James Fitzgerald Therapy PLLC

Depression

Treatment Plans and Interventions for Depression and Anxiety Disorders, 2nd Edition.

Robert L. Leahy, Stephen J. F. Holland, and Lata K. McGinn

This page is for use by clients of James Fitzgerald Therapy PLLC; James Fitzgerald, MS, NCC, LCMHC. This page is meant for educational purposes only and should not take the place of professional, medical, or pharmaceutical treatment options. Your continued use of this page acknowledges and confirms that you provide your informed consent and agree to the terms and conditions of use.

Description & Diagnosis

Depression is one of the most devastating of all psychiatric disorders. It is the leading cause of disability in the United States and the world for people between ages 15 and 44 (Kessler, Chiu, Demler, & Walters, 2005; World Health Organization, 2004). Of all diseases, depression is only exceeded by perinatal conditions, lower respiratory infections, ischemic heart disease, cerebrovascular disease, HIV/AIDS, and diarrheal diseases in terms of disability during a person’s lifetime (World Health Organization, 2004). This is partly because of the chronicity and recurrence of depression. Tragically, 76% of people with moderate depression and 61% of people with severe depression never get help (Pratt & Brody, 2008).

In addition, 80% of depressed people are impaired in their daily functioning, particularly at work; they lose (on average) 5.6 hours of productive work per week (Pratt & Brody, 2008; Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). The cost of depression in the United States is $83 billion per year (Greenberg et al., 2003). Half of the loss of work productivity is due to absenteeism and short-term disability (Kessler et al., 1999). In any 30-day period, depressed workers have 1.5–3.2 more short-term disability days than other workers do (Druss, Schlesinger, & Allen, 2001). People with symptoms of depression are 2.17 times more likely than others to take sick days (Adler et al., 2006; Greener & Guest, 2007). And even when they are at work, their
productivity is impaired by inability to concentrate, low efficiency, and inability to organize work. Unsurprisingly, depressed people are seven times more likely than nondepressed people to be unemployed (Lerner et al., 2004). Furthermore, absenteeism and work performance are directly related to how severe the depression is: The more severe the depression, the worse the outcome. In one study, the costs of absenteeism were directly related to taking versus not taking antidepressant medication (Birnbaum et al., 2010; Dewa, Hoch, Lin, Paterson, & Goering, 2003); those who took the prescribed medication had a 20% lower cost of absenteeism.

In one of the largest studies of its nature, children were followed for 40 years to determine the effects of illness and psychological problems on their life chances (Smith & Smith, 2010). Children or adults who suffered from depression earlier were found to have lower incomes, lower educational attainment, and fewer days working each year. In fact, their psychological problems led to 7 fewer weeks of work per year, a loss of 20% in potential income, and a lifetime loss for each family that had a depressed family member of $300,000 (Smith & Smith, 2010). People who suffered from depression also ended up with 0.6. year less schooling, an 11% decrease in the probability of getting married, and a loss (on average) of $10,400 per year in income by age 50 (Smith & Smith, 2010). In fact, there was a 35% decrease in lifetime income due to depression. The cost for the total group over a person’s lifetime was estimated at $2.1 trillion (Smith & Smith, 2010).

On this page we will identify the characteristics of major depression and describe a treatment package for it. Although depression may be devastating for some, it is highly treatable; combining treatments, and the possibilities of switching medication classes and including cognitive-behavioral therapy in particular, can substantially increase the likelihood of recovery. For the treatment of bipolar disorders, we refer the reader to other publications (Basco, 2000; Miklowitz, 2008; Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2002).

Although the interventions that are useful for unipolar depression are also useful for bipolar depression (Miklowitz et al., 2007), a treatment package for bipolar depression needs to include the use of mood-stabilizing medication, as well as socialization of the patient (and family) into the biomedical model of bipolar disorders. The differential diagnosis of bipolar and unipolar depression is essential to competent treatment. Hypomania or mania, with the accompanying sense of grandiosity, sexual excitement, and risk taking, is seldom a cause for self-referral in clinical practice. Indeed, a patient with a bipolar disorder may initially present with depression (or, in a mixed state, with agitation and depression), which often obscures the diagnosis. This is why all patients presenting with depression should also be evaluated for a history of hypomania or mania. Obtaining such a history will sometimes
require the corroborating input of family members, who may be better historians of the patient’s past behavior than the patient is.

Symptoms

Patients suffering from major depressive disorder (MDD) must first be determined to be experiencing a major depressive episode. The two key symptoms of a major depressive episode are depressed mood or sadness, and greatly lessened pleasure or interest in most activities. Other symptoms may include insomnia or hypersomnia, significant weight loss or gain, feelings of guilt or worthlessness, fatigue, impaired concentration, indecision, psychomotor retardation or agitation, and recurrent thoughts of death or suicide. A patient must be experiencing at least five of these symptoms, one of which must be either depressed mood or a loss of pleasure or interest in regular activities. The symptoms must be present nearly every day for 2 weeks and must hamper the patient’s functioning, as evidenced by difficulty at work, in relationships, or in general enjoyment of life. A major depressive episode is also not considered to be present if the symptoms can be attributed to a general medical condition or to a substance (e.g., alcohol or drugs).

Besides the presence of a major depressive episode, a formal diagnosis of MDD requires several “rule-outs.” There must never have been a hypomanic, manic, or mixed episode, and the symptoms must also be distinguished from those of several psychotic disorders. Once MDD has been diagnosed, it can be classified in several ways to indicate its clinical status and course. For a detailed description of the current diagnostic criteria for MDD, refer to DSM 5 TR.

