British Medical Bulletin

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British Medical Bulletin 57:101-113 (2001)
© 2001 Oxford University Press

Cognitive therapy for depression

Jan Scott

University Department of Psychological Medicine, Gartnavel Royal Hospital, Glasgow, UK

	Abstract

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
There is considerable empirical support for the use of cognitive therapy in the treatment of mild to moderately severe acute major depression. More recent research has focused on the utility of this approach in severe or chronic depressive disorders, in relapse prevention and also on the potential benefits of combining cognitive therapy with medication. This paper attempts to clarify the empirical data on these important issues in order to identify further the role of cognitive therapy in day-to-day clinical practice. It also provides an overview of findings regarding predictors of response to cognitive therapy and the possible mediators of its effects.

	Introduction

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
The American Psychological Association Task Force¹ published list of empirically validated treatments reports that cognitive therapy (CT) for depression meets all the criteria for designation as a ‘well-established psychological treatment’. Nevertheless, there are still a significant number of unanswered questions regarding the appropriate place of CT in the treatment of depressive disorders. This paper will assess the role of CT through a review of research data published in the last decade. It takes as its starting point the large scale National Institute of Mental Health (NIMH) randomized controlled trial of the treatment of depression². This study represents an important landmark in depression research that influenced thinking about CT, shaping both the research agenda and advice given in clinical guidelines on the treatment of depression^3,4. However, before embarking on the review of subsequent outcome studies, it is useful to recap briefly the basic premises of the cognitive theory and therapy of depression.

	Brief overview of cognitive theory and therapy

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
Beck's⁵ cognitive theory of depression represents a stress-diathesis model. It postulates that some individuals may be vulnerable to depression because they develop dysfunctional beliefs as a result of early learning experiences. These beliefs may be latent for long periods, but become primed by events that carry a specific meaning for that individual. Beck⁶ suggests that the underlying beliefs that render an individual vulnerable to depression may be broadly categorized into beliefs about being helpless or unlovable. Thus events that are deemed uncontrollable or involve relationship difficulties may re-activate these beliefs and be important in the genesis of depressive symptoms. Negative cognitions about the self, world and future are concomitants of depression but serve to re-inforce the core underlying dysfunctional beliefs. The negative automatic thoughts that dominate the thinking of many depressed patients are sustained through systematic distortions of information processing (e.g. focusing only on negative aspects of an interpersonal interaction) and contribute to further depression of affect. Beck⁷ clearly states that whilst the vicious cycle of low mood enhancing negative thinking leading to further lowering in mood may represent a causal theory in some cases, it represents a maintenance model for other depressions. However, he proposes that intervention in the cycle can be effective in alleviating acute depressive symptoms in the latter group.

Cognitive therapy is a collaborative ‘hypothesis-testing’ approach that uses guided discovery to identify and re-evaluate distorted cognitions and dysfunctional beliefs. However, the common misconception that CT simply uses a fixed set of behavioural (e.g. activity scheduling) and cognitive (e.g. challenging automatic thoughts) techniques is unfortunate. The therapy is not simply technique driven. The interventions are selected on the basis of a cognitive conceptualization that uniquely identifies the likely core negative beliefs of that individual and explains the onset and maintenance of their depression. If the patient shows a low level of functioning, behavioural techniques may be used to improve activity levels and improve mood, but the goal is still to identify and modify negative cognitions and maladaptive underlying beliefs. Verbal interventions are initially employed to re-evaluate negative cognitions. Between session experiments, frequently focused on inter-personal functioning, are used to re-evaluate ideas. Later, when the patient has developed his or her cognitive and behavioural skills, these interventions are used to try to modify underlying dysfunctional beliefs. This is critical to the process as the expressed goal of CT is to reduce vulnerability to future depressive relapse.

