Use of Cognitive Behavioural Therapy (CBT) for Depression

Major depressive disorders destroy a person’s ability to enjoy many ordinary parts of life. All of the activities which many consider normal such as eating, sleeping, working and playing, become empty for the depressed individual. Research has attempted to address the prevalence of depression and pharmacological treatments have often been the first line of defence in its treatment. Medications, however, usually have unpleasant side-effects and so psychological or talking therapies are often preferred by patients. One type of therapy that has been found to be effective in the treatment of depression is cognitive-behavioural therapy (CBT). This essay will first address the basic features and use of CBT in the treatment of depression before moving on to behavioural activation therapy which effectively uses a subset of the approaches used in CBT, finally the approaches will be compared and contrasted.

CBT is often referred to as though it was a single treatment, but it actually comprises a number of approaches from both the cognitive and behavioural theories. Aaron Beck, the grandfather of cognitive therapy, describes the cognitive aspect of the approach as targeting the way that people interpret the events around them (Beck, 1991). In depression, within the theory, people are seen to have beliefs that are essentially maladaptive to the world around them. Their powers of interpretation have a number of significant biases which contribute towards their depression. In order to treat depression, then, cognitive therapy attempts to challenge the way that patients interpret the world. This is done by working through the various beliefs which are considered maladaptive by the therapist and testing them against the real world.

Along with the cognitive aspects of CBT, behavioural approaches are also used. The behavioural aspect is based on ideas put forward by behaviourist psychologists such as B. F. Skinner, which describe people’s behaviour in terms of whether it is encouraged or discouraged by the environment. Hollon, Thase & Markowitz (2002) point out that one of the assumptions of the therapy is that people who are depressed receive a high degree of reinforcement for their depressive thoughts and a low degree for their non-depressive thoughts. Behavioural strategies are particularly useful in CBT for allowing the patient to carry out behavioural experiments in which they are encouraged to try out different types of behaviour and check how the outcomes marry with their beliefs. The aim in CBT is that the evidence of these experiments will help to convince the patient that, through testing their contact with reality, they will come to adjust those maladaptive beliefs. The typical belief that a depressed person has is that they are unlikely to succeed in many activities because of their have low expectations of their own abilities.

Hollon et al. (2002) emphasise that the aim of CBT is not to think ‘happy thoughts’, but rather to try and encourage the patient to become more accurate in the way they perceive the world. One of the most important aspects of CBT is encouraging the patient themselves to continue to use the strategies learned in CBT after the therapy has finished. Compared to psychodynamic therapies, CBT is relatively brief at around 14-16 one-hour sessions, and so these learned strategies and changed beliefs need to be maintained after the contact with the therapist is finished.

A large range of different studies have been carried out into the effectiveness of the use of CBT. Gloaguen, Cottraux, Cucherat & Blackburn (1998), for example, used a meta-analytic approach to examine the evaluation of cognitive therapy (CT) in 78 studies between 1977 and 1996. Overall this meta-analysis showed that CT was effective in cases of mild to moderate forms of depression when compared to placebo or control conditions. There was even some evidence that the use of CT produced a better outcome than the use of anti-depressant medications and other psychotherapies. Criticisms of this research were aimed at the fact that this meta-analysis amalgamated wait-list groups with placebo groups, which, Parker, Roy & Eyers (2003) argue, are not equivalent. Further, the effectiveness of the ‘other therapies’ category to which CT was compared, was weakened by the inclusion of weaker types of intervention such as ‘bibliotherapy’. This research has also been questioned by Wampold, Minami, Baskin & Tierney (2002) who, in reanalysing the meta-analytic data taking into account the control treatments, found that CT was not superior but equivalent to other forms of psychological therapy.

