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Depression Treatment: Part 2 – Cognitive Behavior Therapy

Cognitive Behavior Therapy

While Freud pioneered the development of psychotherapy in the Western world, psychotherapy underwent many iterations before the advent of cognitive behavior therapy in the 1960s, eventually becoming a widely utilized treatment for depression. Central to cognitive behavior therapy is the tenet that thoughts, feelings, and behaviors influence each other and can result in dysfunctional reactions to situations. Further, psychological problems result from distorted thinking and previously learned unhelpful behavior, and psychological functioning can be improved by learning more adaptive ways of coping with both of these factors (American Psychological Association, 2017). 

Interestingly, Aaron Beck actually developed cognitive behavior therapy as a response to his research findings regarding psychoanalytic psychotherapy (Beck Institute, 2020). Dr. Beck was trained and also had practiced in psychoanalytic psychotherapy, and was in the process of conducting research to validate the psychoanalytic conceptualization of depression. However, much to Dr. Beck’s surprise, his research findings did not support psychoanalytic theory, and left him searching for a novel way to understand depression. Through his work with patients, he came to the realization that people with depression experienced automatic negative thoughts. These unhelpful and pessimistic thoughts often surfaced unprompted and were in reference to themselves, the world, and the future. Dr. Beck began to treat these patients by helping them think objectively about and analyze their own thoughts, developing better responses to situations they were facing in the process. This in turn improved emotional well-being and overall functioning (Beck Institute, 2020). 

Depression TreatmentCognitive behavior therapy is currently one of the treatments that has garnered the most empirical backing for the management of depression (Gautam et al., 2020). 

Cognitive behavior therapy has become popular for a variety of reasons. The manualization of this treatment has facilitated standardizing treatment for the purpose of clinical trials and evaluation of effectiveness treatment modalities. Cognitive behavior therapy has also been studied more than any other treatment (Rupke et al., 2006). Cognitive behavior therapy is a problem-focused approach and is intended for use as a more short-term approach to quickly reducing distressing symptoms. Therefore, it is important to note that manualized cognitive behavior therapy without additional modifications may not be appropriate for some patients, such as those who have experienced extensive trauma.  Conversely, cognitive behavior therapy utilizes a great deal of structure in its format, which may be helpful for patients who could potentially benefit from more explicit instructions, a ‘teaching’ style of therapy, or knowing what to expect throughout treatment. In terms of format, sessions may involve discussing roadblocks that occurred over the course of the preceding week. Factors contributing to these difficulties are identified and new skills are taught. The session is typically concluded with the assignment of ‘homework’ that prescribes an activity in which the patient participates to practice newly learned skills on their own. 

Cognitive behavior therapy has the potential to benefit a wide range of patients. It is fairly easily modified to be employed with patients of varying cognitive abilities–from children to older adults. Unlike other forms of treatment, cognitive behavior therapy demonstrates the added advantages of deliverability across primary care and other healthcare settings, as well as online. Web-based cognitive behavior therapy was found to be effective even without additional follow-up with treatment providers via telephone (Farrer et al., 2011). For example, cognitive behavioral techniques have been utilized on numerous mobile apps (Slogar, 2017). Mobile apps facilitate access to therapeutic techniques to a greater number of people for whom therapy would otherwise be time- or cost-prohibitive. 

When comparing effectiveness of depression treatment, cognitive behavior therapy seems about as beneficial as medication (Roshanaei-Moghaddam et al. 2011). However, it is important to note that there may be some caveats to this finding. For example, a meta-analysis found that patients who endorsed specific symptoms (depressed mood, feelings of guilt, suicidal thoughts, psychic anxiety, and somatic symptoms) on a depression rating scale responded better to an antidepressant, with no treatment difference apparent for other symptoms. In terms of cost-effectiveness, neither second-generation antidepressant medication nor cognitive behavior therapy was relatively more economical for patients as a first line of treatment (Ross et al., 2019). Additionally, patients whose depression is not severe enough to require treatment by a healthcare provider may benefit from self-help modalities of different types. One study found that patients equally benefited from books based on either cognitive behavior or positive psychology principles (Hanson, 2018). These research findings all highlight the importance of tailoring treatment to the individual patient as well as continually assessing progress throughout treatment. 

References

American Psychological Association. (2017). What is cognitive behavioral therapy? https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral

Beck Institute. (2020). History of cognitive behavior therapy. https://beckinstitute.org/about-beck/history-of-cognitive-therapy/

Boschloo, L., Bekhuis, E., Weitz, E. S., Reijnders, M., DeRubeis, R. J., Dimidjian, S., Dunner, D. L., Dunlop, B. W., Hegerl, U., Hollon, S. D., Jarrett, R. B., Kennedy, S. H., Miranda, J., Mohr, D. C., Simons, A. D., Parker, G., Petrak, F., Herpertz, S., Quilty, L. C., Rush, A. J., Segal, Z. V., Vittengl, J. R., Schoevers, R. A., & Cuijpers, P. (2019). The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis. World Psychiatry, 18(2), 183–191. https://doi.org/10.1002/wps.20630

Farrer, F., Christensen, H., Griffiths, K. M., & Mackinnon, A. (2011) Internet-based CBT for depression with and without telephone tracking in a national helpline: Randomised controlled trial. PLOS One. https://doi.org/10.1371/journal.pone.0028099

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive behavioral therapy for depression. Indian Journal of Psychiatry, 62(Suppl. 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Hanson K. (2019). Positive psychology for overcoming symptoms of depression: A pilot study exploring the efficacy of a positive psychology self-help book versus a CBT self-help book. Behavioural and Cognitive Psychotherapy, 47(1), 95–113. https://doi.org/10.1017/S1352465818000218

Roshanaei-Moghaddam, B., Pauly, M. C., Atkins, D. C., Baldwin, S. A., Stein, M. B., & Roy-Byrne, P. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: Is medication somewhat better for depression, and CBT somewhat better for anxiety?. Depression and Anxiety, 28(7), 560–567. https://doi.org/10.1002/da.20829

Ross, E. L., Vijan, S., Miller, E. M., Valenstein, M., & Zivin, K. (2019). The cost-effectiveness of cognitive behavioral therapy versus second-generation antidepressants for initial treatment of major depressive disorder in the United States: A decision analytic model. Annals of Internal Medicine, 171(11), 785–795. https://doi.org/10.7326/M18-1480

Rupke, S. J., Blecke, D., & Renfrow, M. (2006). Cognitive therapy for depression. American Family Physician, 73(1), 83-86. https://www.aafp.org/afp/2006/0101/p83.html

Slogar, M. A. (2017). Bridging gaps in mental healthcare with mobile apps. https://blog.time2track.com/bridging-gaps-in-mental-health-care-with-mobile-apps/

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