This brief overview has two aims. First, it highlights the key elements of the cognitive theory that should be assessed in research on the unique mechanisms of action of CT. This is important if we are to understand how CT produces its effect or wish to abbreviate the intervention. Second, the overview clarifies the key components of the therapy. This allows a comparison of CT with other brief psychotherapies (e.g. interpersonal therapy [IPT], behavioural family therapy) for depression. Scott⁸ noted that whilst the emphasis of each approach varies, the brief therapies all assume that cognitive, behavioural, emotional and interpersonal domains are related factors associated with the maintenance of depression and that these are the key targets for change. Not only do brief interventions overlap in their objectives, Teasdale⁹ reported that brief psychotherapies of proven effectiveness in depression demonstrate similarities in their core clinical characteristics (Table 1).

View this table: [in this window] [in a new window]   Table 1 Shared characteristics of effective brief therapies

 
The potential implication of the above is that there will be no specific link between the empirical status of a cognitive or interpersonal theory of depression and the respective clinical effectiveness of CT, IPT or variants of these approaches. Furthermore, we may not be able to demonstrate differences in the efficacy of CT, IPT, or similar interventions. This is important to note. Although CT is the most widely researched brief therapy, there are a number of plausible alternatives that may become equally well established in the future.

	Outcome research

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
The NIMH study² represents an important landmark in depression research. It was the largest (n = 239) multi-model intervention trial of acute depressive disorders ever undertaken. It compared antidepressant medication (ADM) and structured clinical management (CM), with pill-placebo plus CM, CT and IPT. Although the trial confirmed that CT was an effective treatment of mild-to-moderate major depressive disorders, it suggested CT was not an effective treatment for severely depressed out-patients. The trial reported equivocal findings about the effect of CT as compared with ADM in preventing relapse, but noted that chronic symptomatology was a predictor of poor outcome with any intervention. Although previous research data did not concur with all of the findings of Elkin and colleagues², the study greatly influenced published treatment guidelines for depression^3,4. These documents emphasized that CT was best targeted at mild-to-moderate depression. The authors went on to document that there was no robust evidence of any additional benefits of combining CT with ADM, although they recognized that many clinicians would value advice on when to employ this approach in practice. Empirical data are now explored on the role of CT in each of these situations to clarify our current understanding.

Severe depressive disorders

The NIMH study suggested that ADM plus CM outperformed CT in severe depression (defined as a Hamilton Depression Rating Scale score > 21). However, further exploration of the NIMH results revealed that, overall, only 26 subjects with severe depression received CT across three study sites and that ADM was more effective than CT with severely depressed patients at only one centre¹⁰. Furthermore, a similar study by Hollon and colleagues¹¹ did not demonstrate any advantage for ADM in severe depression. A meta-analysis has recently been undertaken¹² to integrate these conflicting data. Outcomes were compared for subjects with severe depression who were treated with ADM (n = 102) or CT (n = 62) from four randomised controlled trials. Response rates to both CT and ADM were over 50% and the overall effect sizes demonstrated no significant differences between treatments (in fact the trends consistently favoured CT). Dropout rates were also comparable (ADM = 39%; CT = 31%).

These findings suggest that CT is as effective as ADM in severe depressive disorders. However, before revising clinical practice guidelines, it is important to note that because an intervention is effective does not automatically make it a treatment of choice. Whilst DeRubeis and colleagues¹² have demonstrated that CT can be an effective alternative to ADM, the findings of two other research groups, led by Thase in the US and by Shapiro in the UK, provide important caveats about the use of CT in severe depression that may also influence a clinician.

In a series of studies, Thase and colleagues demonstrated that individuals with severe depressions, sometimes accompanied by abnormal Dexamethasone Suppression Test (DST) or delayed Rapid Eye Movement (REM) sleep latency, showed a parallel but slower rate of response to CT than those with less severe depressions^13,14. The results suggested a significant dose-response relationship and it was suggested that individuals with severe depression required a more intensive course of CT. Scott and DeRubeis¹⁵ noted a similar phenomenon and commented that CT therapists treating individuals with severe depression tend to target behavioural activation for a prolonged period, rather than cognitive techniques, such as hypothesis testing. This may mean that, in time-limited trials of CT, more severely depressed patients may receive less of the therapy components that are particularly associated with improvement.