Prevalence and Life Course

The lifetime prevalence of MDD is estimated at 16.9% (Kessler et al., 2003). A 12-year prospective study indicated that for any given year of assessment the prevalence rates were 4–5%, but that over the whole 12-year period rates were 24.2% of women and 14.2% of men, which were twice as high as previous estimates (Patten, 2009). MDD may be a chronic diathesis for many: 80% of individuals who have one major depressive episode will have another episode—and, in fact, such a person will have an average of seven episodes across his or her lifetime (Kessler et al., 2003). Relationship conflict is associated with increased risk for MDD: Women experiencing conflict in their marriages are 25 times more likely to become depressed (Hammen, 2004; Weissman, 1987). In addition, approximately 8–12% of women experience postpartum depression (Heneghan, Silver, Bauman, & Stein, 2000). The greatest risk for MDD occurs for individuals between 18 and 44 years of age, and the lowest risk is for those age 60 and over. Over a 6-month period, 50% of children and adolescents and 20% of adults report some symptoms of depression (Kessler, Avenevoli, & Ries Merikangas, 2001). The age cohorts born after World War II are at greater risk for MDD as well as other disorders (e.g., substance abuse).

The lifetime prevalence rates of MDD for females are twice those of males. Rates for attempted suicide are higher for females, but completed attempts are higher for males, who prefer more lethal methods of suicide (e.g., guns and hanging as compared to medication overdose or wrist cutting). The highest suicide risk is for the separated, divorced, and recently widowed, and the lowest risk is for single and married individuals. Living alone and urban environment confer greater risk than cohabiting or rural residence. Those individuals whose families show a history of suicide, alcoholism, and depression, or who perceive that they do not have good social support, are at greater risk. Greater risk is also found for individuals with a personal history of self-harm or injury, with less social connectedness, and with perceptions of themselves as a burden to others (Joiner, Van Orden, Witte, & Rudd, 2009).

Genetic/Biological F actors

Estimates of the heritability for depression range between 37% and 66%, with early-onset depression marked by greater heritability (Sullivan, Neale, & Kendler, 2000). The concordance for monozygotic twins for MDD is about 50%, whereas the concordance for dizygotic twins is about 35% (Kaeler, Moul, & Farmer, 1995). Kendler, Neale, Kessler, Heath, and Eaves (1992) estimate heritability for MDD at 39%, indicating some biological predisposition, but reflecting that other factors (such as life events, developmental history, and coping skills) are more prominent. Early onset depression is associated with a family history of depression, implicating genetic factors in early onset (Nierenberg et al., 2007). Genetics interacts with socialization, so that individuals at higher genetic risk are more likely to become depressed after experiencing stressful events during childhood; this interaction supports the stress–diathesis model of depression (Kendler, Kessler, et al., 1995; Kendler, Walters, et al., 1995).

Socialization

Depression is higher among individuals whose parents divorced, separated, or died during the individuals’ childhood (Blatt & Homann, 1992). Although loss of a parent is associated with greater risk for later depression, the way in which the loss was handled may be more important: Decreased warmth, care, and attention following the loss are associated with increased risk of depression (Harris, Brown, & Bifulco, 1986). Sexual abuse—or any abuse—is also associated with increased risk for depression (Bifulco, Brown, & Adler, 1991; Ingram, 2003). There is evidence that a combination of parental cognitive styles (negative attributional style), negative inferential feedback, and emotional maltreatment confer greater risk for depression later in life. All these factors mediate the effects of stressful life events in leading to depression (Alloy et al., 2004; Alloy, Abramson, Smith, Gibb, & Neeren, 2006; Gibb, Abramson, & Alloy, 2004; Gibb et al., 2001; Panzarella, Alloy, & Whitehouse, 2006). In particular, socialization experiences that affect cognitive styles may lead to greater vulnerability to depression.

Coexisting Conditions

MDD has high comorbidity with other disorders, including panic disorder, agoraphobia, social anxiety disorder (social phobia), generalized anxiety disorder, posttraumatic stress disorder, and substance abuse. As indicated, marital conflict (for both males and females) is an excellent predictor of depression; indeed, some clinicians recommend marital/couple therapy as the treatment of choice for patients presenting with depression associated with relationship discord (Beach, Dreifuss, Franklin, Kamen, & Gabriel, 2008). Physical illness, especially in the elderly, is correlated with depression. For individuals with chronic depression or a history of MDD, there is increased risk of Alzheimer’s disease, stroke, and poor outcome of HIV disease (Andersen, Lolk, Kragh-Sørensen, Petersen, & Green, 2005; Bos et al., 2008; Leserman, 2003). Elderly people who are depressed are more likely to die earlier (Janzing, Bouwens, Teunisse, Vant’ Hof, & Zitman, 1999). Several physical conditions are associated with depression; these may be pharmacological (steroid use, amphetamine/cocaine/alcohol/sedative withdrawal), endocrine (hypothyroidism and hyperthyroidism, diabetes, Cushing’s disease), infectious (general paresis, influenza, hepatitis, AIDS), or neurological (multiple sclerosis, Parkinson’s disease, head trauma, cerebrovascular disorder). (See Akiskal, 1995, for a more complete list.) In addition, MDD is highly correlated with personality disorders, although the diagnosis of a personality disorder may be uncertain until the depression is alleviated.

Differential Diagnosis

In addition to the diagnosis of MDD, there are several DSM disorders of related interest. Dysthymic disorder is a milder form of depression, with symptoms for most days over at least a 2-year period. MDD may be superimposed on dysthymia, resulting in a diagnosis of so-called “double depression.” Bipolar I disorder refers to the presence of at least one manic episode in the past, and usually also to the presence of one or more depressive episodes. (The past or present existence of a manic episode is necessary for the diagnosis of bipolar I disorder. A manic episode is characterized by grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, irritability, increase in goal-directed activity or psychomotor agitation, and/or excessive engagement in pleasurable but risky behaviors.) Bipolar II disorder is similar to bipolar I disorder, except that a past or present hypomanic episode (a milder form of a manic episode) is required. Finally, cyclothymic disorder consists of frequent (but not severe) episodes of hypomania and depression. The lifetime prevalence of bipolar (I and II) disorders is 4.4% (Kessler, Berglund, et al., 2005).

