Cognitive Behavioral Treatment of Cognitive Behavioral Treatment of

Major DepressionMajor Depression

The original version of these slides was provided by The original version of these slides was provided by

Michael W. Otto, Ph.D. Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston the Center for Anxiety and Related Disorders at Boston

UniversityUniversity

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Presentation information is listed in the notes section Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode).below the slide (in PowerPoint normal viewing mode).

References are also provided on the slide, or at times, References are also provided on the slide, or at times, in the note sections.in the note sections.

Why Consider CBT for the Treatment of Why Consider CBT for the Treatment of Major Depression?Major Depression?

AcceptableAcceptable– Recent meta-analysis indicates that psychotherapy is preferred 3:1 Recent meta-analysis indicates that psychotherapy is preferred 3:1

to pharmacotherapy for depressionto pharmacotherapy for depression (McHugh et al., 2013, J Clin (McHugh et al., 2013, J Clin Psychiatry)Psychiatry)

Efficacious and Cost-Effective Efficacious and Cost-Effective – CBT is more cost-effective than pharmacotherapy over follow-up CBT is more cost-effective than pharmacotherapy over follow-up

periods) (periods) (Dobson et al. 2009; Hollon et al. 200x)Dobson et al. 2009; Hollon et al. 200x) Long-term Maintenance of GainsLong-term Maintenance of Gains

– CBT has a strong enduring effect over time CBT has a strong enduring effect over time (Cuijpers et al., 2013, (Cuijpers et al., 2013, BMJ open)BMJ open)

CBT Efficacy Extends Across SettingsCBT Efficacy Extends Across Settings1. From the Research Clinic to the Outpatient Clinic1. From the Research Clinic to the Outpatient Clinic

Outpatient CBT in clinical settings offers significant benefits, Outpatient CBT in clinical settings offers significant benefits, although…although…– According to meta analysis, the degree of benefit offered According to meta analysis, the degree of benefit offered

by CBT in the clinic may be somewhat less than what is by CBT in the clinic may be somewhat less than what is achieved in controlled clinical trials, it still reflects achieved in controlled clinical trials, it still reflects important benefit on both depression (d=1.13) and important benefit on both depression (d=1.13) and secondary outcomes (d=.67-.88) for within subject benefitssecondary outcomes (d=.67-.88) for within subject benefits

– Dropout rates for such treatment are in the range of 25%Dropout rates for such treatment are in the range of 25%(Hans & Hiller, 2013, JCCP)(Hans & Hiller, 2013, JCCP)

CBT Efficacy Extends Across SettingsCBT Efficacy Extends Across Settings2. Across Formats/Patient Subgroups2. Across Formats/Patient Subgroups

CBT for depression offers CBT for depression offers Benefits when offered in a group, albeit less than achieved in individual Benefits when offered in a group, albeit less than achieved in individual

therapy, but this difference is attenuated over time therapy, but this difference is attenuated over time (Hunt et al., 2012, Br J (Hunt et al., 2012, Br J Psychiatry, 200, 184-90).Psychiatry, 200, 184-90).

Benefit for older people as judged by meta analysis of 23 studies Benefit for older people as judged by meta analysis of 23 studies (Gould (Gould et al., 2012, J Am Geriatr Soc, 60, 1817-30)et al., 2012, J Am Geriatr Soc, 60, 1817-30)

Similar gains in those with and without disability benefits Similar gains in those with and without disability benefits (Ebrahim et al., (Ebrahim et al., 2012, PLoS One)2012, PLoS One)

Benefit when offered as a brief (6 to 8 sessions) treatment (controlled Benefit when offered as a brief (6 to 8 sessions) treatment (controlled effect size = .42) effect size = .42) (Nieuwsma et al., 2012, Int J Psychaitri Med, 43, 129-51)(Nieuwsma et al., 2012, Int J Psychaitri Med, 43, 129-51)

Benefit for medical populations such as cancer patients Benefit for medical populations such as cancer patients (check Hart et al., (check Hart et al., 2012, J Natl Cancer Inst, 2012, 104: 990-1004).2012, J Natl Cancer Inst, 2012, 104: 990-1004).