Shapiro and colleagues¹⁶ separately pursued this issue, exploring the impact of different lengths of treatment with CT (8 or 16 sessions) on outcome for mild (Beck Depression Inventory [BDI] score < 21), moderate (BDI = 21–26) and severe (BDI > 26) depression. They demonstrated a significant interaction between initial symptom severity and duration of therapy. Individuals with mild or moderately severe depression did equally well with either eight or 16 sessions of CT (50–53% response rate). However, individuals with severe depression demonstrated a significantly improved response rate with 16 sessions (50%) as compared to eight sessions (35%) of CT (Fig. 1).

View larger version (17K): [in this window] [in a new window]   Fig. 1 Effect of longer duration of cognitive therapy or use of combined therapy and medication on response rates in severe depression.

 
Whilst extending the course of therapy may improve the response of severe depressive disorders to CT, an alternative approach is to combine CT with ADM. Previous analyses³ of combined CT and ADM for depression were inconclusive, suggesting that the overall efficacy of the combination (response rate 54–63%) was not significantly different from either treatment alone. However, these analyses did not differentiate outcomes according to initial severity of depression. Thase and colleagues¹⁷ assessed the potential benefits of the combined treatment in less and more severe depressions through a meta-analysis of 595 subjects allocated to different standardized treatment groups including CT or IPT alone (n = 243) or brief therapy in combination with ADM (n = 352). The results demonstrated that the combination of brief therapy with ADM was no more effective than either IPT or CT alone in less severe recurrent depressions. However, in severe recurrent depressive disorders (Fig. 1), the overall response rate to combined therapy (63%) was 3 times higher than to brief psychotherapy alone (20%). An analysis of rate of response also demonstrated no additional benefit of combined versus single therapy in less severe depression – just over 50% of subjects responded to either approach by 16 weeks. However, in severe recurrent depression, 50% of subjects receiving combined treatment responded by 16 weeks as compared to only 26% of those receiving psychological interventions alone.

The above studies only explored the use of brief therapy alone compared with brief therapy plus ADM. Hollon and colleagues^10,11 explored the benefit of CT plus ADM versus either ADM or CT alone in a sample of subjects with moderate and severe depressions. They report a consistent modest advantage in response rates (a 10–15% increment in absolute terms) for combined treatment compared with ADM alone.

Depressive relapses

A common argument for the selective role of CT in the treatment of acute episodes of depression is that a course of therapy is more expensive than a course of ADM. This contention has some validity, but would obviously be weakened if CT had a significant effect on relapse rates. The trend in the NIMH study was for CT to reduce relapse rates¹⁸. Indeed, at 12-month follow-up the relapse rate for CT (9%) was only a third of that of individuals who received ADM plus CM (28%). Furthermore, of the patients who recovered during the treatment phase of the study, only 5% of CT subjects sought further treatment, compared with 38% of IPT and 39% of ADM subjects. Although these differences may be significant, the data are hard to interpret. Like most CT studies of relapse, it comprised a naturalistic follow-up of treatment responders from previously published acute depression studies, sometimes without adequate ADM continuation. An exception is the prospective follow-up¹⁹ of the cohort of subjects treated in the randomised controlled trial of CT and ADM conducted by Hollon et al¹⁰. The relapse rate in the CT group (20%) was not significantly different from that in the ADM continuation treatment group (27%), but was less than half that of subjects whose ADM was withdrawn at the time their depression remitted (50%). Given the strong tendency for individuals to stop taking ADM when they feel better, it is interesting to note that CT appears to have a durable effect beyond the end of a course of treatment.

