Cognitive Behavioural Therapy for Depression in Adults

Cognitive behavioral therapy (CBT) is an effective tool in the treatment of depression in adults. This therapy considers depression as a consequence of negative thoughts, which primarily reflect violations in the perception and assessment of events. The essence of CBT lies in the thorough study of negative thoughts, the detection of distortions, and their correction in the process of cognition. Cuijpers et al. (2013) state that “cognitive” refers to the fact that processes occurring in a depressed patient should be realized by him or her. This is a policy for receiving CBT to address processes that cause mental stress and improve one’s psychological condition. In other words, people who suffer from depression have a cognitive pattern of self-esteem that reduces their value: they have a rather strong tendency to the negative assessment of their actions and their behavior and generally evaluate their abilities as inferior. This feature of thought operates almost automatically, and, in a depressed patient, it is implemented quite deeply combined with a pessimistic view on life.

CBT is the method that allows (if necessary) to correct unconscious perceptions of a patient that are also called “automatic”. A patient perceives them as truth, but in reality, they can greatly distort the actual events. These thoughts often become a source of painful emotions and inadequate behavior, as well as depressions, anxiety disorders, and other diseases. In their study, Driessen et al. (2013) note that patients suffering from depression disorder tend to have a rather pronounced super-ego. They feel hopeless and helpless and have unrealistically negative self-esteem along with the unconstructive evaluation of a specific situation and everyday events. The mentioned article is beneficial as it identifies the signs of depression. Among other symptoms, there are extremely pessimistic views on the future, the inability to recognize positive aspects, the loss of self-confidence and self-respect, as well as destructive emotions that are fraught with setbacks and slow down the recovery. In this regard, cognitive behavioral therapy is designed to give a patient the opportunity to understand the constantly recurring pessimistic assessments of his or her personality and environment, and also help him or her to gain a more optimistic vision by avoiding and preventing inherent negative thoughts.

In the study by Cuijpers et al. (2013), it was shown that CBT in the phase of work with acute depression is inferior in effectiveness to drug treatment of severe depressions, and this determined the approach of the American Psychiatric Association (APA) to the prevalence of treatment. However, approximately two-thirds of the scholarly studies indicate that the effectiveness of CBT in depression is at least as effective as that of antidepressants. Estimates of this type are complex, since the question of the application of a particular treatment always remains, be it of psychotherapeutic or medicated nature. This article’s value is in that it indicates that data on the lower efficiency of CBT, as the authors believe, exist due to the fact that not all psychotherapists are able to adequately use it since the degree of inadequacy is rising as the severity of depression increases. Therefore, the occurrence of CBT is identified by the specific approach to a patient, his or her awareness of this method, and any other factors that may affect the effectiveness of the treatment.

Key Issues

Individual Approach

Comparing cognitive behavioral therapy with other methods such as behavioral therapy and medication, Cuijpers et al. (2013) conducted a meta-analysis of 115 studies related to depression in adults. The results of the research show that cognitive therapy is superior in efficiency to purely behavioral procedures and non-directive forms of therapy. The similar result was obtained by Chiang et al. (2015), who compared groups with a client-centered approach to the treatment of depression (study value). All these data makes the untenable attempts to explain the positive effects of group cognitive therapy with general factors or the structuredness of behavioral procedures. However, both of the mentioned studies emphasize that there is a need for further research due to the lack of evidence and the detailed investigation of the theme.

Arch, Wolitzky-Taylor, Eifert, and Craske (2012) compared the effectiveness of cognitive therapy and acceptance and commitment therapy (ACT) for anxiety disorders in terms of the randomized trial method. 67 patients were randomly divided into two groups – subjected to ACT and CBT, respectively. Cognitive therapy lasted a maximum of six sessions, and ACT involved one session-by-session mediation. It turned out that cognitive treatment reduced the signs of anxiety according to Anxiety Sensitivity Index (ASI) and Believability of Anxious Feelings and Thoughts (BAFT). The indicators significantly improved and remained so after the completion of the treatment for 3-6 months. In addition, some patients who underwent pharmacotherapy needed additional therapy later, while only ten percent of patients who had undergone cognitive therapy turned to re-therapy. This article is worth considering as it reflects the longitudinal perspective of BCT for depression in adults.

Accelerating the resolution of positive symptoms, cognitive therapy is also effective in treating patients with human immunodeficiency virus (HIV). In the study by Safren et al. (2012), the patients receiving inpatient treatment for HIV were given a course of individual and group cognitive therapy, consisting of four procedures performed in stages during their stay in the hospital. During a randomized controlled trial involving 89 respondents, cognitive behavioral therapy for adherence and depression (CBT-AD) was provided for careful analysis and verification of the key delusional beliefs. The enhanced treatment as usual (ETAU) was conducted in the form of group meetings of hospital patients (up to six people), whose participants offered alternative explanations for the irrational beliefs of other patients, questioned negative perceptions of HIV illness, and supported each other in their attempts to integrate the concept of disease into their lives and to develop new coping strategies. This article provides good research as it explores the effect of therapy on adult patients with HIV.

