The use of daily diaries to assess the relations among mood state, overt behavior, and reward value of activities

Abstract

Recent data has sparked renewed interest in behavioral treatments for depression; however several fundamental questions remain regarding the mechanisms of such approaches. To this end, the current study directly tested the assumption that non-clinical mildly depressed individuals receive less response-contingent positive reinforcement than non-depressed individuals, indicated by less engagement in behaviors perceived as rewarding in terms of both immediate pleasure and potential for these behaviors to result in more distal rewards. The data presented support this assumption and provide support for the role of reinforcement-based strategies such as behavioral activation in the treatment of depression.

Introduction

The fundamental behavioral model of depression implicates decreases in response-contingent positive reinforcement for non-depressive behavior as the causal factor in eliciting depressive affect (Ferster, 1973, Lewinsohn, 1974, Skinner, 1953). Low rates of positive reinforcement may be a function of the quantitative (i.e., number or intensity) or qualitative (e.g., type: social, intellectual; function: stimulation seeking, achievement) aspects of the reinforcing events, availability of reinforcement in the environment (e.g., social isolation, poverty), inadequate instrumental behaviors (e.g., social skill, academic ability), and/or the result of an increased frequency of punishment (Lewinsohn, 1974, Lewinsohn, Antonuccio, Breckenridge and Teri, 1984). Through use of research designs that incorporate the Pleasant Events Schedule (PES; MacPhillamy & Lewinsohn, 1971), several empirical findings support this theory. First, following generation of individualized pleasant event schedules and subsequent monitoring of the frequency of events and daily mood state, depressed, nondepressed psychiatric, and normal controls all exhibit a significant positive relation between mood level and frequency of pleasant activities (Lewinsohn and Graf, 1973, Lewinsohn and Libet, 1972). Second, depressed individuals engage in fewer pleasant activities and report less pleasure from these activities (Lewinsohn and Graf, 1973, MacPhillamy and Lewinsohn, 1974). Third, the finding that depressed individuals emit fewer interpersonal behaviors suggest they may receive less social reinforcement (Lewinsohn and Shaffer, 1971, Libet and Lewinsohn, 1973). Finally, behavioral therapies that increase access to pleasant events and positive reinforcers and decrease the frequency of aversive events and consequences have been markedly successful in treating depression (DeRubeis, Gelfand, Tang and Simons, 1999, DeRubeis and Crits-Christoph, 1998, Hopko, Lejuez, LePage, Hopko and McNeil, 2003, Jacobson et al., 1996, Lejuez, Hopko and Hopko, 2002, Lejuez, Hopko, LePage, Hopko and McNeil, 2001, Lewinsohn, Antonuccio, Breckenridge and Teri, 1984, Lewinsohn, Sullivan and Grosscup, 1980, Martell, Addis and Jacobson, 2001, Robinson, Berman and Neimeyer, 1990).

Although incorporation of the PES into research designs has proven useful in providing support for the behavioral model of depression, alternate assessment strategies such as the monitoring of overt behavior via diary-based approaches might facilitate a more naturalistic and stringent test of the behavioral hypothesis. Indeed, diary methods have long been used as an assessment strategy in the domains of clinical and health psychology, with increasing evidence supporting the reliability and validity of such an approach. In the area of depression, for example, self reported depressive symptoms (as measured by the Beck Depression Inventory; Beck & Steer, 1987) and aversive behavioral experiences as reported in daily diaries (e.g., conflictual experiences, feeling trapped) were highly convergent (Robbins & Tanck, 1984). Among samples that included individuals with clinical depression (Stamenkivoc et al., 2001) and premenstrual syndrome (Freeman, DeRubeis, & Rickels, 1996), daily reports of depressive symptoms also were characterized as highly reliable (α=0.92; Freeman, DeRubeis & Rickels, 1996) and were strongly convergent with the Beck Depression Inventory and the Hamilton Rating Scale for Depression (Hamilton, 1960). Diary methods also are associated with strong psychometric properties in other domains, including research on anxiety (Fydrich, Dowdall and Chambless, 1992, Nelson and Clum, 2002), pain (Feldman, Downey and Schaffer-Neitz, 1999, Grant, Long and Willms, 2002) alcohol abuse (Watson, 1999), sexual behaviors (Okami, 2002), gambling (Atlas & Peterson, 1990), and insomnia (Haythornthwaite, Hegel, & Kerns, 1991). Similarly, diaries completed by socially phobic children (Beidel, 1996), adolescents with headaches (Van den Brink, Bandell, & Huijer, 2001), and parents of children with sickle cell disease (Ely, Dampier, Gilday, O’Neal, & Brodecki, 2002) have been associated with adequate internal consistency as well as good convergent and discriminant validity.