The use of continuation or maintenance psychotherapy to prevent relapse is a new concept in psychological treatment studies. In two sequential cohort studies, Jarett et al²⁰ demonstrated that, compared with acute phase CT, acute phase CT plus 10 sessions of continuation CT reduced relapse rates over 24 months by an additional 30%. Likewise, in a small 24 month pilot study of atypical depression²¹, subjects who continued to receive phenelzine (relapse rate = 57%) or CT (40%) were significantly less likely to relapse than those who, after initially responding to treatment, stopped receiving either phenelzine (relapse rate = 75%) or CT (83%). In the largest study so far, Blackburn and Moore²² allocated 75 subjects with recurrent major depression to 16 weeks of acute treatment and 2 years of maintenance treatment. The group treatments comprised ADM alone, CT alone or ADM followed by maintenance CT. All three groups improved in the acute phase and there were no between-group differences in relapse rates in the maintenance phases. The authors suggested that maintenance CT is a viable alternative to maintenance medication.

Chronic, residual or treatment refractory depressive disorders

At least 20% of people with an initial episode of major depressive disorder do not recover within 2 years, and those with residual depressive symptoms have a 50–80% risk of a further relapse. The poor response of chronic depression to treatment with ADM alone is not fully understood, but was frequently quoted as a reason for the use of psychotherapy. Unfortunately, a review of nine early psychotherapy studies revealed poor research designs and limited benefits from this alternative¹⁵. Three randomized controlled trials published in the last few years give greater insight into the effectiveness of CT in this patient population. The studies differ in the model of CT used (standardized CT, well-being therapy, cognitive behavioural analysis system psychotherapy) and the samples studied, but together they provide important data on acute, 18 month and longer term (6 year) outcome of chronic depressive disorders.

Keller et al²³ reported a comparison of the efficacy of a single ADM (nefadazone) and a modified version of CT (cognitive behavioural analysis system psychotherapy) given alone, or in combination in a sample of over 650 patients with chronic depressive disorders. The groups were well matched for severity and chronicity of depression at baseline, but more than 20% of those randomized had not received any treatment for their disorder prior to entry into the study and many others had received sub-therapeutic doses of ADM. After 12 weeks, the group receiving the combined treatment had a significantly greater overall reduction in depressive symptoms (an increment of about 25%) as compared with single therapies. Furthermore, almost twice as many people receiving both ADM and CT (42%) met remission criteria as compared to those receiving either ADM or CT alone (22–24%). The study supports the view that the rate of change, i.e. the trajectory of improvement, is faster in people who received a combined as compared with a single therapy. However, this study does not indicate whether response rates continue to improve in those treated with ADM or CT alone, nor whether there were any long-term differences in outcome for subjects in each group.

The other two trials evaluated relapse rates following treatment of chronic depression. Paykel et al²⁴ assessed 158 subjects with residual treatment refractory depressive symptoms throughout 20 weeks of treatment and for a year afterwards. Subjects received ADM plus CM or ADM plus CM plus CT. At 18-month follow-up, relapse rates in the CT group (29%) were reduced by 45–50% compared with the control group and the CT group also showed significantly greater reductions in hopelessness, pessimism, guilt and self-esteem. Subjects who received additional CT showed significantly greater improvements in social adjustment than those receiving ADM plus CM²⁵. Furthermore, those allocated to CT and ADM plus CM had significantly fewer visits with their psychiatrist than the control group. Such findings are clearly important when considering the overall benefits and costs of treatment.

Fava et al²⁶ reported the 6 year outcome of 40 subjects randomly allocated to either CT (a model of called well-being therapy) or to CM. Unlike the other studies of chronic depression, ADM was gradually tapered off, so that most subjects were medication-free during the follow-up phase. At 2 and 4 years, relapses in the CT group were significantly lower than in the CM group. This trend continued at 6 years (CT relapses = 50%; CM = 75%), but was no longer significant. However, subjects in the CT group experienced significantly fewer new episodes of depression (mean = 0.8) than those receiving CM (mean = 1.7) over the 72 months of the study.

