicts
change in depression among in these and other subgroups
not represented in the present or study. In addition,
although we found no evidence of systematically missing
data at either time point, it is possible that those who did
not complete the final assessment were different from those
who did.
The information available from the current study is also
limited to the very short inpatient time frame. Although we
observe a trend in decreasing depression predicted by
baseline willingness scores on average 4 days earlier, the
present data do not provide any information on long term
change in depression severity. However, numerous previ-
ous outpatient studies over 12 week periods of time have
produced nearly identical results. Further long term
research on the effects of willingness on changes in
depression over time would be useful.
It is encouraging that all of the findings were cross-
validated across two independent inpatient cohorts, and
that the fits of the models were outstanding in both groups.
However, even when a model is consistent with the data, or
when a causal pathway is statistically significant, this does
not mean that the model is valid or that the causal pathway
has been confirmed. Perhaps the most conservative con-
clusion of the current study would be that higher scores on
the WS predict substantially reduced depression severity in
inpatients over short time periods, whereas lower scores
will be associated with considerably more severe depres-
sive symptoms.
Although the naturalistic design of the current study is a
strength, experimental studies will be required to test the
causal role of willingness in recovery from depression, to
delineate the mechanisms through which willingness
facilitates clinical improvement, and to evaluate the utility
of motivation enhancement techniques in treatment.
123
Cogn Ther Res
Sample size is another potential limitation. While it would
be desirable to replicate these findings with a larger sam-
ple, it is encouraging that that identical results were
observed in two independent samples and that the findings
have been replicated in five inpatient and outpatient sam-
ples with a combined N of greater than 650 patients (Burns
et al. 1987; Burns and Nolen-Hoeksema 1991; Burns and
Spangler 2000; Neimeyer et al. 2008.) In one previous
study of the effects of a brief mailed intervention on 177
mildly depressed college students, a modified Willingness
Scale was not correlated with subsequent changes in
depression (Geisner et al. 2006). However, these students
were not seeking clinical care and the changes in depres-
sion appeared to be extremely small, so it is difficult to
interpret the results of that study.
Taken together, these results suggest that the WS pre-
dicts response to treatment in inpatient and outpatient
settings. Since the revised, 6-item WS scale can easily be
completed and scored in less than 1 min, it may prove
useful in identifying patients who may benefit from specific
methods to reduce resistance and enhance motivation prior
to engaging with more action-oriented methods such as
CBT. Further studies will be needed to determine whether
this new treatment strategy will substantially enhance the
speed of recovery from clinical depression.
Acknowledgments This authors wish to thank the following indi-
viduals who provided help or collaboration in the EASY Diagnostic
Research Study: Britney Blair, Debra Burnett, Psy.D., Kim Chu,
Jennifer Coughlin, Katherine Claypool, Leigh Harrington, M.D.,
Chris Hayward, M.D., Neda Kharrazi, Anthony Mascola, M.D.,
Wendy O’Connor, Psy.D., Jonah Paquette, Psy.D., Lindsay Paquette,
Psy.D, and Debra Safer, M.D.
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