Cognitive behavioral psychotherapy by Beck presents a number of techniques for the treatment of depression, fears, and personality disorders. The cognitive part of it consists in the fact that pathogenic or inadequate thoughts, beliefs, assumptions, and expectations that precede pathological feelings of depression or behavior are revealed (Mohr et al., 2012). Thoughts manifest themselves in different ways – in conversation, systematic notes (special diaries) of thoughts, feelings, behavior, events, confrontation, role-playing game, etc. Beck proposed that a therapist changes a patient’s behavior by means of the so-called Socratic dialogue and comparison with reality presented and described by a certain patient. The effectiveness of cognitive behavioral psychotherapy by Beck has been studied since 1977 in 16 studies at a high scientific level and with great success. The therapy lasted from four to 24 weeks. In seven studies, less than ten sessions were conducted. In all groups, all the measured parameters, including symptomatology, personality, and general health significantly improved in comparison with the control groups.

Following the ideas and findings elaborated by Beck, Mohr et al. (2012) explored the effectiveness of telephone-administered cognitive behavioral therapy (T-CBT) compared to face-to-face CBT. The authors utilized a randomized controlled trial within three years and focused on 325 participants. As a result of 18 sessions, the authors came to the conclusion that those who received face-to-face CBT were less prone to depression rather than those who were provided with T-CBT. More to the point, the explanation of the results should also be noted. The effectiveness of the therapeutic relationships depends to a large extent on the ability of a patient to experience and express emotions during the session (Mohr et al., 2012). Depressive patients often have a feeling of their own “unnaturalness”. Consistent with Hoifodt et al. (2013), they find it difficult to tell others about their negative feelings, since they are ashamed and forced to hide them behind the social attitude. Adult patients with depression interpret the above fact as dishonesty in relation to other people. Therefore, many of them say that by itself the possibility of open expression of emotions, the opportunity to “be oneself” helps them feel honest and sincere. The two above article provide important insights on the therapeutic relationships between a therapist and a patient.

Group Therapy

Several scholarly articles investigate the effectiveness of group cognitive behavioral therapy. The majority of them reveal the enhanced health outcomes in patients, yet those that discover ineffectiveness of CBT also exist. There is enough data to show that group cognitive therapy leads to the elimination or significant alleviation of the initial symptomatology. Plenty of depressed adult patients had a significant decrease in Beck Depression Inventory (BDI) scores after a course of group therapy.

Chiang et al. (2015) treated two groups of depressed patients: intervention and control ones. The overall result of both groups was compared with the results of patients who underwent a course of group cognitive therapy accompanied by a series of brief supportive contacts with a psychotherapist. The authors found that group cognitive behavioral therapy is superior to pharmacotherapy by results, yet it is inferior to individual therapy. Taking a BDI score of no more than nine for a complete remission certificate, they state that that “the average BDI-II score of the experimental group was reduced from 40.30 (SD = 9.09) points at the pretest to 10.17 (SD = 4.33) points at the posttest” (Chiang et al., 2015, p. 8). In other words, group therapy effectively decreased the level of depressive thoughts in patients and revealed that by learning to reconstruct their thoughts, patients might improve their health condition.

In the study of Nakagawa et al. (2014), group cognitive behavioral therapy was directly correlated with individual cognitive therapy, while the latter was carried out both in pure form and in combination with pharmacotherapy. Based on assessor-blinded randomized and parallel-groups superiority trial, all the therapeutic modalities used led to weakening of the initial symptomatology, the effect of individual cognitive therapy was significant. After a ten-week course of therapy, complete remission was noted in 40 percent of the group patients. It is also interesting to note that 18 percent of patients did not complete treatment with group therapy due to several reasons.

The results of the above two studies seem to suggest that group cognitive behavioral therapy is less effective than individual cognitive therapy and is characterized by higher retirement rates. However, such a conclusion seems to be premature. In their study, Chiang et al. (2015) compared samples that are not comparable in the strict sense. The selection of patients for individual cognitive therapy in pure form and individual cognitive therapy in combination with drug treatment was random, while Nakagawa et al. (2014) did not focus on a randomly selected sample. The patients undergo changes over time that may not be noticeable, but have a significant effect on the results of the study. To draw conclusions about the comparative effectiveness of group cognitive therapy based on quasi-experimental comparisons, it is essential to conduct further research. The results of these studies merely demonstrate the possibility of using group cognitive behavioral therapy in the treatment of depressed adult patients, but do not give grounds to state unambiguously that group therapy occupies an intermediate position between less effective pharmacotherapy and more effective individual cognitive behavioral therapy.