	Predictors of response

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
Predictors of response can be divided into patient factors and therapy/therapist factors.

Individual characteristics

A critical issue for clinicians is to try to identify not just which depressed patients may benefit from CT, but which individuals will differentially respond to CT as compared with ADM. Research attempts to characterize this latter group of CT responders have been disappointing. For example, work suggesting certain cognitive variables such as learned resourcefulness or dysfunctional attitudes may predict specific response to CT have not been replicated^27,28. Currently, it is easier to define demographic or clinical limitations to the effectiveness of CT²⁹.

No demographic factors have consistently predicted poor response to CT. Age, gender, ethnicity, IQ and educational status do not appear to be predictors. However, there are some data suggesting that being married may predict a better response to CT than being single²⁷. Also, attrition rates may be higher in younger males of lower socio-economic status³⁰.

As noted previously, severity and chronicity of depression may predict less favourable response to psychological or pharmacological treatments. However, the evidence regarding level of depressive symptoms and response to CT suggests that it may be the nature of the depression (endogenous/melancholic) that predicts poorer response to CT independent of severity²⁸.

The data on the outcome of depression associated with co-morbid personality disorder are equivocal^27,32. Recent studies have clarified that the beliefs held by individuals with certain personality types are more specific predictors of outcome than traditional diagnoses of personality disorder. For example, the NIMH study found that high levels of perfectionism predicted poor outcome of depression with any treatment³³. In a study of 162 subjects with major depressive disorders who were treated with CT, Kuyken and colleagues³⁴ demonstrated that maladaptive avoidant and paranoid beliefs rather than personality disorder status predicted a significant proportion of the variance in depression outcome.

Cognitive variables, such as high pretreatment levels of dysfunctional attitudes may predict poor outcome with ADM or CT²⁷, but the role of other variables such as learned resourcefulness is uncertain²⁸. Addis and Jacobson³⁵ demonstrated that a stronger match between an individual's model of the cause of his or her depression and the treatment offered predicts better response to treatment. This parallels the findings of Fennel and Teasdale³⁶ who showed that individuals who reported a negative reaction to being depressed (referred to as ‘depression about depression’) responded more rapidly to CT than individuals who did not endorse this view.

Therapy factors

An apparently suitable candidate for CT may fail to respond if the therapy is not carried out competently²⁹. Pooled data from 15 psychotherapy studies suggests there is a significant relationship between the therapist's level of training or experience, the degree of adherence to the treatment manual, the type of therapy used (CT being superior to psychodynamic therapies) and patient outcome³⁷. Gortner and colleagues demonstrated a significant correlation between ratings of competency and patient outcome³⁸. In a study of CT in 185 depressed patients, individuals treated by senior therapists (> 4 years' CT experience) showed significantly greater improvement than those treated by novice therapists³². The experience of the therapist is a particularly important determinant of outcome when treating more severe or complex cases²⁹. DeRubeis and Feeley³⁹ demonstrated a significant correlation (r = 0.53) between adherence to symptom focused CT techniques and patient outcome. However, technical fidelity and competency are not the only important ‘intra-therapy’ factors, therapist empathy³² and the therapeutic alliance^11,16 both significantly influence outcome of depression treated with CT.

	Mediators of effect

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
Although there is robust evidence that CT can be an effective treatment of acute depressive disorders and emerging evidence of its prophylactic effect, the process through which CT achieves these effects is not well understood. For example, individuals with good outcome from depression treated with ADM or CT all show reductions in post-treatment levels of dysfunctional attitudes²⁹. Data on changes in depressogenic attributional style (a tendency to attribute negative events to internal, stable, global causes) produced by CT are also equivocal. The lack of evidence for specific cognitive mediators led Persons⁴⁰ to propose that the key therapeutic process may not lead to the cognitive change but be the acquisition of compensatory skills that allowed the individual to cope with isolated depressive symptoms and prevented the symptoms evolving into a depressive episode. However, a recent study⁴¹ sheds new light on cognitive mediation of relapse prevention demonstrating that CT reduced relapse via changes in the style rather than the content of thinking. Good outcome from CT was achieved via reductions in absolutist, dichotomous thinking. Individuals with persistent extreme response styles to depression related material (relapse rate = 44%) were more than 2.5 times as likely to experience early relapse as compared with individuals without this extreme style (relapse rate = 17%). This suggests that training individuals to change the way that they process depression related material, rather than changing their belief in depressive thought content may be a critical component of CT.

