The Cognitive Approach to treating depression

• CBT is currently being seen as the most effective psychological method of treating depression. Originally devised by Aaron T. Beck
• CBT combines primarily the cognitive model with aspects of psychoanalysis and behaviour therapy
• The basic aim of CBT is 'cognitive restructuring' designed to bring about 'lasting changed in target emotions and behaviour' - Wessler

  To this end the therapist and the patient form a relationship in which the irrational and overly negative beliefs of the client are recognised and challenged by the therapist
• CBT has been widely used by many therapists for many years. During this time it has undergone many revisions with each therapist tailoring the procedure to their own needs - as a result there are many forms of CBT in use
• All forms of CBT have various characteristics in common and Beck and Weishaar suggest the following 5 common elements:

  Patients are taught to:

  1. monitor their negative and automatic cognitions
  2. recognise the link between cognitions, affect (mood) and behaviour
  3. Consider evidence for and against these automatic thoughts
  4. Replace biased thouhts with more realistic ones
  5. Learn to identify and then change the beliefs that predispose the client to distorted thinking
  6. Making the client aware of the way cognitive and behavioural aspects feed into mood is referred to as the educational phase
• Thought catching?

  Considers the link between irrational thinking and low mood. Typically the therapist will set homework in which the client is set clear and achievable goals such as talking to a member of the opposite sex, or a stranger perhaps recognising their automatic thoughts and challenging these.
• Homework extends the therapy into everyday life, however the therapist needs to be certain that the homework set is relaistic, setting a task that cannot be achieved is likely to reinforce the client's negative thinking further still
• Behavioural activation (Behaviourist element):

  The client is encouraged to take part in enjoyable activities. It is common for patients with depression to cut themselves off and stop socialising. Here the therapist encouraged the client to get out and engage in activities that they enjoyed before the depression e.g. play sports, go to the cinema, socialise with friends
• Exercise is seen as being particularly beneficial - Babyak et al randomly allocated 156 depressed patients into one of three groups

  1. four months of aerobic exercise
  2. drug treatment
  3. combination of exercise and drug treatment
• After the 4 months, all showed significant improvement.
• Six months later when the patients were revisited the groups taking exercise had a significantly lower level of relapse
• With CBT there are usually about 20 sessions, followed by boosters in the first year to help prevent relapse
• Does CBT work?

  an early study by rush showed CBT to be more effective in reducing low mood than the drug imimprimine (tricyclic). However, in this particular study, the most striking feature was the lack of success of the drug
• Elkin made a similar comparison and found that both CBT and imipramine resulted in 'almost complete removal' pf depressed symptoms in 55% of patients. Both were significantly better than placebo, but the drug did work faster
• Hollon et al: Depressed patients were treated for 16 weeks. They received either an SSRI (paroxetine) of cognitive therapy. Similar numbers of each group (about 60%) showed considerable improvement. These successes were then followed up for a further 12 months
• When CBT was stopped and no further treatment was received, relatively few suffered relapse into depression. This suggests that cognitive therapy has dealt with the cause of depression
• When drug therapy is given and maintained relapse rate is relatively low (though not as low as therapy) which suggests that drugs are working provided they are maintained
• 76% relapse when the drugs are withdrawn. This confirms that drugs are fine until medication stops. During the prescribed period the drugs are reducing the symptoms but not dealing with the causes. If they were then the patient would be fine when medication stopped. In fact, three quarters of patients become depressed again
• Drugs appear to be palliative - suggests that CBT is to be preferred to drugs
• Further evidence for the curative nature of CBT was produced by Segal et al. Groups of patients were treated with either CBT or drugs. As with the Hollon study both were similarly successful. Later the recovered patients were 'made to feel sad'. Those who had been treated with drugs returned to their negative and dysfunctional thinking (evidence for palliative) whereas those who had received CBT remained more positive and rational (evidence for curative)
• CBT seems to be the most appropriate given that so many symptoms of depression are cognitive in nature. It is also worth mentioning that CBT also tackles the behavioural components such as seeking to encourage greater contact and interactions with others and seeking more pleasurable activities
• CBT might not be suitable for everyone - it does require a certain level of intelligence and an ability to be introspective as well as to be able to communicate your thoughts adequately
• A lot is made in the literature about the competence of the therapist in ensuring a positive outcome. However there have been recent and successful attempts to produce more automated forms of CBT that can be delivered online - this would seem to negate the need for a therapist at all
• One of the biggest issues with CBT is the cost, particularly in the UK where health care is delivered by the NHS at the taxpayer's expense. Whitfield and Williams found evidence that the NHS was struggling to provide CBT on a weekly basis to the many patients that would clearly benefit from the procedure
• Recently there have been attempts to train other healthcare workers in the basics of CBT so it can be administered more widely. One such initiative is SPIRIT (Structured Psychosocial InteRvention in Teams).
• SPIRIT is a training programme designed to run for just under 40 hours together with 5 hours of clinical supervision in the administering of the therapy. Medical professionals are taught how to build relationships with their clients and how to use Beck's techniques to alter distorted thinking. This does illustrate however, how popular the therapy has become
• Weakness: many problems leading to depression centre of dysfunctional and failing personal relationships with others. CBT generally overlooks these and so might not be as effective in dealing with depression with these causes.