UNDERSTANDING DEPRESSION IN COGNITIVE BEHAVIORAL TERMS

Behavioral Factors

Behavioral models of depression can be traced to Ferster’s (1973) operant model, according to which depression is a consequence of a loss, decrease, or absence of rewards, or the inability to obtain rewards. In behavioral models, depression is understood in terms of the relationship between the individual and environment, such that depression is characterized by the difficulty in obtaining reinforcements or by the noncontingency of reinforcement and behavior. According to this view, depression is not something “inside” the person (such as “cognition”), but rather part of the context or relationship between the person and the environment (Zettle, 2007).

A Model of Behavioral Activation

This conceptualization has been expanded to a model of behavioral activation, which stresses a functional analysis of behavior to determine what maintains or reinforces depressive functioning or behavior. A functional analysis examines the antecedents and consequences of depressive behavior. For example, consider Ted, a patient who sits in front of a television for hours (arguably a depressive-type behavior). What is the antecedent? Perhaps it is thinking of going out and meeting someone, which activates anxious feelings. The passive and isolated behavior of watching television is reinforced by the reduction of anxiety—escape from the immediate anxiety and avoidance of further anxiety (negative reinforcement). Therapy emphasizes activation of more rewarding and predictable patterns of response, increasing the contingency of behavior and reward (Martell, Addis, & Jacobson, 2001).

The behavioral activation model emphasizes predictability and control of outcomes related to behavior. For example, Ted may find that he cannot sufficiently control or predict social outcomes, since he anticipates rejection. Consequently, he turns to the one source of behavior that is controllable—staying at home. The behavioral approach stresses taking a tally of the behaviors that characterize Ted’s depression (e.g., passively watching television, complaining, ruminating), examining these behaviors through functional analysis, developing a menu of behaviors that Ted views as rewarding, and setting up behavioral assignments to increase rewarding behaviors. Depression is often the result of passive, repetitious, unrewarding behavior; for example, staying home and watching television removes Ted from opportunities for other rewards. The goal of behavior therapy is gradually to increase the frequency and intensity of rewarding behavior by the use of techniques such as “activity schedules” and “reward menus”—the latter are lists of behaviors that were previously rewarding or could become rewarding in the future (Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984; Lewinsohn, Munoz, Youngren, & Zeiss, 1986). The emphasis is on acting better before feeling better.

A related behavioral factor contributing to depression is that behavior that was once rewarding is no longer rewarding. This may be due to greater demands or standards in the environment (i.e., it takes more of the same behavior to get the same level of reward). Consequently, an individual may need to increase the intensity of previously rewarded behavior. Furthermore, if rewarding agents in the environment are no longer available or no longer providing rewards, a therapist may need to assist a patient in identifying alternative sources of rewards. Moreover, depression may be the result of a reduction of positive behavior, lack of self-reward, use of self-punishment (e.g., self-criticism) or focus on skill deficits, lack of assertion, poor problem-solving skills (see below), exposure to aversive situations, sleep deprivation, and/or noncontingency of behavior and outcomes (D’Zurilla & Nezu, 1990; Nezu, 2004; Rehm, 1990). Similarly, stressful life events or aversive consequences for an individual are predictive of depressive episodes, and individuals who experienced childhood adversity are at greater risk of becoming depressed after stressful life events as adults (Kendler, Kuhn, & Prescott, 2004a, 2004b). Stressful life events can include divorce/separation, loss of job, increased conflicts, moving, and/or change in financial status—although daily hassles that accumulate can also be predictive of depression.

The behavioral activation model has been modified by Hayes, Strosahl, and Wilson (1999) to stress clarification of values (e.g., being a good mother or father) that can help motivate the individual to carry out difficult or unpleasant behaviors. Hayes et al.’s acceptance and commitment therapy (ACT) stresses acceptance of the situation as “the given,” recognition of “creative hopelessness” (i.e., that prior attempts to feel better have failed); flexibility in response, depending on context; and willingness to change. In addition, ACT emphasizes eliminating tendencies to avoid or escape from unpleasant emotions and an emphasis on tolerating unpleasant feelings. Similar to Ferster’s (1973) original formulation in its emphasis on context, contingency, avoidance, and activity, ACT has made significant contributions to appreciating the role of “a life worth living” as part of the motivational repertoire in therapy.

Problem-Solving Skills

Lack of social skills and lack of appropriate assertion skills are also useful behavioral targets for therapy. Many depressed patients need to learn appropriate social behaviors (e.g., in some cases, fundamentals of hygiene and appearance are important goals). Poor assertion skills may result in the inability to obtain rewards, greater feelings of helplessness and (in some cases) more aggressive and nonrewarding behavior directed toward others. Consequently, the behavior therapist will often include assertion training as part of their treatment plan.

D’Zurilla and his colleagues have argued that depression may stem from a lack of problem-solving skills or behaviors, which results in the persistence of mundane problems that contribute to feelings of helplessness (Bell & D’Zurilla, 2009; D’Zurilla, Chang, Nottingham, & Faccini, 1998). Behavior therapists assist patients in developing problem-solving skills by helping the patients identify their frustrations as “problems to be solved,” rather than issues about which they will ventilate. A therapist may programmatically train a patient in problem definition (“What is the problem you are trying to solve?”), collecting information (“What resources do you have?”, “How have others solved similar problems?”), brainstorming possible solutions (“How many different ways could this problem be solved?”), rank-ordering possible solutions, setting up an experiment to implement a possible solution, executing the plan, evaluating the outcome, and revising the plan if necessary.