Given the demonstrated utility of diary methods in clinical research, we utilized a one-week diary keeping procedure to further evaluate the behavioral model of depression. In assessing overt behaviors and associated reward values using a diary method, our primary aim was to more directly test the assumption that mildly depressed individuals receive less response-contingent positive reinforcement than non-depressed individuals. Compared with previous research where activities to monitor were selected a priori from an assessment instrument (i.e., PES), we speculated that a diary strategy might promote a more representative and naturalistic measure of activity. Specifically, we theorized that diary-keeping might reduce demand characteristics of previous studies where pre-specification of rewarding activities might have made participants more apt to commit to engaging in these behaviors, particularly since they were accountable in having to record their frequency on a daily basis (Kazdin, 1974). Further, because depressed individuals may have dysfunctional views that include expectations of failure, incapability (Beck, 1967), decreased self-efficacy (Maddux & Meier, 1995) and learned helplessness (Seligman, 1975), this process might differentially (and artificially) increase the frequency of pleasant events for non-depressed individuals while not affecting more depressed participants.

This study also was important in that it extended the research of Lewinsohn and colleagues who primarily examined the quantitative aspects (i.e., frequency) of reinforcing events but generally did not evaluate whether measuring the intensity of reinforcement yielded similar findings. That is, in addition to reporting a decreased frequency of pleasant events, are individuals with depressive symptoms also more apt to report decreases in the intensity of reinforcement for activities in which they do engage? Furthermore, in contrast to having participants indicate the pleasantness of activities in an a priori manner (MacPhillamy & Lewinsohn, 1974), we had participants assess reward value following engagement in daily activities. This strategy was incorporated to control for the contextual aspects of reinforcement (Hayes, Strosahl, & Wilson, 1999), or the idea that although previous activities or behaviors may have elicited pleasure or reward in the past, these contingencies may not generalize across time or setting. In previous studies, this contextual quality of behavior may not adequately have been addressed, as pleasant events were identified and monitored according to retrospective accounts of their reward value. Accordingly, this research does not rule out the possibility that alternative (non-monitored) activities may come to be reinforced at a higher rate than those specified on the PES, making it conceivable that individuals with depressive symptoms may not be engaging in fewer pleasant events, but rather pleasant events that are different from those initially targeted for self-monitoring. If this hypothesis were supported, although extinction of previously reinforced behaviors may be evident, the establishment of alternative rewarding activities (in the presence of depressive symptoms) would signify the need to explore alternative etiological explanations for depressive affect.

A final extension of previous work involved assessing behaviors as they related to possible future rewards (as opposed to only immediate reward). This modification seemed particularly necessary given the importance of negative future-oriented cognitions in maintaining depressive affect. The most prominent cognitive models of depression, for example, have highlighted negative perspectives about the future such as helplessness, hopelessness, and decreased control that are central toward understanding the etiology and maintenance of depression (Abramson, Metalsky and Alloy, 1989, Beck, Rush, Shaw and Emory, 1979, Seligman, 1975). In line with these theories, a significant body of research suggests that depressed individuals report fewer anticipated positive experiences, ruminate more about the future, and make predictions about negative future events rather automatically, particularly when they are exhibiting feelings of hopelessness (Alloy and Ahrens, 1987, Andersen and Limpert, 2001, MacLeod and Cropley, 1995, MacLeod and Salaminiou, 2001).

To address these issues and limitations, we examined the behavioral model of depression by incorporating a more naturalistic process of monitoring behavior, increasing the contiguity between behavior and appraisal of reward value, and assessing the reward value of all behavioral responses within a specified time frame. As behavioral theory highlights decreases in response-contingent positive reinforcement as a precursor to depressive affect, the more temporal measurement of the relations between behaviors and (reward) consequences was thought to be a more stringent test of the behavioral hypothesis. We hypothesized that individuals with depressive symptoms would report decreased (immediate and future) reward value of activities, a lower level of general activity, and daily mood ratings consistent with self-reported depressive symptoms as well as reduced pleasure and activity.