CBT vs. Other PsychotherapiesCBT vs. Other Psychotherapies CBT and IPT appear to offer similar outcomes when CBT and IPT appear to offer similar outcomes when

offered for unipolar depressionoffered for unipolar depression– (Jakobsen et al., 2012, Psychol Med, 42, 1343-1357)(Jakobsen et al., 2012, Psychol Med, 42, 1343-1357)

Similar outcomes for Cognitive Therapy (CT) and Behavioral Similar outcomes for Cognitive Therapy (CT) and Behavioral Activation (BA), with advantages over supportive therapies Activation (BA), with advantages over supportive therapies (Braun et al., 2013, Plos One)(Braun et al., 2013, Plos One)

Whether CBT differs from focused dynamic therapy or supportive Whether CBT differs from focused dynamic therapy or supportive therapy depends on the specific studies included in meta-therapy depends on the specific studies included in meta-analyses analyses (cf., Tolin, 2010, Clin Psychol Rev; Braun et al., 2013)(cf., Tolin, 2010, Clin Psychol Rev; Braun et al., 2013)

Perspectives on More Severe Depression Perspectives on More Severe Depression

Early evidence that ADM may outperform CBT for Early evidence that ADM may outperform CBT for moderate to severe depression moderate to severe depression (Elkins et al., 1989)(Elkins et al., 1989)…………But this association has not stood up in subsequent But this association has not stood up in subsequent trials trials (e.g., DeRubeis et al., 2005)(e.g., DeRubeis et al., 2005), with evidence that , with evidence that CBT offers protection from relapse CBT offers protection from relapse (Hollon et al., 2005, (Hollon et al., 2005, Arch Gen PsychiatryArch Gen Psychiatry) in these patients) in these patients

See the following example findings…See the following example findings…

CT vs. ADM vs. Placebo for Moderate to Severe DepressionCT vs. ADM vs. Placebo for Moderate to Severe Depression

DeRubeis et al, 2005 Arch Gen Psychiatry

Sustained ImprovementSustained Improvement(Hollon et al. 2005, Arch Gen Psychiatry) (Hollon et al. 2005, Arch Gen Psychiatry)

CBT Helps Protect Against RelapseCBT Helps Protect Against Relapse Meta-Analysis of Acute Phase Treatment (ADMs were Meta-Analysis of Acute Phase Treatment (ADMs were

discontinued) discontinued) (Vittengl et al., 2009; JCCP)(Vittengl et al., 2009; JCCP)– CT vs. ADM (7 studies): CT associated with a 61% less CT vs. ADM (7 studies): CT associated with a 61% less

relapse/recurrencerelapse/recurrence– Addition of CT to pharmacotherapy (6 studies): adding CT Addition of CT to pharmacotherapy (6 studies): adding CT

associated with a 61% less relapse/recurrenceassociated with a 61% less relapse/recurrence Example Study Example Study (Dobson et al., 2008, JCCP)(Dobson et al., 2008, JCCP)

– CT and Behavioral Activation (BA) each equal to continuation CT and Behavioral Activation (BA) each equal to continuation of medication and better than ADM withdrawal for protecting of medication and better than ADM withdrawal for protecting against relapse (BA at a trend-level advantage)against relapse (BA at a trend-level advantage)

CBT for Medication-Resistant DepressionCBT for Medication-Resistant Depression

Fava et al., 1997Fava et al., 1997 19 Patients who failed 2 trials of ADMs19 Patients who failed 2 trials of ADMs Mean 15 Mean 15 4 sessions of CBT 4 sessions of CBT 63% remission rate63% remission rate Maintenance at two years (83%)Maintenance at two years (83%)

Residual Symptoms and RelapseResidual Symptoms and Relapse

Residual symptoms are a predictor of relapse over time Residual symptoms are a predictor of relapse over time (Jarrett et al., 2008, J Affect Disord)(Jarrett et al., 2008, J Affect Disord), encouraging full , encouraging full treatment of depression before cessation of treatmenttreatment of depression before cessation of treatment

Example Study Example Study (Thase et al., 1992)(Thase et al., 1992)– 9 % Relapse among full responders9 % Relapse among full responders– 52 % Relapse among patients with residual symptoms52 % Relapse among patients with residual symptoms

CBT for Prevention of Recurrent DepressionCBT for Prevention of Recurrent Depression