To summarize, the behavioral approach (and, to some extent, the interpersonal approach; see below) suggests that various behavioral deficits and excesses characterize depression, and that depression has distinctive behavioral precursors. All these factors are listed in Table 2.1. Behavioral interventions for depression target the characteristic deficits and excesses of behavior. In Table 2.2, we identify some of the major behavioral techniques. For fuller descriptions, refer to Chapter 9 and Appendix A of this volume or to Leahy’s (2003) Cognitive Therapy Techniques: A Practitioner’s Guide.

Behavioral Deficits and Excesses in, and Precursors of, Depression

Summary of Behavioral Techniques for Depression

Cognitive Factors

The Three Levels of Cognitive Distortions

The cognitive models of depression (there are several) propose that the cognitive, motivational, and vegetative symptoms of depression are either caused by, increased, or maintained by biases, distortions, or styles in thinking. According to Aaron T. Beck and his colleagues, the depressed individual suffers from negative views of self, experience, and future—in other words, the beliefs that “I am a failure,” “Nothing in this experience is worthwhile,” and “The future will be filled with failure” (Beck & Alford, 2008; Beck, Rush, Shaw, & Emery, 1979). The content is negative because it is supported by biases or distortions in thinking—that is, distorted “automatic thoughts.” These types of thoughts include labeling, fortunetelling, personalizing, all-or-nothing thinking, discounting the positive, catastrophizing, and mind reading. Thus, when an event occurs—for example, a conflict at work—it is processed through distorted automatic thoughts in an excessively negative fashion: “I am a failure” (labeling) or “It’s terrible that this happened” (catastrophizing). The consequences of this pervasive negativity are that the individual becomes depressed, experiences even more negativity, and becomes even less motivated to pursue rewarding behaviors.

Vulnerability to future depressive episodes is predicted by a patient’s endorsement of “maladaptive assumptions.” (During nondepressed phases, the individual may not be more likely to endorse maladaptive assumptions, but these cognitive biases may be more likely to be manifested through “priming”; that is, they are latent and more accessible, given negative affect or triggering events. (See Scher, Ingram, & Segal, 2005.) As indicated in Chapter 10, maladaptive assumptions are the guiding principles that underlie distorted automatic thoughts and that include “should” or “must” statements—for example, “I should succeed at everything I try,” or “I must be accepted by everyone.” Assumptions also include “if–then” statements—for example, “If I don’t succeed on this, then I am a failure,” or “If someone doesn’t love me, then I am unlovable.” These underlying assumptions are “maladaptive” in that they are rigid, punitive and almost impossible to live up to.

Consider the following: A patient, Susan, predicts that she will do poorly on an exam. This would qualify as the type of automatic thought called “fortunetelling”—that is, a negative expectation for the future. (Of course, this thought could prove to be true.) The thought becomes problematic for Susan because of an underlying assumption or rule. What will it mean to Susan if she does do poorly on the exam? If she adheres to the assumption that “I must do well on everything in order to be worthwhile,” then she is vulnerable to depression whenever she falls short of her expectations on exams. Because underlying assumptions confer greater risk, the cognitive therapist seeks to modify both depressive symptoms and underlying cognitive vulnerabilities. Beck has proposed that when an individual is confronted with loss or failure, early maladaptive negative concepts of the self and others are activated (Beck & Alford, 2008; Beck et al., 1979). These “schemas” constitute the deepest level of thinking. They reflect core beliefs about the self (e.g., the self is unlovable, helpless, vulnerable to abandonment, controlled by others, unlovable, ugly, and incompetent) and about others (e.g., others are judgmental, unreliable, controlling, or superior). In the example above, Susan predicts that she will do poorly on the exam because she believes that she is basically incompetent and prone to failure. Getting “better” in cognitive therapy is not only a matter of feeling better, but also of thinking and acting differently by modifying the core negative schemas that underlie distorted automatic thoughts and maladaptive assumptions.

Schemas (sometimes called “core beliefs”) have been proposed as a model for understanding personality disorders (Leahy, 2002a; Young, Klosko, & Weishaar, 2003). Personality disorders are related to specific core beliefs about self and others that result in specific coping styles (such as avoidance or compensation). For example, individuals whose core belief is that they are irresponsible or lazy may compensate through excessively high standards for self and others, thereby leading to a vulnerability to depression in the event of “failure” in achieving desired goals. Specific dimensions on the Young Schema Questionnaire are related to depression: Shame, Defectiveness, Insufficient Self-Control, Failure to Achieve, and Social Isolation (McBride, Farvolden, & Swallow, 2007; Oei & Baranoff, 2007). The schema model stresses linking the origins of these beliefs to early childhood experiences, using experiential techniques, imagery induction, role play, cognitive restructuring, and “reparenting” to modify these early maladaptive schemas (Young et al., 2003). Thus far, however, there is no empirical evidence that adding this schema-focused component to traditional cognitive-behavioral therapy enhances treatment efficacy for depression.

Cognitive therapy involves the initial assessment of the patient’s depression, with a focus on automatic thoughts, maladaptive assumptions, and core beliefs/schemas. (The previous sections provide a table with examples of all three of these types of cognitive distortions.) The therapist develops a case conceptualization with the patient, linking the three levels of thinking with earlier socialization experiences, current relationships and life stressors, triggers for depressogenic thinking, maladaptive coping strategies (e.g., avoidance, compensation, rumination), and other relevant material (Kuyken, Padesky, & Dudley, 2009). Therapy proceeds through socialization to the cognitive model (especially with the use of bibliotherapy); use of behavioral activation (activity scheduling, structuring reward menus, establishing short-term and long-term goals); addressing hopelessness and suicidal ideation or risk; and monitoring distorted automatic thoughts. Cognitive therapy techniques cover a wide range of interventions, including categorizing thoughts, examining costs and benefits of thoughts, evidence for and against thoughts, semantic techniques, continuum techniques, the double-standard technique, reverse role play, and many other behavioral and cognitive experiments to test and modify the patient’s thinking and coping styles.