Comparison of Cognitive Therapy and Medication Effectiveness

CBT in scholarly studies shows higher efficacy (the effect strength is average) compared with no treatment or waiting for treatment as noted by Yoshimura et al. (2013), Stangier et al. (2013), etc. The studies comparing the effectiveness of CBT with that of short-term psychodynamic therapy, problem-solving, and interpersonal therapy demonstrate conflicting results. A number of studies have concluded that the methods listed above are approximately equal in effectiveness (for example, Cuijpers et al., 2013), while other studies find evidence of higher efficacy of CBT (Driessen et al., 2013). Thus, Yoshimura et al. (2013) illustrate a benefit of CBT compared to relaxation techniques (after treatment), and Stangier et al. (2013) – a higher efficacy of CBT compared with psychodynamic therapy. When revealing the effectiveness of CBT in comparison with psychopharmacological treatment, the researchers come to the conclusion that their effectiveness with respect to chronic symptoms of depression is approximately the same, while the strength of the effect is medium-high. In this case, the combination of CBT with pharmacotherapy is a more effective treatment method than the use of CBT in a separate manner.

Risk of Repeated Depression

According to modern protocols for depression therapy, CBT and pharmacotherapy with antidepressants are the two main methods of therapy in adult depression. In a depressive episode of mild to moderate degree, the two methods are equally effective, since all depression symptoms, including biological ones, are also reduced. In case of severe depression, pharmacotherapy is more effective as an isolated treatment method, and combining pharmacotherapy and CBT is even more effective than using isolated antidepressant therapy (Stangier et al., 2013). In addition, the combination of pharmacotherapy and CBT is more effective in recurrent depression: studies have shown that the addition of CBT to pharmacotherapy significantly reduces the frequency of relapses.

A meta-analysis of eight studies by Gloaguen comparing the risk of relapse in patients after treatment with CBT or antidepressants led to the following generalized conclusion: on average, only 29.5percent of patients receiving CBT had relapses versus 60 percent in those who received only antidepressants (Cuijpers et al., 2012). In 2013, the Lancet journal published the results of the mentioned study showing that in patients with severe depressive depression, who were not helped by antidepressant medication, CBT used as a supplement to pharmacotherapy, can reduce the symptoms of depression and improve the quality of life of patients.

Web-Based Approach

Taking into account the rapid development of technology, new approaches are also introduced in psychology (Donker et al., 2013). The recent automated online non-inferiority trial compared face-to-face CBT and interpersonal psychotherapy (IPT) delivered via the Internet. IPT participants show less satisfaction with the treatment provided rather than their colleagues, who received face-to-face CBT. However, the results regarding depression level were almost the same: both of the treatment options led to the significant reduction of the depressive behaviors. Consistent with Berking, Ebert, Cuijpers, and Hofmann (2013), the long-term effectiveness of the therapy depends on the patient’s use of the skills acquired during the treatment, and the latter remain at the patient’s disposal after the completion of the therapy.

Inadequacies or Contradictions

The negative impact of the members of the group on each other was noted by Johnsen and Friborg (2015). The authors presented data that prove that the presence of a depressed person in a group can enhance the dysphoric feelings of the rest of the group and lead to the fact that other participants will reject this person. Although this study examined the effects of interaction between depressive and non-depressive patients, based on the dynamics of the phenomenon, it could be assumed that in a homogeneous group consisting only of depressed patients, the same picture will be observed. In particular, it is possible to state that the participants of the group will be irritated and hostile to each other.

Limitations

Systematic studies devoted to the study of the results of cognitive behavioral therapy have shown that this method offers great opportunities in the treatment of depression. However, more research is needed to confirm this conclusion and indicate the limits of the applicability of the mentioned approach to specific types of depression. As an example, it is possible to mention the so-called “borderline” depressive states that were not investigated yet. There is the lack of the consideration of the social and personal characteristics of patients, such as level of education, attitude to psychotherapy, mind or character, “the power of the Ego,” and various demographic factors, as noted in the study by Unwin, Tsimopoulou, Kroese, and Azmi (2016). The effectiveness of cognitive behavioral therapy has been proven only in cases of monopolar non-psychotic depression (Hans & Hiller, 2013). For patients with severe forms of depression, bipolar affective disorders, and suicidal patients, standard procedures are to be used.