40 recovered outpatients40 recovered outpatients Random assignment to CBT or clinical management Random assignment to CBT or clinical management

(CM), tapering of ADMs(CM), tapering of ADMs 2-yr relapse rates:2-yr relapse rates:

– CBTCBT 25%25%– CMCM 80%80%

(Fava et al., 1998)(Fava et al., 1998)

Ratings of Therapeutic AllianceRatings of Therapeutic Alliance

CBT > Psychodynamic-InterpersonalCBT > Psychodynamic-Interpersonal

Alliance was correlated with impact (helpfulness) of the Alliance was correlated with impact (helpfulness) of the sessionsession

(Raue et al., 1997)(Raue et al., 1997)

A nice reminder that “doing” in therapy is importantA nice reminder that “doing” in therapy is important Primary treatment strategies Primary treatment strategies

– Self-monitoring of daily activities and moodSelf-monitoring of daily activities and mood– Week-by-week scheduling of activities that bring Week-by-week scheduling of activities that bring

patients a sense of pleasure or masterypatients a sense of pleasure or mastery– Identifying and reducing avoidance behaviors that Identifying and reducing avoidance behaviors that

increase depressive symptoms. increase depressive symptoms.

Behavioral Activation (BA) TreatmentBehavioral Activation (BA) Treatment

BA typically has received less attention than CT, despite BA typically has received less attention than CT, despite evidence of similar efficacy evidence of similar efficacy (e.g., Dimidjian et al., 2006, (e.g., Dimidjian et al., 2006, JCCP 2006; Jacobson et al., 1996, JCCP)JCCP 2006; Jacobson et al., 1996, JCCP)

BA has been shown to be efficacious for treatment of BA has been shown to be efficacious for treatment of depression across a diverse array of samples (e.g., depression across a diverse array of samples (e.g., inpatients, patients with cancer, smokers).inpatients, patients with cancer, smokers).

Adaptable in length Adaptable in length – 6-session BA treatment for illicit drug users significantly 6-session BA treatment for illicit drug users significantly

reduced depressive symptoms reduced depressive symptoms (Magidson et al., 2011)(Magidson et al., 2011)– Potential role in early intervention: A single session of BA Potential role in early intervention: A single session of BA

followed by two weeks of activity assignments reduced followed by two weeks of activity assignments reduced depressive symptoms in undergraduates (d = 1.61) depressive symptoms in undergraduates (d = 1.61) (Gawrysiak et al., 2009, J Counseling Psych)(Gawrysiak et al., 2009, J Counseling Psych)

In the last decade, BA has enjoyed diverse In the last decade, BA has enjoyed diverse application as a brief treatmentapplication as a brief treatment

Problem Solving InterventionsProblem Solving Interventions Strong effect sizes for problem solving therapy for Strong effect sizes for problem solving therapy for

depression depression (Bell & E’Zurilla, 2009, Clin Psychol Rev)(Bell & E’Zurilla, 2009, Clin Psychol Rev) Elements: Elements:

– Training in a positive problem orientation Training in a positive problem orientation – Training in problem-solving skills:Training in problem-solving skills:

problem definition and formulation problem definition and formulation generation of alternativesgeneration of alternativesdecision makingdecision making solution implementation and verificationsolution implementation and verification

Treatment ConsiderationsTreatment Considerations

Structure of the SessionStructure 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:emotionsproblemschange process

Structure of SessionsStructure 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 EffortCBT: A Collaborative Effort

Active collaboration (patient as cotherapist)Active collaboration (patient as cotherapist) Review of the week, rehearsals, roleplays and other Review of the week, rehearsals, roleplays and other

active practice in sessionactive practice in session Practice of skills in life through weekly assignments Practice of skills in life through weekly assignments

ranging from monitoring of thoughts and other ranging from monitoring of thoughts and other behaviors to rehearsal of skills in specific contextsbehaviors to rehearsal of skills in specific contexts

Session 1 - Establishing a Cotherapist Session 1 - Establishing a Cotherapist on the Caseon the Case

To help the patient be an active cotherapist in treatment, provide a:Model of the disorderModel of the change processInformation on the role of the patient

Elements of TreatmentElements of TreatmentCognitive Restructuring and Skill AcquisitionCognitive Restructuring and Skill Acquisition