Although cognitive therapy and medication are both effective for treating depression, greater change in dysfunctional attitudes is seen as a result of cognitive therapy than as a result of medication (DeRubeis et al., 1990). In some cases, patients experience improvement in their depression in as few as one or two sessions of therapy (Tang, DeRubeis, Hollon, Amsterdam, & Shelton, 2007). Patients with such sudden improvement are even more likely to maintain their improvement a year later (Tang, DeRubeis, Beberman, & Pham, 2005). Researchers have found that changes in negative thinking precede this improvement—so there is now support for the concept that changing the way you think changes the way you feel. In short, there is considerable evidence that cognitive therapy is just as effective a treatment for depression as medication is (DeRubeis et al., 2005).

Other Cognitive Models

Seligman’s (1975) earlier behavioral model of depression stressed that the noncontingency of behavior and consequences can lead to a learned belief in the self’s helplessness—that is, “No matter what I do, it doesn’t matter.” Seligman and his colleagues later revised the noncontingency model to include cognitive components to explain individual differences relevant to the depressive syndrome—namely, the tendency of depressed persons to explain their helplessness? by referring to stable internal causes of failure (lack of ability) and the belief that their failure will generalize to other situations. Later, however, Abramson, Seligman, and Teasdale (1978) proposed a reformulated model of “learned helplessness.” According to the reformulated model, self-critical depression and helplessness are consequences of a particular pattern of explanations, or “attributions,” that the individual makes for his or her failure. Depression results from the tendency to attribute failure to internal, stable qualities (e.g., lack of ability) as opposed to internal but unstable qualities (e.g., lack of effort). The individual who believes that he or she can try harder (more effort) is less like ly to feel helpless, hopeless, self-critical, and depressed. Furthermore, attributing failure to task difficulty (“Everyone does poorly on biochemistry”) as opposed to internal deficits (“I’m no good at biochemistry”) may lead to giving up on the task, but not to getting depressed and self-critical.

Seligman’s learned helplessness model has been further modified by Abramson, Metalsky, and Alloy (1989) into a “hopelessness” model of depression. According to the hopelessness model, specific symptoms of depression (e.g., lack of energy, lack of goal-directed activity, lowered self-esteem, suicidal ideation, and sadness) are partially the result of specific interpretations about neg ative events—namely, that they are due to stable, global, and internal causes (e.g., “I am always a loser”). This is particularly the case for events with high importance and/or for events that are deemed to have considerable negative consequences for the self (Abramson et al., 1989).

Both cross-sectional and longitudinal research supports hopelessness as a significant cognitive vulnerability to depression (Alloy, Abramson, Safford, & Gibb, 2006; Haeffel et al., 2005). The attribution-based models may be incorporated in a cognitive-behavioral treatment program by helping patients attribute their failure to lack of effort or bad luck (unstable factors) and/or to task  difficulty (external factor), and to attribute their successes to ability, to overcoming difficult tasks, and to permanent qualities about themselves. Another aspect of attribution training is to help a patient evaluate a goal as an alternative rather than a necessity—that is, to help him or her modify the idea that this particular goal must be attained. Evaluating other achievable or controllable goals reduces the sense of hopelessness that may have resulted from overfocus on one goal as a necessary condition.

Several recent cognitive models of depression place less stress on the content of thoughts (such as schemas) and more on the process, function, or strategy of thinking. Depression is often characterized by the response style of “rumination”—that is, a passive and excessive focus on thoughts, feelings, and problems associated with negative affect, without a focus on active problem solving or distraction (Nolen-Hoeksema, 1991; Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). Ruminators get “stuck” in their rumination: Their repetition of negative thoughts traps these thoughts in their minds, increases their access to negative content, reduces their self-efficacy, limits their alternatives, and restricts their productive problem solving. A ruminative response style is associated with greater risk for depression and with female gender (Nolen-Hoeksema, Larson, & Grayson, 1999).

Wells (2009) has proposed a metacognitive model of rumination and depression. Depressive ruminators, with their overfocus on thinking related to negative affect, believe that their rumination will help them solve their problems but that their rumination is uncontrollable. (Note the similarities between rumination and worry.) The pattern of rumination then leads to depressive behaviors (avoidance), depressive thoughts (“It’s hopeless”), and lowered mood (sadness). These unhelpful responses exacerbate the ruminative cycle. Wells’s metacognitive therapy (which has also been discussed as a treatment for anxiety disorders) provides specific interventions to address a patient’s theory of rumination. Techniques include attention training, detached mindfulness, rumination postponement, and a set of interventions to modify beliefs about rumination (Wells, 2006). For example, the therapist can evaluate the costs and benefits of rumination, examine mood fluctuations related to rumination, review the evidence that rumination works, and even assign rumination to test the patient’s metacognitive beliefs about its efficacy (Wells, 2008).

Mindfulness-based cognitive therapy (MBCT) has been proposed as an intervention for reducing the vulnerability to recurrent depressive episodes (Segal, Williams, & Teasdale, 2002)—that is, as a treatment for relapse prevention. Individuals who are prone to recurrent depressive episodes tend to have overgeneralized autobiographical memory, recalling events in vague and general ways. Moreover, these individuals are more likely to ruminate, as noted above (Nolen-Hoeksema, 2000). “Mindfulness” is a technique that assists the patient in focusing attention in the present moment in a nonjudgmental way, relinquishing control of the situation, and experiencing recurrently a sense of letting go of each moment. MBCT has been found to be useful in reducing relapse of MDD for individuals who have experienced three or more prior episodes, but has not been shown to be helpful for individuals with fewer episodes (Teasdale et al., 2000).