The results discussed so far were mainly obtained for the treatment of mild to moderate depression. In the treatment of severe depression, however, the use of CT compared to pharmacological interventions has been questioned. Elkin, Gibbons, Shea, Sotsky, Watkins, Pilkonis & Hedeker (1995) carried out a large study and found that CT was less effective than medication and only as effective as the placebo combined with clinical management. Hollon et al. (2002), however, point out that this, despite being a large influential study, was one of the only published studies that questioned the effectiveness of CT. Hollon et al. (2002) argue that the results were weak because of the lack of therapist training in two of the three sites at which the CT was given. In comparison, Jarrett, Schaffer, McIntire, Witt-Browder, Kraft & Risser (1999) in a placebo-controlled, double-blind study looked at the use of CT compared to the most effective medication in the treatment of atypical depression. This study found that CT was as effective as the medication and better than the placebo in the treatment of atypical depression. The criticism of this study is that not all of the patients selected were suffering from severe depression, although many were.

DeRubeis, Gelfand, Tang & Simons (1999) carried out a mega-analysis^[1] of severely depressed patients using the data from sub-groups of studies already carried out. Included in the analysis was the data from the study carried out by Elkin et al. (1995). Aggregating the results they found that, in fact, in this patient group with severe depression, CBT was as effective as medication. Indeed there was a small, but non-significant advantage for CBT over medications. This backed up findings from Hollon, DeRubeis, Evans, Wiemer, Garvey, Grove & Tuason (1992) who had found a small, although non-significant, advantage for CBT over a pharmacological intervention. Hollon et al. (2002) argue that it is the expertise of the therapist that is most important, and those studies that do not support the use of CT or CBT tend not to involve the best trained therapists.

So far, the way in which the studies have been discussed has treated depression as though the only variable in its makeup is its severity. Parker et al. (2003) point out that many of the studies report headline findings of the overall efficacy of the treatment of depression by CBT rather than examining the gradations in between. In fact, instead of talking about the severity of depression, Parker et al. (2003) suggest it is better to consider the different types of depression. Parker et al. (2003) split depression into psychotic, melancholic and other non-melancholic depressive disorders. The first two categories, Parker et al. (2003) argue, are considered more biological in origin and are, therefore, more responsive to pharmacological treatment. It is suggested that the last, more heterogeneous group of those with severe non-melancholic depression, are more responsive to psychotherapies, especially CBT.

Taking a closer look at the way in which CBT works reveals a more ambivalent picture. MacLeod (1988) points to the distinction in psychotherapies between what are called common and specific factors. The common factors that have been found to be effective in all types of therapy include the therapist’s warmth, acceptance and empathy. Examining this idea, Strupp (1996) found that across different psychotherapies, as much as 85% of the variability could be accounted for by common factors. In other words, it doesn’t matter which therapeutic modality is used, the simple fact that someone is taking an interest and being supportive has a beneficial effect. In addition, Ilardi & Craighead (1994) point out that many of the major improvements during CBT occur before cognitive restructuring techniques are introduced. This also suggests that the importance of non-specific factors of the psychotherapy is paramount.

A further factor which needs to be considered in the efficacy of CBT is the prevention of relapses. While patients often show good response to CBT, the suggestion is that, once the therapist’s support has been removed, a patient can easily regress. Gloaguen et al.’s (1998) study suggested only tentatively that, when followed up, patients who had been treated with CBT were better able to maintain their gains than those treated with pharmacological treatments. Fava, Rafanelli, Grandi, Canestrari & Morphy (1998) examined a relatively small sample of patients (40) in a follow-up study to compare the standard clinical management^[2] with CBT. After 4 years, the CBT was shown to have a significant preventative effect against depression; however, this had faded at the 6 year follow-up. In similar work, Scott, Teasdale, Paykel, Johnson, Abbott, Hayhurst, Moore & Garland (2000) looked at the effect of using CT on those with residual depressive symptoms and compared it to clinical management. The authors found that CT did significantly reduce residual depressive symptoms although there were some methodological problems with the study including the fact that the patient’s response could be a placebo effect as well as the authors suggesting that the effects seen might not have clinical significance – in other words, they might not be practically useful. Parker et al. (2003) argue that, overall, these studies show only limited support for CT in the prevention of relapses and, in any case, do not provide the most useful comparisons as they do not compare CT to other psychotherapeutic or psychopharmacological approaches.

