stress perception and depressive symptoms after the treat-
ment. It is possible that depressive symptoms inﬂuenced
stress perception, or that bidirectional relations exist between
these variables. To assess causality, prospective designs as-
sessing mediating variables and outcome variables at differ-
ent time points will be required. Second, we did not investi-
gate single PD diagnoses or subgroups of patients differing in
clinical and sociodemographic variables that have been asso-
ciated with differential treatment response (Fava et al., 1997).
Although conceptually of great interest, subgrouping would
have produced sample sizes too small for the SEM analyses.
Moreover, the use of DSM-based clusters has received sup-
port in several factor and cluster-analytic studies (Bagby et
al., 1993). Third, although the present SEM provided an
excellent ﬁt to the data, it is important to keep in mind that it
is always possible that other models not tested in the present
study might ﬁt the data equally well or even better. The
present model was, however, developed based on previous
empirical ﬁndings and current etiological theories of depres-
sion, and the ﬁndings conﬁrmed the a priori hypotheses.
Fourth, analyses were primarily based on self-report assess-
ments. Although the questionnaires used in the present study
have been widely used in the literature and possess satisfac-
tory reliability and validity, reporting biases cannot be ex-
cluded. Finally, in light of the rather extensive exclusion
criteria used in the current study, future work should evaluate
the generalizability of the present ﬁndings to community
samples, which will likely be more heterogeneous.
In spite of these limitations, the present ﬁndings indi-
cate that the relation between PD and treatment outcome was
fully mediated by intervening variables. Speciﬁcally, the
SEM analyses revealed that the presence of PD comorbidity
was associated with increased maladaptive cognitive patterns
(dysfunctional attitudes and depressogenic cognitions) lead-
ing to elevated stress appraisal after the treatment, which in
turn was associated with higher depression severity after an
8-week ﬂuoxetine treatment. More generally, the present
ﬁndings underscore the need to address underlying cognitive
and personality vulnerability, in addition to symptoms of
depression, in treatments for depression (Hayes et al., 1996;
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Candrian et al. The Journal of Nervous and Mental Disease • Volume 195, Number 9, September 2007
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