Other cognitive models view depression as the failure to use self-enhancing or egoistic thinking, failure to use mitigating excuses, excessive self-focus, and passivity. Thus those with depression are seen as differing from those without depression because they do not engage in ego-boosting, or even distorted, positive illusions that enhance their self-esteem.

Similarly, depressed individuals are less likely to discount their negative illusions or to offer situational explanations for failure that do not imply personal responsibility. Self-focus models view depression as increased self-preoccupation, which is seen as a general process that increases negative affect.

Supportive evidence on this topic indicates that depressed persons are more likely to ruminate about their negative feelings, especially by asking rhetorical questions that have no answers, and that they are less likely to take an instrumental, proactive, and distracting approach to their negative affect.

A summary of typical cognitive techniques used in the treatment of depression is provided below

Examples of the Three Types of Cognitive Distortions in Depression

Distorted automatic thoughts

• Labeling: “I’m a failure.”
• Dichotomous (all-or-nothing) thinking: “Nothing I do works out.”
• Fortunetelling: “My life won’t get better.”
• Personalizing: “My depression is entirely my fault.”

Maladaptive assumptions

• “If I don’t pass the exam, it means that I’m a failure.”
• “I’m weak because I have problems.”
• “If I’m depressed now, then I’ll always be depressed.”
• “People will think less of me if I’m depressed.”
• “My value depends on what people think of me.”
• “I don’t deserve to be happy.”

Negative core beliefs (schemas)

• Undeserving: “People have treated me poorly because I don’t deserve better treatment.”
• Failure: “I’m doomed to fail.”
• Unrelenting standards: “I can only succeed and gain approval if I’m perfect.”
• Approval: “People will reject me if I’m imperfect. I need their approval to be worthwhile.”

Summary of Cognitive Techniques for Depression

• Distinguishing thoughts, feelings, and reality: Socialize the patient in recognizing how thoughts and reality may differ, and how thoughts are related to feelings.
• Monitoring automatic thoughts: Encourage the patient to track situations, thoughts, feelings, degree of belief in thoughts; degree of emotion
• Identifying distorted automatic thoughts: Train the patient in recognizing and categorizing the different types of distorted automatic thoughts (mind reading, fortunetelling, catastrophizing, etc.)
• Examining costs and benefits: Help the patient to weigh the costs and benefits of a belief.
• Examining the evidence: Help the patient to evaluate the quality of evidence for and against a negative belief, as well as the balance of evidence.
• Defining the terms: Examine how depressive thoughts and terms are defined by the patient (e.g., what is a “failure”?); defining the opposite of the construct (e.g., what is a “success”?)
• Vertical descent: Ask, “Why would it bother you if X were true? What would happen next?”
• Identifying and challenging underlying assumptions: Examine the patient’s “rule book”—the “shoulds,” “musts,” and “if–then” statements that underlie the depression.
• Externalization of voices: Have the patient argue back at his or her negative thoughts, using role plays.
• Double standard: Ask the patient whether he or she would apply the same standards to other as to the self; why/why not?
• Acting in opposition to a thought: Have the patient develop a plan of action to act against a thought
• Identifying and challenging negative schemas: Examine the patient’s negative views of self and others (e.g., self as defective or having demanding standards, and others as judgmental or abandoning); challenge these negative beliefs
• Attribution retraining: Help the patient change from personal, stable attributions for failure to attributions emphasizing universal, variable, and external attributions (e.g., from “I must be a failure” to “Almost everyone would have done poorly, I can change in the future, and it does not reflect on me”); have the patient reexamine the importance of the goal (perhaps there are other goals that can be pursued)

Interpersonal and Social-Behavioral Approaches

Lewinsohn, Peter, Antonuccio, Steinmetz, and Terri (1984) and Coyne (1989) and others have identified maladaptive interpersonal behaviors as a source of depression. According to Coyne’s (1989) interpersonal reward model, depressed individuals begin the maladaptive cycle by complaining, often obtaining reassurance and attention as a result of their complaints. The depressed persons initially receive positive reinforcement from others for their complaining. However, their continued complaining and self-preoccupation leads others to reject the depressive, which results in a decrease in social reward and support and further confirmatory evidence of the depressive’s negative self-concept.

As the depressive increases his or her complaining and rejects the help and reassurance provided, others view these behaviors as personally aversive and either withdraw from the depressed person or punish him or her by criticizing. This negative response by others adds further to the depression, and the cycle continues. Consequently, behavioral models that emphasize the interpersonal nature of depression focus on decreasing complaining and increasing positive interpersonal behaviors (e.g., “Rather than complain to others, try rewarding others”). Joiner has proposed an interpersonal theory of suicide and of depression. According to Joiner’s model, individuals at highest risk of suicide are those who desire to kill themselves and who are capable of doing so. In particular, suicidal desire is related to one’s perceived burden on others and lack of a sense of belongingness. Capability is related to habituation to suffering pain (through life events, injury, or prior experiences of self-harm) (Joiner et al., 2009).

Although not considered a cognitive-behavioral approach, the interpersonal theory of depression, derived from Harry Stack Sullivan’s social-psychodynamic model of psychopathology, has considerable relevance to depression. Klerman, Weissman, Rounsaville, and Chevron (1984) have proposed that depression is the result of dysfunctions in interpersonal relationships, such as interpersonal conflict and termination of valued relationships. According to this model problems in childhood relationships (such as loss of a parent, lack of nurturance, or disrupted communication patterns), as well as current interpersonal difficulties (such as marital conflict or termination, lack of social support, or lack of intimacy), may precipitate or exacerbate depression.

