Cognitive-Behavioral Therapy

for Depression

PSYC 4500: Introduction to Clinical Psychology

Brett Deacon, Ph.D.

November 26, 2013

Welcome Back!

• Catching up

• Please complete course evaluations

Remaining Schedule

• Tuesday 12/3: Eye movement desensitization

and reprocessing

• Herbert et al. article

• Thursday 12/5: Meeting with Laura Delano

• Final exam: Tuesday, 12/10 at 10:15

Very Important Announcement

• I have decided NOT to require you to write

response papers for the last two readings

• I will give all of you full credit for these papers

• The Herbert et al. EMDR article is posted; you

still need to read the articles, ponder the

questions I’ve posted, and come prepared to

discuss the articles

• The Fox et al. prescriptive authority article is

posted in case you’d like to read it

Readings (Blog Posts) for Class with Laura Delano next Thursday 12/5

• http://www.madinamerica.com/2013/02/reflections-on-a-psychiatric-indoctrination-or-how-i-began-to-free-myself-from-the-cult-of-psychiatry/

• http://www.madinamerica.com/2013/05/mental-illness-the-dsm-5-and-dreams-for-a-post-psychiatry-world/

• http://www.madinamerica.com/2013/09/urge-take-life-decision-take-back-mental-health-system-instead/

• Come prepared with 3 written questions

From Last Class

• Cognitive and behavioral processes in anxiety disorders

• Cognitive and behavioral treatment strategies

• Exposure therapy

Exposure Therapy for Snake Phobia video clip

• http://www.youtube.com/watch?v=zKTpecooiec

• Look for educational, cognitive, and behavioral techniques

• What it’s like to be a therapist using this approach?

• What it’s like to be a patient in this therapy?

• Is it torture?

Pediatric OCD Treatment Study (POTS I):

Penn, Duke, & Brown

CBT +SER

n = 28

CBT

n = 28

SER

n = 28

PBO

n = 28

12 Week Treatment Phase

16 Week Follow-up Phase for Treatment Responders

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

SER CBT COMB

Penn

Duke

Pediatric OCD Treatment Study Team (2004). JAMA

Site x Treatment Interaction

Psychotherapist Outcomes for CBT: Pre- and Post-TX CY-BOCS

0

5

10

15

20

25

30

35

40

1 6 5 3 7

Pre-Tx CY-BOCS

Post-TX CY-BOCS

Therapists account for 8.0% of variance within CBT, NS

CBT for Depression

• Assess cognitive and behavioral factors that are contributing to the problem

• Develop cognitive and behavioral strategies to address them

Nature of Depression

• Basic psychological processes that contribute to depression

• Behavioral processes

• Cognitive processes

Cognition in Depression

• Cognitive triad• Negative view of self, world, future

• Depressed persons engage in cognitive errors - tendency to interpret life events negatively

• Examples:• Overgeneralization• All-or-nothing thinking• Mind reading

CBT for Depression

• Basic clinical strategies in CBT for depression

• Education

• Behavior modification techniques: behavioral activation

• Cognitive modification techniques

• Integrating these: behavioral experiments

Education

A → B → C Activating Belief Consequence

Event (Emotion)

Cognitive Restructuring

• http://www.youtube.com/watch?v=45U1F7cDH5k

• Disputing inaccurate thoughts

• 1. Identify the specific, inaccurate thought

• 2. Examine the evidence for alternative possibilities

• 3. Replace it with a more realistic thought

• Goal is to eventually modify core beliefs

Construct Validity of Cognitive Therapy

• Dismantling cognitive therapy for depression: Jacobson et al. (1996)

• Cognitive therapy consists of: (a) behavioral activation, (b) modification of automatic thoughts, (c) modifying core schema

• 150 patients randomly assigned to receive (a) only, (a) + (b), or the full treatment (a + b + c)

• Findings and implications

Construct Validity of Cognitive Therapy

• Does cognitive therapy work?

• Do we need to formally discuss thoughts to change thinking?

• How to choose between cognitive and behavioral interventions of equal benefit?• Evidence base: efficacy and effectiveness• Parsimony• Efficiency• Degree of difficulty to competently deliver

Behavioral Activation

• Basic components

• Self-monitoring of daily activities

• Identifying hierarchy of meaningful, healthy activities

• Gradually scheduling activities into routine

Behavioral Activation

“Behavioral activation. The BA treatment condition utilized in the study was an expanded version of the approach used in the component analysis study, which was based exclusively on the behavioral interventions recommended by A. T. Beck, Rush, Shaw, and Emery (1979). The expanded BA model is based on a conceptualization of depression that emphasizes the relationship between activity and mood and the role of contextual changes associated with decreased access to reinforcers that may serve an antidepressant function. The model highlights the centrality of patterns of avoidance and withdrawal (e.g., of interpersonal situations, occupational or daily-life routine demands, distressing thoughts or feelings, and so forth). Because contacting potential antidepressant reinforcers is often initially punishing, avoidance of contact minimizes distress in the short term but is associated with greater long-term difficulty, both by reducing opportunities to contact potentially antidepressant environmental reinforcers and by creating or exacerbating new problems secondary to the decreased activity. Increased activation is presented as a strategy to break this cycle. In general, BA seeks to identify and promote engagement with activities and contexts that are reinforcing and consistent with an individual’s long-term goals. Specific behaviorally focused activation strategies include self-monitoring, structuring and scheduling daily activities, rating the degree of pleasure and accomplishment experienced during engagement in specific daily activities, exploring alternative behaviors related to achieving participant goals, and using role-playing to address specific behavioral deficits. In addition, the expanded BA model includes an increased focus on the assessment and treatment of avoidance behaviors, the establishment or maintenance of regularized routines, and behavioral strategies for targeting rumination, including an emphasis on the function of ruminative thinking and on moving attention away from the content of ruminative thoughts toward direct, immediate experience.”

Dimidjian et al., 2007

Emerging Research on CBT for Depression: Short-Term Outcomes of Cognitive Therapy vs. Antidepressants

DeRubeis et al., 2005

Emerging Research on CBT for Depression: Long-Term Outcomes of Cognitive Therapy vs. Antidepressants

Hollon et al., 2005

“Patients withdrawn from CT were significantly less likely to relapse during continuation than patients withdrawn from medications (30.8% vs 76.2%; P=.004), and no more likely to relapse than patients who kept taking continuation medication (30.8% vs 47.2%; P=.20). There were also indications that the effect of CT extends to the prevention of recurrence.”

CT vs. BT vs. Antidepressants: Short-Term

Dimidjian et al., 2007

CT vs. BT vs. Antidepressants: Long-Term Maintenance of Gains

Dobson et al., 2008

CT and BT vs. Antidepressants: Long-Term Cost-Effectiveness

Dobson et al., 2008

Aaron Beck Therapy Session

• Begin at 17:40

• Cognitive therapy for a woman with depression

• Look for use of education and cognitive restructuring

• What it’s like to be a therapist using this approach?

• What it’s like to be a patient in this therapy?