RestructuringRestructuring Education (role andEducation (role and

nature of thoughts)nature of thoughts) Self-monitoringSelf-monitoring

of thoughtsof thoughts Identification of errorsIdentification of errors Substitution ofSubstitution of

useful thoughtsuseful thoughts Core beliefs and strategiesCore beliefs and strategies

Skill acquisitionSkill acquisition AssertivenessAssertiveness

Communication skillsCommunication skills

Problem solvingProblem solving

Cognitive RestructuringCognitive Restructuring

Examine the evidence for the thoughtExamine the evidence for the thought Generate alternative explanationsGenerate alternative explanations De-catastrophizeDe-catastrophize Debunk Debunk ““shouldsshoulds”” Find the logical errorFind the logical error Test out its helpfulnessTest out its helpfulness

Questions Used to Formulate Rational Questions Used to Formulate Rational ResponseResponse

What is the evidence that the automatic thought is true? What is the evidence that the automatic thought is true? Not true?Not true?

Is there an alternative explanation?Is there an alternative explanation? What is the What is the worstworst that could happen? Would I live that could happen? Would I live

through it?through it? WhatWhat’’s the s the bestbest that could happen? that could happen? WhatWhat’’s the most s the most realisticrealistic outcome? outcome?

Questions Used to Formulate Rational Questions Used to Formulate Rational Response (ContResponse (Cont’’d)d)

What is the effect of my believing the automatic What is the effect of my believing the automatic thought?thought?

What is the cognitive error?What is the cognitive error? If a friend was in this situation and had this thought, If a friend was in this situation and had this thought,

what would I tell him/her?what would I tell him/her?

Targets for Cognitive RestructuringTargets for Cognitive Restructuring

Emotional tone of self talk Distortions in interpretations of events Core beliefs Development of adaptive thinking

Respecting Hot EmotionsRespecting 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

Self-monitoring of daily activities and moodSelf-monitoring of daily activities and mood Week-by-week scheduling of activities that bring Week-by-week scheduling of activities that bring

patients a sense of pleasure or masterypatients a sense of pleasure or mastery Identifying and reducing avoidance behaviors that Identifying and reducing avoidance behaviors that

increase depressive symptoms. increase depressive symptoms.

Behavioral Activation (BA) TreatmentBehavioral Activation (BA) Treatment

Activity Assignments - 1Activity Assignments - 1

Used in conjunction with cognitive restructuringHelp ensure that therapy is not over-focused on

thinking rather than doingStarts with monitoring of activities and setting of

goals for valued activities for both pleasure and mastery (competence goals)

Activity Assignments - 2Activity Assignments - 2

When structuring assignmentsStart where the patient isBe specific about assignments (defining desired outcomes

specifically)Rehearse elements in sessionTroubleshoot problems and signpostsReview cognitions (expectations and concerns)

Activity Assignments - 3Activity 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 PhaseWell-Being Therapy Phase

Consolidate skills Focus on increasing the positive not just

reducing the negative Fade out treatment

Relapse Prevention - Relapse Prevention - Metacognitive AwarenessMetacognitive Awareness

Classic CT and Mindfulness-based CT both enhance Classic CT and Mindfulness-based CT both enhance metacognitive awarenessmetacognitive awareness

Level of metacognitive awareness is linked to relapseLevel of metacognitive awareness is linked to relapse Changing the relationship people have to their thoughts, Changing the relationship people have to their thoughts,

rather than changing beliefs, may be important for rather than changing beliefs, may be important for preventing relapsepreventing relapse(Teasdale et al., 2002)(Teasdale et al., 2002)

Sudden GainsSudden Gains Group data vs. individual dataGroup data vs. individual data Sudden Gains = 1-session gain of 7 BDI pts & 25% Sudden Gains = 1-session gain of 7 BDI pts & 25%

improvementimprovement Sudden gains evident in 39% of patientsSudden gains evident in 39% of patients Gains accounted for 50% of overall treatment gainsGains accounted for 50% of overall treatment gains

– 11 BDI points on average11 BDI points on average– tended to be maintainedtended to be maintained– resulted in improved allianceresulted in improved alliance

(Tang & DeRubeis, 1999; see also Tang et al. 2007, JCCP)(Tang & DeRubeis, 1999; see also Tang et al. 2007, JCCP)