The interpersonal therapist provides the patient with the diagnosis (i.e., depression), encourages the patient to adapt the “sick role” (i.e., the role of a person with an illness), and enters into an agreement with the patient that the two of them will discuss the patient’s feelings and interpersonal relationships as related to the depression. As in the cognitive-behavioral model, there is considerable emphasis on the here and now, and on a short-term, active, and relatively structured format of therapy. However, interpersonal psychotherapy differs from cognitive-behavioral therapy in that the former does not logically dispute the patient’s negative thinking, nor is there an emphasis on homework. Furthermore, interpersonal therapists place greater emphasis on the interpersonal context of depression. The initial evaluation focuses on when symptoms began; the current stressors; interpersonal conflicts, disputes, losses, or changes; skill deficits (especially in interacting with others); and loneliness. Interpersonal psychotherapy stresses four problem areas: grief, role disputes, role transition, and interpersonal deficits (Weissman, 2000). Specific techniques include nondirective exploration (e.g., open-ended questioning); encouragement of affect (e.g., acceptance of painful affect, relating affect to interpersonal problems, eliciting suppressed affect); clarification; communication analysis; behavior change techniques; and the use of the transference (Klerman et al., 1984; Weissman, 2000).

Marital or couple conflict is often either a cause or a consequence of depression. Fifty percent of individuals seeking treatment for depression manifest such conflict (Rounsaville, Weissman, Prusoff, & Herceg-Baron, 1979), and 50% of couples seeking marital/couple therapy have at least one depressed member (Beach, Jouriles, & O’Leary, 1985; Beach, Katz, Kim, & Brody, 2003). Weissman (1987) has found that individuals in conflicted marriages are 25 times more likely to be depressed than individuals in nondistressed marriages. Depressed spouses/partners complain more, are less likely to reward others or to be rewarded themselves, show deficits in communication and problem solving, and are more likely to express negative affect. Furthermore, depressed individuals are more likely to elicit negative responses or withdrawal from their spouses/partners.

Because of the high concordance of depression and marital/couple conflict, the clinician may consider individual or couple therapy as the treatment for patients presenting with both problems. Excellent descriptions of behavioral and cognitive approaches to marital/couple therapy may be found elsewhere (Beach et al., 2008; Epstein & Baucom, 2002a). The general approach involves assessment of areas of relationship distress; increasing the awareness, frequency, and contingency of rewards between spouses/partners; assertiveness training; scheduling of “pleasure days” where rewards can be dramatically focused; problem-solving training; communication training focusing on both listener and speaker roles; identification and modification of dysfunctional thoughts and assumptions; use of time out to decrease aggressive interactions; sexual therapy where necessary; and training in acceptance of problems and self-care.

The advantage of couple therapy over individual cognitive-behavioral therapy or medication is that both the individual’s depression and the supportive environment (the marital/couple relationship) are significantly modified. Since depression is so highly correlated with relationship conflict, the clinician should always consider whether conjoint therapy should be the treatment of choice or whether it should be used in addition to individual therapy or medication. It is beyond the scope of this volume to describe the marital/couple therapy interventions available, but the reader is referred to the work of Beach, Dattilio, Epstein, and Baucom (Beach et al., 2008; Dattilio, 2005; Epstein & Baucom, 2002a).

Outcome Studies for the Treatment of Depression

Numerous outcome studies attest to the efficacy of cognitive-behavioral
therapy and/or antidepressant
medication in the treatment of major depression; cognitive-behavioral
therapy is generally
found to be equivalent or superior to antidepressant medication (Butler, Chapman, Forman,
& Beck, 2006; Williams, Watts, MacLeod, & Mathews, 1997), with a number of studies demonstrating
that most patients maintain their improvements 12 months later. In particular, cognitive
therapy has been found to be as effective as medication in the treatment of moderate to severe
depression (DeRubeis et al., 2005).
An extensive meta-analysis
comparing the various types of psychotherapy described above
has recently indicated equivalent efficacy for all types in the treatment of depression (Cuijpers,
van Straten, Andersson, & van Oppen, 2008). Given this finding that several forms of psychotherapy
can be effective, we attempt to include elements of each of these in our coverage of treatment
planning for depression. The clinician may use individual judgment to determine the most
relevant approach for each patient. Moreover, the multisite Sequenced Treatment Alternatives to
Relieve Depression (STAR*D) study indicates that switching nonresponders to different modalities
of treatment can increase remission rates significantly, with 67% of individuals completing

treatment (with augmentation or switching) showing remission (Rush, Trividi, et al., 2006; Rush
et al., 2009). Finally, although we have not discussed electroconvulsive treatment (ECT), there
is clear evidence of its efficacy for refractory depression; therefore, it should be considered as an
alternative for patients with severe, life-threatening,
and treatment-resistant
depression (Kho,
van Vreeswijk, Simpson, & Zwinderman, 2003).