Future Research Direction

In general, based on the above studies, it can be argued that cognitive behavioral therapy can be used in the treatment of depression in adults quite effectively and that, in its effectiveness, it is not inferior to other modalities except for individual cognitive therapy. The conclusion is encouraging, but not final. It should be noted that this initial data would give impetus to new, more thorough and rigorously researched studies comparing group cognitive behavioral therapy with other viable approaches, especially with individual cognitive therapy. Various types of patients and care settings are to be explored as well. In addition to the above, it should be noted that at present, science does not have sufficient data to accurately assess the effectiveness of group therapy in terms of preventing depression relapses. It is not known whether it causes the same effects as individual cognitive therapy or not. The future research would contribute to the deeper investigation of the effectiveness of cognitive behavioral therapy for depression in adults by eliminating the existing gaps and revealing new challenges and opportunities.

References

Arch, J. J., Wolitzky-Taylor, K. B., Eifert, G. H., & Craske, M. G. (2012). Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders. Behaviour Research and Therapy, 50(7), 469-478.

Berking, M., Ebert, D., Cuijpers, P., & Hofmann, S. G. (2013). Emotion regulation skills training enhances the efficacy of inpatient cognitive behavioral therapy for major depressive disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 82(4), 234-245.

Chiang, K. J., Chen, T. H., Hsieh, H. T., Tsai, J. C., Ou, K. L., & Chou, K. R. (2015). One-year follow-up of the effectiveness of cognitive behavioral group therapy for patients’ depression: A randomized, single-blinded, controlled study. The Scientific World Journal, 2(1), 1-11.

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. The Canadian Journal of Psychiatry, 58(7), 376-385.

Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: A meta-analysis. Clinical Psychology Review, 32(4), 280-291.

Donker, T., Bennett, K., Bennett, A., Mackinnon, A., van Straten, A., Cuijpers, P.,… Griffiths, K. M. (2013). Internet-delivered interpersonal psychotherapy versus internet-delivered cognitive behavioral therapy for adults with depressive symptoms: Randomized controlled noninferiority trial. Journal of Medical Internet Research, 15(5), 82-96.

Driessen, E., Van, H. L., Don, F. J., Peen, J., Kool, S., Westra, D.,… Dekker, J. J. (2013). The efficacy of cognitive-behavioral therapy and psychodynamic therapy in the outpatient treatment of major depression: A randomized clinical trial. American Journal of Psychiatry, 170(9), 1041-1050.

Hans, E., & Hiller, W. (2013). Effectiveness of and dropout from outpatient cognitive behavioral therapy for adult unipolar depression: A meta-analysis of nonrandomized effectiveness studies. Journal of Consulting and Clinical Psychology, 81(1), 75-88.

Hoifodt, R. S., Lillevoll, K. R., Griffiths, K. M., Wilsgaard, T., Eisemann, M., Waterloo, K., & Kolstrup, N. (2013). The clinical effectiveness of web-based cognitive behavioral therapy with face-to-face therapist support for depressed primary care patients: Randomized controlled trial. Journal of Medical Internet Research, 15(8), 153-172.

Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747-768.

Mohr, D. C., Ho, J., Duffecy, J., Reifler, D., Sokol, L., Burns, M. N.,… Siddique, J. (2012). Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: A randomized trial. Jama, 307(21), 2278-2285.

Nakagawa, A., Sado, M., Mitsuda, D., Fujisawa, D., Kikuchi, T., Abe, T.,… Ono, Y. (2014). Effectiveness of cognitive behavioural therapy augmentation in major depression treatment (ECAM study): Study protocol for a randomised clinical trial. BMJ Open, 4(10), 1-13.

Safren, S. A., O’cleirigh, C. M., Bullis, J. R., Otto, M. W., Stein, M. D., & Pollack, M. H. (2012). Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 80(3), 404-415.

Stangier, U., Hilling, C., Heidenreich, T., Risch, A. K., Barocka, A., Schlösser, R.,… Weck, F. (2013). Maintenance cognitive-behavioral therapy and manualized psychoeducation in the treatment of recurrent depression: A multicenter prospective randomized controlled trial. American Journal of Psychiatry, 170(6), 624-632.

Unwin, G., Tsimopoulou, I., Kroese, B. S., & Azmi, S. (2016). Effectiveness of cognitive behavioural therapy (CBT) programmes for anxiety or depression in adults with intellectual disabilities: A review of the literature. Research in Developmental Disabilities, 51(1), 60-75.

Yoshimura, S., Okamoto, Y., Onoda, K., Matsunaga, M., Okada, G., Kunisato, Y.,… Yamawaki, S. (2013). Cognitive behavioral therapy for depression changes medial prefrontal and ventral anterior cingulate cortex activity associated with self-referential processing. Social Cognitive and Affective Neuroscience, 9(4), 487-493.