Clinical handbook of psychological disorders d barlow,( 2008)mxmllACADEMIC

OVERVIEW AND RESEARCH Depression and the Emergence of Cognitive Therapy Depression is one of the most common disor-ders encountered by mental health profession-als.. Research on Treatmen

CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS

DISORDERS

THE GUILFORD PRESS

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Genetics and Temperament

Anxiety Sensitivity

History of Medical Illness and Abuse

Interoceptive Awareness

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Parts of ADIS-IV Panic Disorder Section

In what kinds of situations do you have those feelings?

Did you ever have those feelings come “from out of the blue,” for no apparent reason, or in situations where you did not expect them to occur?

How long does it usually take for the rush of fear/discomfort to reach its peak level?

How long does the fear/discomfort usually last at its peak level?

In the last month, how much have you been worried about, or how fearful have you been about having another panic attack?

Parts of ADIS-IV Social Phobia Section

In social situations, where you might be observed or evaluated by others, or when meeting new people, do you feel fearful, anxious, or nervous?

Are you overly concerned that you might do and/or say something that might embarrass or humiliate yourself in front of others, or that others may think badly of you?

What are you concerned will happen in these situations?

Are you anxious about these situations because you are afraid that you will have an unexpected panic attack?

Other than when you are exposed to these situations, have you experienced an unexpected rush

of fear/anxiety?

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Home alone and shortness of breath

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In Vivo Exposure

Interoceptive Exposure

Optimizing Learning during Exposure

Stress Inoculation Training

Exposure Techniques

Cognitive Therapy/Cognitive Restructuring

Combination Treatments/Additive Studies

Eye Movement Desensitization and Reprocessing (EMDR)

Gender and Ethnicity

Vicarious Traumatization

Multiply Traumatized Victims

Group Treatment

Measures of Social Anxiety

Other Self-Report Measures

Psychoeducational Segment

Cognitive Restructuring Training Segment

Exposure Segment

Advanced Cognitive Restructuring Segment

Termination Segment

EX/RP Treatment Variables

EX/RP versus Other Treatment Approaches

Effectiveness of Medications

EX/RP versus Pharmacotherapy

Obsessive–Compulsive Inventory—Revised

Other Self-Report Measures

Current Symptoms

History of Symptoms and Treatment History

One of the most important developments in psychosocial approaches to emotional

prob-lems has been the success of cognitive therapy for depression Evidence for the powerful

efficacy of this approach has increased steadily over the years, particularly in regard to

successful long-term outcome Employing a variety of well-specified cognitive and

behav-ioral techniques, cognitive therapy is also distinguished by the detailed structure of each

session with its specific agendas, and by the very deliberate and obviously effective

thera-peutic style of interacting with the patient through a series of questions Moreover, the

au-thors underscore very clearly the importance of the collaborative relationship between

therapist and patient and outline specific techniques to achieve this collaborative state so

that patient and therapist become an investigative team In this chapter, the authors

pres-ent a second important phase of treatmpres-ent that represpres-ents an interesting variation of

cog-nitive therapy This phase, called the “schema-focused” phase of treatment, concentrates

on identifying and modifying early maladaptive or “core” schemas that developed during

childhood in severely depressed and treatment-resistant patients These schemas may

make the patient vulnerable to relapse Detailed explication of this second phase of

treat-ment will be invaluable to experienced cognitive therapists, as well as to those becoming

acquainted with cognitive therapy for depression for the first time Two compelling cases,

new to this edition, illustrate each approach.—D H B.

OVERVIEW AND RESEARCH

Depression and the Emergence

of Cognitive Therapy

Depression is one of the most common

disor-ders encountered by mental health

profession-als Recent research from the U.S

Nation-al Comorbidity Survey Replication (NCS-R)

studies and data provided by the National

In-stitute of Mental Health (NIMH) indicate the

following:

• The lifetime prevalence estimate for aDSM-IV mood disorder is 20.8% (Kessler,Beglund, et al., 2005)

• The 12-month prevalence estimate for aDSM-IV mood disorder is 9.5% (Kessler,Chiu, Demler, Merikangas, & Walters, 2005)

• Major depressive disorder is associated with27.2 lost workdays and bipolar disorder (I orII) with 65.5 lost workdays for each illworker per year (Kessler, Akiskal, et al.2006)

250

• Depression increases the risk of heart attacks

and is a frequent and serious complicating

factor in stroke, diabetes, and cancer

(NIMH, 1999)

• Major depressive disorder is the leading

cause of disability in the United States for

ages 15–44 (NIMH, 2006)

• The associated costs are more than $30

bil-lion per year (NIMH, 1999)

The high risk of relapse (Scott, 2000), high

re-source utilization (Howland, 1993), and loss of

human capital (Berndt et al., 2000) associated

with depression reveal the seriousness of the

problem Current estimates suggest that by

2010, depression will be the second most costly

of all illnesses worldwide; in 1990 it was

ranked fourth (Keller & Boland, 1998) As

these reports indicate, depression is

wide-spread, debilitating, and costly

No amount of data can adequately capture

or convey the personal pain and suffering

expe-rienced in depression Many depressed people

do not get professional help (Frank & Thase,

1999; Jarrett, 1995) and although the number

seeking help has increased over the last decade,

undertreatment has remained a serious

prob-lem (Olfson et al., 2002) The social stigma still

attached to people with depression is no doubt

one factor, but the obstacles encountered while

looking for appropriate care can be another

stumbling block in getting help Obtaining the

right type of help can be at once inhibiting and

overwhelming, especially to those already

im-paired:

