***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Depression is one of the more severe and serious health problems because of its morbidity , disabling effects and for its societal and economic burden . Despite the variety of existing pharmacological and psychological treatments , most of the cases evolve with only partial remission , relapse and recurrence . Cognitive models have contributed significantly to the underst and ing of unipolar depression and its psychological treatment . However , success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them . One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence . Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory . We use a novel method for identifying those conflicts using the repertory grid technique ( RGT ) . Preliminary results with depressive patients show that about 90 % of them have one or more of those conflicts . This fact might explain the blockage and the difficult progress of these patients , especially the more severe and /or chronic . These results justify the need for specific interventions focused on the resolution of these internal conflicts . This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s ) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy ( CBT ) for depression . Design A therapy manual for a dilemma-focused intervention will be tested using a r and omized clinical trial by comparing the outcome of two treatment conditions : combined group CBT ( eight , 2-hour weekly sessions ) plus individual dilemma-focused therapy ( eight , 1-hour weekly sessions ) and CBT alone ( eight , 2-hour group weekly sessions plus eight , 1-hour individual weekly sessions ) . Method Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder , with a score of 19 or above on the Beck depression inventory , second edition ( BDI-II ) and presenting at least one cognitive conflict ( implicative dilemma or dilemmatic construct ) as assessed using the RGT . The BDI-II is the primary outcome measure , collected at baseline , at the end of therapy , and at 3- and 12-month follow-up ; other secondary measures are also used . Discussion We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression , thus result ing in a significant contribution to the psychological treatment of depression . Trial registration IS RCT N92443999 ; Clinical Trials.gov Identifier : NCT01542957 Objectives The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations . However , internal conflicts have not received enough empirical attention , nor has their importance in depression been fully elaborated . This study is based on the notion of cognitive conflict , understood as implicative dilemma ( ID ) , and on a new way of identifying these conflicts by means of the Repertory Grid Technique . Our aim was to explore the relevance of cognitive conflicts among depressive patients . Design Comparison between persons with a diagnosis of major depressive disorder and community controls . Methods A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of  IDs  and level of symptom severity . The content of these cognitive conflicts was also analysed . Results Repertory grid analysis indicated conflict ( presence of ID/s ) in a greater proportion of depressive patients than in controls . Taking only those grids with conflict , the average number of IDs per person was higher in the depression group . In addition , participants with cognitive conflicts displayed higher symptom severity . Within the clinical sample , patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts . Conclusions Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity . Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics . Practitioner points Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them . We developed a method for identifying conflicts using the Repertory Grid Technique .  Depressive patients have higher presence and number of conflicts than controls . Conflicts ( implicative dilemmas ) can be a new target for intervention in depression . Caution s/ Limitations A cross-sectional design precluded causal conclusions . The role of implicative dilemmas in the causation or maintenance of depression can not be ascertained from this study We examined the influence of goal conflict and ambivalence on  psychological and physical well-being  through the personal striving framework . Eighty-eight undergraduates in two studies listed 15 of their personal strivings and rated them on the amount of conflict experienced between them and ambivalence experienced about each . Diary and experience sampling methods were used to assess positive and negative affect and physical symptomatology . Conflict and ambivalence were associated with high levels of negative affect , depression , neuroticism , and psychosomatic complaints . Conflict was also associated with health center visits and illnesses over the past year . A 1-year follow-up demonstrated that conflict and ambivalence ratings were stable and that these ratings predicted psychosomatic complaints over time . In a third study , undergraduates ' thoughts and activities were r and omly sample d over a 3-week period . Subjects were less likely to act on conflictful and ambivalent strivings but to spend more time thinking about these strivings This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone , cognitive-behavioral analysis system of psychotherapy ( CBASP ) , or combination therapy .  Contrary to our hypotheses , reactance positively predicted treatment outcome in CBASP on 2 of 4 scales . These effects were independent of the therapeutic alliance , which also positively predicted outcome . Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP . The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship . Results support the importance of Aptitude * Treatment interactions in psychotherapy outcome . The direction and significance of such interactions may vary with different forms of psychopathology 
    Output:
    
Statistically significant associations were observed between the clinical status and the presence of dilemmas , as well as level of conflict across several clinical conditions .
Likewise , the level of conflict was associated with symptom severity .
Results highlighted the clinical relevance and the transdiagnostic nature of implicative dilemmas