Overall, Parker et al. (2003) argue that the efficacy of CBT and/or CT for all types of depression has yet to be established definitively, despite major positive findings in much of the research. Despite their critical approach to CT, Parker et al. (2003) do admit that CT is useful in certain situations. The problem for the research is identifying the situation – specifically those with what is labelled ‘depression’ do not represent a homogenous group and therefore when interventions are tested, it is not surprising that the results are equivocal.

All of the research discussed so far has addressed cognitive behavioural or purely cognitive models of treatments for depression. The behavioural components of this type of therapy are normally used to augment the cognitive approach, with purely behavioural approaches having lost favour after the 1970s. As Parker et al. (2003) point out, though, there are problems with a reliance on cognitive strategies. They find little evidence for some of the basic assumptions of cognitive therapy, such as the centrality of global negative views of self and the world (Beck, Rush, Shaw & Emery, 1979). One example of this is the work of Ingram, Miranda & Segal (1998) who failed to find any support in the literature for cognitive vulnerability, an important factor in the model. While this does not disprove the model, Parker et al. (2003) argue that, overall, the evidence is somewhat inconclusive. For this reason and because of the increasing pressure to provide brief cost-effective interventions for depression, there is now an effort to examine the efficacy of more behavioural methods, specifically behaviour activation (BA) therapies.

As Hopko, Lejuez, Ruggiero & Eifert (2003) point out, the roots of BA come from the radical behaviourism of Skinner (1953) who argued that depression was caused by those reinforcements that encourage healthy behaviour being, for one reason or another, interrupted in the social environment. At its most fundamental, then, those behaviours that are seen as ‘healthy’ are not reinforced, or may even be punished, while ‘unhealthy’ behaviours are reinforced. Jacobson, Martell & Dimidjian (2001) claim that it is possible that CT and CBT do also tap into these ideas (as discussed earlier) but also place considerable emphasis on cognitive models. Jacobson, Martell & Dimidjian (2001) see BA theories as concentrating more on the environment than the internal processes of the individual, and therefore aid in the de-medicalisation of depression. The empirical roots of BA can be seen in the Harmon, Nelson, and Hayes (1980) who found that they could prompt depressed patients into activity using a beeper and increase their activity by more than double. Similarly, Zeiss, Lewinsohn & Munoz (1979) found that depression could be alleviated to a similar level as comparable interventions through the increasing of patient’s activity levels.

BA concentrates, then, on behaviour, returning to formulations developed earlier, but with some modern enhancements. At heart, though, BA relies on some basic behaviourist principles. Extinction is used to attempt to remove those behaviours that lead to depressive feelings through the encouragement of approach behaviour (Hopko et al., 2003). At first, in BA, rigid structures are used to attempt to inculcate new behaviours but over time fading is used to minimise these structures as new behaviours become embedded. Shaping is also used in BA, although to a lesser extent than either extinction or fading. The reason it is not seen as shaping in BA is that the new target behaviours that the therapist hopes to embed in the patient are considered to already be there within the client. Shaping is sometimes required to reach more difficult goals that require a number of steps.

Many of the ideas used in BA rely on classical behaviourism, but there are a number of major differences that Hopko et al. (2003) identifies. Firstly, BA approaches concentrate more on the functional aspects of a person’s behaviour, i.e. those aspects of their environment that reinforce the depressive state. Secondly, close attention is paid in BA to the ongoing assessment of whether particular behaviours are related to depressive symptoms. Thirdly, instead of targeting thoughts, BA targets behaviours specifically and places this as the focus of change for the patient, with the assumption of the model being that these changes will flow back into affective states as well as thoughts. Finally, BA affects the environmental component of depression by influencing a person to change their behaviour and so experience positive consequences.

Early work examining the efficacy of BA as a treatment for depression produced some encouraging results. Jacobson, Dobson, Truax & Addis (1996) attempted to separate out the BA aspects of CT and compare them with each other. The results showed that there was little difference between the groups that received just the BA aspects of CT and those that received the full CT treatment. What was also encouraging for the researchers was that although the BA treatment did not specifically address the idea of negative automatic thoughts – an extremely important component of the cognitive model of depression – they showed the same levels of reduction across both the BA and CT treatment groups.