	Conclusions

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
Cognitive therapy is the most widely researched brief psychological therapy for depression with over 80 randomized controlled trials assessing its utility in the acute and longer-term outcome of this disorder. Despite empirical data supporting its efficacy, there are still problems in gaining access to CT in clinical practice. As highlighted in the National Service Framework, the psychotherapies of proven effectiveness are not necessarily the most readily available in the mental health services. Given the relative scarcity of CT therapists, it is inevitable that clinicians ask for advice on who should be referred to CT. Previous guidelines suggested that individuals with mild-to-moderately severe depressive disorders are the best candidates for CT. However, it can be argued that, as these individuals are equally likely to respond to ADM and show no additional benefit from combined treatment, their treatment should be either ADM or CT. In mild or moderate depression, referral to brief therapy could be restricted to those who cannot be prescribed or will not adhere to ADM regimens. Given the minimal additional benefit (only a 3% increase in overall response rates) of extended courses of CT (16 sessions) over brief CT in this population, it would be worthwhile monitoring the duration of therapy offered to this patient population and asking therapists to justify extensions of CT beyond 8 sessions. This notion is not intended to be draconian, but rather to ensure that the lessons of research are implemented in day-to-day practice.

This review suggests that clinical practice guidelines on the use of CT in severe depression can now be revised to take into account recent research findings. The data suggest that CT could be used alone in severe disorders if there was a particular contra-indication to medication, provided an extended course of therapy is planned. However, progress with CT alone would be slow and a more acceptable trajectory of change in depressive symptoms (equivalent to that of mild and moderate depression) can be achieved by combining CT with ADM.

Perhaps one of the most important roles of CT in the future will be the treatment of individuals with persistent symptoms that have not responded fully to ADM. Thus the recent studies of CT in management of chronic or residual depressive symptoms are particularly important. There appears to be a significant additional health gain from providing CT as an adjunct to medication in this population that not only improves the rate of improvement, but also reduces specific symptoms that appear to be less amenable to change with ADM (such as hopelessness and self-esteem). Most importantly, the addition of CT to usual treatment appears to protect against future relapse in individuals known to be at high risk of repeated episodes of depression. This durable effect of CT beyond the point of treatment termination is critical to grasp – this is not an effect demonstrated for any ADM. Medication only works for as long as it is prescribed or taken. Furthermore, evidence that 16 sessions of CT prevent relapse in the long-term radically changes the balance between the cost and benefits of this intervention.

It is too early to judge whether continuation or maintenance CT will prove a cost-effective intervention. The clinical imperative for this approach is clear as many individuals with severe and complex disorders benefit from longer-term support. Interestingly, this may be a particularly useful treatment for individuals with bipolar depression. There are accumulating data suggesting that the cognitive style of individuals with bipolar depression is indistinguishable from that of individuals with unipolar depression. Furthermore, there is tentative evidence that CT may be as useful or more useful than ADM in reducing bipolar depressive symptoms without the risk of precipitating hypomania⁴².

	Footnotes

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 
Correspondence to: Prof. Jan Scott, University Department of Psychological Medicine, Gartnavel Royal Hospital, Glasgow G12 0XH, UK

	References

Top Footnotes Abstract Introduction Brief overview of cognitive... Outcome research Predictors of response Mediators of effect Conclusions References

 

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