Assessment and Treatment Recommendations

Rationale and Plan for Treatment
The advantage of the cognitive-behavioral
approach is that it links symptoms to therapeutic
goals to specific interventions. Suicidal ideation should always be considered the highest-priority
target for treatment, especially when there is a history of suicidal or parasuicidal behavior. The
other specific symptoms of depression may be grouped into the following categories: low level of
behavior, lack of pleasure and interest, withdrawal, self-criticism,
rumination, sadness, and hopelessness
(among other symptoms). The goals of treatment are to decrease or eliminate suicidal
risk, increase behavioral activity level, increase pleasurable and rewarding behaviors, increase
and enhance social relations, improve self-esteem,
decrease self-criticism,
and assist the patient
in developing short-term and long-term positive perspectives.
The interventions that are generally utilized to achieve these goals include reward planning/
activity scheduling, pleasure predicting, and graded task assignment (in order to increase behavioral
level and increase pleasurable and rewarding behaviors). They also include social skills
training, assertiveness, self-monitoring
complaining (to increase and enhance social relations);
identifying, challenging, and modifying negative automatic thoughts, assumptions, and schemas
(to improve self-esteem
and decrease self-criticism);
and identifying short-term and long-term
goals, developing problem-solving
strategies, carrying out and revising plans, and identifying and
challenging dysfunctional thinking associated with hopelessness (to assist the patient in developing
short-term and long-term positive perspectives).
A behavioral assessment allows the clinician to evaluate the behavioral deficits and excesses
associated with depression, such as low activity level, lack of self-reward,
complaining, and rumination.
In addition, the clinician can evaluate interpersonal problems that may be contributing
to the depression, such as frequent arguments, loss of relationships, lack of assertion, and other
negative aspects of relating. Finally, a cognitive assessment provides an evaluation of typical
distorted automatic thoughts, maladaptive assumptions, and schemas that may be targeted for
cognitive examination or disputation.
The approach described here integrates the behavioral activation model with various cognitive
models—including
traditional cognitive therapy, metacognitive therapy, antirumination
approaches, attribution and hopelessness models, mindfulness based cognitive therapy (MBCT),
and acceptance and commitment theory (ACT). Moreover, mindful of the importance of interpersonal
processes, the clinician will want to be familiar with and able to use behavioral interpersonal
approaches and even interpersonal psychotherapy when they are deemed relevant, or to
utilize marital/couple therapy where indicated. In some cases, parent training can be helpful in
reducing a patient’s sense of helplessness in coping with his or her children. The goal is to focus
on the patient’s needs, not on any particular theory.

Cognitive therapy is not defined by the techniques employed, but rather by the therapist’s
emphasis on the role of thoughts in causing or maintaining the disorder. Behavioral assignments
for patients are excellent (even necessary) vehicles for examining and testing a patient’s negative
schemas (Bennett-Levy et al., 2004). For example, consider the use of self-reward
as a simple
intervention. In assigning this task, a therapist might ask a patient what his or her thoughts
are about it. A typical depressive response might be to “discount the positive”: “It shouldn’t be
a big deal for me to do that [e.g., go to a museum]. Anyone can do that, so why should I reward
myself?” Or negative self-schemas
might emerge from the assignment: “I don’t deserve to reward
myself. I’m worthless.” Or even fears of self-reward
might emerge. One intelligent, articulate,
highly accomplished young woman feared self-reward:
“I’ll become conceited if I say good things
about myself. Then people will reject me.”
A patient’s distorted automatic thoughts clearly emerge with behavioral assignments. For
example, with reward planning/activity scheduling, the patient’s fortunetelling (“I won’t experience
any pleasure”) or negative filtering (“I didn’t enjoy the lunch with Tom”—although the
activity schedule might indicate many other activities with high pleasure ratings) can be examined.
Similarly, thoughts indicating low frustration tolerance may emerge (“It’ll be too hard
to do that” or “I can’t stand failing”). With assertion assignments, the therapist can examine
the patient’s maladaptive assumptions about assertion (“If I get rejected, it’s awful; it means I’m
unlovable,” or “I shouldn’t have to ask for those things. My spouse should know what I need”).
Maladaptive assumptions about entitlement or about the need to ventilate (“I need to express
my feelings; I should always be authentic”) can be examined via assigning the task of decreasing
complaining.
As these examples demonstrate, behavioral assignments such as activity scheduling, graded
task assignment, assertiveness, problem-solving
training, and communication skills training are
utilized in the treatment of depression not only to increase rewards for patients, but also to help
them test or challenge their negative cognitions. For example, the patient who believes that he
has nothing to say and that no one would be interested in talking to him might be assigned the
task of talking to ten people each day. This would not only help him challenge his idea that he
has nothing to say and that everyone will reject him, but it would also help him recognize that
others’ lack of a positive response is not a catastrophe. Indeed, this is a combination of behavioral
activation, assertion, exposure, and challenging negative thoughts. It is hard to do a behavioral
assignment without also thinking about it.
Another important component of behavioral assignments in cognitive therapy is to help
the patient learn to choose which behaviors to engage in. For example, a depressed patient who
sits at home ruminating (thereby getting more depressed) can be asked to consider alternatives
to ruminating—for example, going to a museum. The patient can then be asked to calculate
a cost–benefit
ratio for sitting at home ruminating versus going to the museum. These “choice
calculations” are helpful in motivating patients by getting them to focus on how their negative
predictions are determining their choices. Behavioral assignments are thus used to collect information
about thoughts.
We find that cognitive therapy works best with the integration of these many useful behavioral
interventions (as well as the other components mentioned earlier). Patients often get a
boost of hopefulness from behavioral assignments and can often convincingly see the difference
between their distorted beliefs and reality. Simply having abstract debates with patients about

how good reality is will prove far inferior as a strategy to helping the patients test out their cognitive
distortions by engaging in behaviors that “act against the thoughts.”
The steps in our treatment package for depression are listed in Table 2.5. In addition to
behavioral and cognitive interventions as listed in this table, we review below several other interventions
(problem-solving
skills, basic health maintenance, etc.) that may be included, depending
on a patient’s needs.

Assessment
All patients complete Form 2.1,* a general intake form that asks for information about problems
they would like help with. This “problem list” includes depression, anxiety, fears, marital conflict,
self-esteem,
anger, alcohol/other substance abuse, and other issues. In addition, the patient is
asked after the assessment is completed (see below) to indicate specific goals that he or she would
like to work on in treatment.

Tests and Clinical Interviewing
The specific problems of depression may be evaluated by using self-report
forms and interview
measures. The Quick Inventory of Depressive Symptomatology—Self-Report
(QIDS-SR16; Rush
et al., 2003; Rush, Carmody, et al., 2006) is in the public domain and provides the clinician with
a quick, reliable, and valid self-report
assessment of depression; it is correlated .93 with the Beck
Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996). The QIDS-SR16 is shown in Form
2.2.
Several other self-report
and interview measures may be used to evaluate baseline symptoms
and problems. These include the BDI-II, the Beck Anxiety Inventory (BAI; Beck & Steer, 1993),