Hopko and his colleagues went on to develop a specific manualised intervention aimed at depression called the Behaviour Activation Treatment for Depression (BATD) (Lejuez, Hopko & Hopko, 2001). At heart this method uses the matching law developed by Hernstein (1970). This states that the amount of behaviour a person tends to give to a particular activity is directly proportional to the amount of reinforcement they receive while conducting that activity. The therapist therefore encourages the patient to change their behaviour, with much of the expected change happening outside the therapy sessions. The advantage of this type of treatment is that it is generally delivered over 10 to 12 sessions and is therefore shorter than CBT. In addition, sessions are often reduced in length towards the end of the intervention (Lejuez, Hopko & Hopko, 2001).

In this technique, once the baseline levels of activity and depression have been assessed, the patient moves on to look at the possible activities that could be targeted for increase. Examples provided are such things as the improvement of family and social relationships or courses of education or training that might be embarked upon. The emphasis at all times is focussing on those activities that the patient would find pleasurable and then these are ranked in order of difficulty. The patient also provides them self with rewards if their targeted behaviours have been completed (Lejuez, Hopko & Hopko, 2001). Week by week the patient, with the help of the therapist, moves up through the hierarchy of activities, as they slowly get more and more difficult. The extra exposure to positive reinforcement for healthy behaviours is, within the theoretical model, supposed to encourage them to continue performing these behaviours and so decrease their depression.

Hopko, Lejuez, LePage, Hopko & McNeil (2003) used BATD in a small sample of 25 patients at a psychiatric in-patient facility. BATD was compared to the standard supportive treatments that the in-patient hospital provided. The results showed that, with the BATD requiring fairly low levels of training to implement, significant reductions in depression as measured on the Beck Depression Inventory (Beck & Steer, 1987), such that the effect size and also the clinical significance of the intervention were substantial. In work that looked at both depression and anxiety in a case study, Ruggiero, Morris, Hopko & Lejuez (2005) also found support for the use of BATD.

In their most recent research, Hopko, Bell, Armento, Hunt & Lejuez (2005) have examined the use of BATD in the treatment of depression in cancer patients in a primary care setting. This study was a preliminary clinical trial and therefore only included 6 participants. Each of these participants was suffering from major depression and being treated for cancer. After the BA intervention a variety of different measures showed considerable improvement with significant effect sizes. On top of this, the intervention was reported to be relatively easy to implement and did not require a large amount of resources. The advantages were maintained three months after the intervention and there was also an improvement in the amount of bodily pain.

BA, while being based on techniques that have been long-established, in its current formulation is actually a relatively new method. As such, the types of evaluation that have been carried out to assess its efficacy are, as yet, fairly limited. While the work of Hopko and colleagues certainly provides some interesting and encouraging results, there are not the same scale of studies carried out into BA that have been carried out into CT and CBT. The CT and CBT studies include more than a handful of controlled, double-blinded studies which are the gold-standard of health psychology research. In comparison, the studies into BA have mostly small numbers of participants and do not provide the same rigorous comparisons as those carried out into CT and CBT. The reason for this is that the research into BA is still at an early stage and consequently, even though it is encouraging, cannot hope to provide the same solid evidence base as is already available to CBT.

In conclusion, it can be seen that CBT and CT have a huge and growing evidence base that is largely positive. These cognitive based interventions have been repeatedly shown to be effective in the treatment of mild to moderate depression. For the treatment of severe depression there are some questions as to whether these cognitive methods are effective. Some researchers have suggested that the studies that have looked at CT and CBT have treated those with depression as though they are heterogeneous group – which they are not. Future research should aim to look at which types of intervention are best suited to which types of depression. In comparison, BA shares many roots with CBT but only pays attention to the cognitive component indirectly. In this intervention the changing of behaviour is paramount, and the cognitive changes are thought to flow from these. One of the strongest advantages for BA despite its relative lack of supporting evidence is the easy with which it can be implemented. The evidence base for BA is clearly not as strong as that for CBT and so it will require more research before it can be confidently endorsed.

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