Cognitive Behavioral Treatment of
Major Depression
The original version of these slides was provided by
Michael W. Otto, Ph.D.
with support from NIMH Excellence in Training Award at
the Center for Anxiety and Related Disorders at Boston
University
(R25 MH08478)
Use of this Slide Set

Presentation information is listed in the notes section
below the slide (in PowerPoint normal viewing mode).

References are also provided on the slide, or at times,
in the note sections.
Why Consider CBT for the Treatment of
Major Depression?

Acceptable

Recent meta-analysis indicates that psychotherapy is
preferred 3:1 to pharmacotherapy for depression
(McHugh et al., 2013, J Clin Psychiatry)
Efficacious and Cost-Effective

CBT is more cost-effective than pharmacotherapy over
follow-up periods) (Dobson et al. 2009; Hollon et al. 200x)
Long-term Maintenance of Gains
–
–
–
CBT has a strong enduring effect over time (Cuijpers et
al., 2013, BMJ open)
CBT Efficacy Extends Across Settings
1. From the Research Clinic to the Outpatient Clinic

Outpatient CBT in clinical settings offers significant
benefits, although…
–
–
According to meta analysis, the degree of benefit
offered by CBT in the clinic may be somewhat less
than what is achieved in controlled clinical trials, it
still reflects important benefit on both depression
(d=1.13) and secondary outcomes (d=.67-.88) for
within subject benefits
Dropout rates for such treatment are in the range of
25%
(Hans & Hiller, 2013, JCCP)
CBT Efficacy Extends Across Settings
2. Across Formats/Patient Subgroups
CBT for depression offers

Benefits when offered in a group, albeit less than achieved in
individual therapy, but this difference is attenuated over time (Hunt
et al., 2012, Br J Psychiatry, 200, 184-90).

Benefit for older people as judged by meta analysis of 23 studies
(Gould et al., 2012, J Am Geriatr Soc, 60, 1817-30)

Similar gains in those with and without disability benefits (Ebrahim
et al., 2012, PLoS One)

Benefit when offered as a brief (6 to 8 sessions) treatment
(controlled effect size = .42) (Nieuwsma et al., 2012, Int J Psychaitri
Med, 43, 129-51)

Benefit for medical populations such as cancer patients (check
Hart et al., 2012, J Natl Cancer Inst, 2012, 104: 990-1004).
CBT vs. Other Psychotherapies

CBT and IPT appear to offer similar outcomes when
offered for unipolar depression
–
(Jakobsen et al., 2012, Psychol Med, 42, 1343-1357)

Similar outcomes for Cognitive Therapy (CT) and Behavioral
Activation (BA), with advantages over supportive therapies
(Braun et al., 2013, Plos One)

Whether CBT differs from focused dynamic therapy or supportive
therapy depends on the specific studies included in metaanalyses (cf., Tolin, 2010, Clin Psychol Rev; Braun et al., 2013)
Perspectives on More Severe Depression
Early evidence that ADM may outperform CBT for
moderate to severe depression (Elkins et al., 1989)…
…But this association has not stood up in subsequent
trials (e.g., DeRubeis et al., 2005), with evidence that
CBT offers protection from relapse (Hollon et al., 2005,
Arch Gen Psychiatry) in these patients
See the following example findings…
DeRubeis et al, 2005 Arch Gen Psychiatry
CT vs. ADM vs. Placebo for Moderate to Severe Depression
Sustained Improvement
(Hollon et al. 2005, Arch Gen Psychiatry)
CBT Helps Protect Against Relapse

Meta-Analysis of Acute Phase Treatment (ADMs were
discontinued) (Vittengl et al., 2009; JCCP)
CT vs. ADM (7 studies): CT associated with a 61%
less relapse/recurrence
– Addition of CT to pharmacotherapy (6 studies):
adding CT associated with a 61% less
relapse/recurrence
Example Study (Dobson et al., 2008, JCCP)
–

–
CT and Behavioral Activation (BA) each equal to
continuation of medication and better than ADM
withdrawal for protecting against relapse (BA at a
trend-level advantage)
CBT for Medication-Resistant Depression
Fava et al., 1997

19 Patients who failed 2 trials of ADMs

Mean 15  4 sessions of CBT

63% remission rate

Maintenance at two years (83%)
Residual Symptoms and Relapse

Residual symptoms are a predictor of relapse over time
(Jarrett et al., 2008, J Affect Disord), encouraging full
treatment of depression before cessation of treatment

Example Study (Thase et al., 1992)
–
9 % Relapse among full responders
–
52 % Relapse among patients with residual symptoms
CBT for Prevention of Recurrent Depression

40 recovered outpatients

Random assignment to CBT or clinical management
(CM), tapering of ADMs

2-yr relapse rates:
–
–
CBT
CM
25%
80%
(Fava et al., 1998)
Ratings of Therapeutic Alliance

CBT > Psychodynamic-Interpersonal

Alliance was correlated with impact (helpfulness) of the
session
(Raue et al., 1997)
Behavioral Activation (BA) Treatment

A nice reminder that “doing” in therapy is important

Primary treatment strategies
–
–
–
Self-monitoring of daily activities and mood
Week-by-week scheduling of activities that bring
patients a sense of pleasure or mastery
Identifying and reducing avoidance behaviors that
increase depressive symptoms.
In the last decade, BA has enjoyed diverse
application as a brief treatment



BA typically has received less attention than CT, despite
evidence of similar efficacy (e.g., Dimidjian et al., 2006,
JCCP 2006; Jacobson et al., 1996, JCCP)
BA has been shown to be efficacious for treatment of
depression across a diverse array of samples (e.g.,
inpatients, patients with cancer, smokers).
Adaptable in length
– 6-session BA treatment for illicit drug users significantly
reduced depressive symptoms (Magidson et al., 2011)
– Potential role in early intervention: A single session of BA
followed by two weeks of activity assignments reduced
depressive symptoms in undergraduates (d = 1.61)
(Gawrysiak et al., 2009, J Counseling Psych)
Problem Solving Interventions

Strong effect sizes for problem solving therapy for
depression (Bell & E’Zurilla, 2009, Clin Psychol Rev)

Elements:
–
–
Training in a positive problem orientation
Training in problem-solving skills:
 problem definition and formulation
 generation of alternatives
 decision making
 solution implementation and verification
Treatment Considerations
Structure of the Session


Each session, with its assessment of emotions
and alternative responses, allows the therapist
to model emotional regulation and problem
solving
Therapist models responses to:
emotions
 problems
 change process

Structure of Sessions






Review of symptoms, progress, and problems
Construction of the agenda
Discussion, problem solving, rehearsal
Consolidation of new information/strategies
Assignment of home practice
Troubleshooting of homework (including signposts of
adaptive change)
CBT: A Collaborative Effort

Active collaboration (patient as cotherapist)

Review of the week, rehearsals, roleplays and other
active practice in session

Practice of skills in life through weekly assignments
ranging from monitoring of thoughts and other
behaviors to rehearsal of skills in specific contexts
Session 1 - Establishing a Cotherapist
on the Case
To help the patient be an active cotherapist in
treatment, provide a:
Model of the disorder
Model of the change process
Information on the role of the patient
Elements of Treatment
Cognitive Restructuring and Skill Acquisition
Restructuring

Education (role and
nature of thoughts)

Self-monitoring
of thoughts

Identification of errors

Substitution of
useful thoughts

Core beliefs and strategies
Skill acquisition

Assertiveness

Communication skills

Problem solving
Cognitive Restructuring

Examine the evidence for the thought

Generate alternative explanations

De-catastrophize

Debunk “shoulds”

Find the logical error

Test out its helpfulness
Questions Used to Formulate Rational
Response

What is the evidence that the automatic thought is true?
Not true?

Is there an alternative explanation?

What is the worst that could happen? Would I live
through it?

What’s the best that could happen?

What’s the most realistic outcome?
Questions Used to Formulate Rational
Response (Cont’d)

What is the effect of my believing the automatic
thought?

What is the cognitive error?

If a friend was in this situation and had this thought,
what would I tell him/her?
Targets for Cognitive Restructuring




Emotional tone of self talk
Distortions in interpretations of events
Core beliefs
Development of adaptive thinking
Respecting Hot Emotions


Interventions are in relation to, not in spite of,
the patient’s current mood.
Attention to current mood states helps the
therapist get access to mood-state dependent
cognitions
Behavioral Activation (BA) Treatment

Self-monitoring of daily activities and mood

Week-by-week scheduling of activities that bring
patients a sense of pleasure or mastery

Identifying and reducing avoidance behaviors that
increase depressive symptoms.
Activity Assignments - 1
Used in conjunction with cognitive
restructuring
 Help ensure that therapy is not overfocused on thinking rather than doing
 Starts with monitoring of activities and
setting of goals for valued activities for both
pleasure and mastery (competence goals)

Activity Assignments - 2
When structuring assignments
 Start where the patient is
 Be specific about assignments (defining
desired outcomes specifically)
 Rehearse elements in session
 Troubleshoot problems and signposts
 Review cognitions (expectations and
concerns)

Activity Assignments - 3
Review performance relative to objective
criteria (and the degree of mood
disturbance)
 Assess the patient’s cognitive and affective
response to the activity
 Discuss next steps

Well-Being Therapy Phase



Consolidate skills
Focus on increasing the positive not just
reducing the negative
Fade out treatment
Relapse Prevention Metacognitive Awareness

Classic CT and Mindfulness-based CT both enhance
metacognitive awareness

Level of metacognitive awareness is linked to relapse

Changing the relationship people have to their thoughts,
rather than changing beliefs, may be important for
preventing relapse
(Teasdale et al., 2002)
Sudden Gains

Group data vs. individual data

Sudden Gains = 1-session gain of 7 BDI pts & 25%
improvement

Sudden gains evident in 39% of patients

Gains accounted for 50% of overall treatment gains
–
–
–
11 BDI points on average
tended to be maintained
resulted in improved alliance
(Tang & DeRubeis, 1999; see also Tang et al. 2007, JCCP)