Americans who do seek treatment for depressive

symptoms must decide where to seek which

treat-ment and from what type of practitioner The

clinician must select a somatic, psychological, or

combination of treatment, at a given dose and/or

schedule of appointments Throughout this

procedure, the patient decides to what extent he/

she will comply with the recommendations, for

how long, against recognized and unrecognized

economic, practical, physical, and emotional

costs Sadly, the lack of information as well as

the continued social stigma of psychiatric illness

and treatment influence decision-making

Simul-taneously, the decisions occur in an environment

filled with social, political, and economic debate,

and tension among policy makers, third-party

payers, and clinicians, as well as among different

types of practitioner guilds (Jarrett, 1995, p 435)

When care is provided, it is frequently

inade-quate, reflecting a public health crisis (Keller &

Boland, 1998) The need for delivery of ments with proven and rapid efficacy remainsparamount

One of the major developments in the ment of depression has been the emergence ofcognitive therapy, developed by Aaron T Beckover the past 40-plus years His work and that

treat-of his colleagues (Beck, 1967, 1976; Beck,Rush, Shaw, & Emery, 1979) has led to a para-digm shift within psychotherapy (Salkovskis,1996) Due in part to Beck’s development oftestable hypotheses and clinical protocols, cog-nitive therapy has received an enormousamount of professional attention (Hollon,1998; McGinn & Young, 1996; Rehm, 1990)

Of all the cognitive-behavioral treatment proaches to depression, Beck’s paradigm (Beck,1967; Beck et al., 1979) has received the great-est amount of empirical study, validation, andclinical application (Barlow & Hofmann,1997; de Oliveira, 1998; Dobson & Pusch,1993; Hollon, 1998; Hollon, Thase, &Markowitz, 2002; Rehm, 1990; Roberts &Hartlage, 1996; Scott, 1996a) There are manyexcellent books for practitioners that teachcognitive therapy procedures (e.g., J S Beck,1995)

ap-Along with this attention, however, hascome confusion about what is actually meant

by the term “cognitive therapy.” The actualcognitive therapeutic strategies employed in

“cognitive” treatments may differ in manyways from one another and from those explic-itly prescribed by Beck and colleagues (1979)

in their manual for cognitive therapy of sion Thus, the reader should be aware thatcommon use of the term “cognitive therapy”does not necessarily imply uniformity in proce-dures The therapy described by Beck and col-leagues involves the use of both cognitive andbehavioral techniques, and can therefore be ac-curately labeled “cognitive-behavioral”; how-ever, in the literature, both terms have been ap-plied in describing the Beck and colleaguesprocedures, with some articles utilizing theterm “cognitive therapy” (Sacco & Beck, 1995,

depres-p 345)

Research on Treatment of the Acute Phase

Outcome research has found cognitive therapy

to be effective with clinical populations in anumber of controlled trials (Hollon & Shelton,2001) Although some early studies(Blackburn, Bishop, Glen, Whalley, & Christie,

Cognitive Therapy for Depression 251

1981; Rush, Beck, Kovacs, & Hollon, 1977)

suggested that cognitive therapy may be

supe-rior to drug treatment for depression at

termi-nation, Meterissian and Bradwejn (1989)

noted that psychopharmacological

interven-tions often were not adequately implemented

In research where interventions have been

ade-quate, cognitive therapy generally has been

shown to be equivalent in efficacy to

antide-pressant medications, including tricyclic

anti-depressants (TCAs) and selective serotonin

reuptake inhibitors (SSRIs) in the treatment of

outpatients with nonbipolar depression

(DeRubeis et al., 2005; Hollon et al., 1992;

Murphy, Simmons, Wetzel, & Lustman, 1984)

and a monoamine oxidase inhibitor (MAOI) in

the treatment of outpatients with atypical

de-pression (Jarrett et al., 1999) Although many

studies have not included pill-placebo

condi-tions, the studies by Jarrett and colleagues

(1999) and DeRubeis and colleagues (2005)

found the active treatments superior to

pill-placebos In a mega-analysis by DeRubeis,

Gelfand, Tang, and Simons (1999) of treatment

outcome in four studies with severely depressed

outpatients, cognitive therapy was equivalent

to antidepressant medication (imipramine or

nortriptyline)

Only two studies that included a pill-placebo

have found cognitive therapy to be less

effec-tive than psychopharmacological intervention

The first was the NIMH Treatment of

Depres-sion Collaborative Research Program

(TDCRP) with moderate to severe depression

in adults The second was the multisite

Treat-ment for Adolescents with Depression Study

(TADS) for reduction of depressive symptoms

in adolescents

The NIMH TDCRP was the first major

study to include a pill-placebo condition The

initial results (Elkin et al., 1989) suggested

lower rates of improvement with

cognitive-behavioral therapy (CBT) than did earlier

stud-ies It also appeared that with more severely

depressed patient groups, interpersonal

psy-chotherapy and antidepressant drugs might be

superior to CBT The high visibility and

pres-tige of the NIMH TDCRP study generated a

great deal of debate (Hollon, DeRubeis, &

Ev-ans, 1996; Wolpe, 1993), because it appeared

that the benefits of CBT in the acute treatment

phase might have been overestimated in

previ-ous studies However, on later examination of

the data, Elkin, Gibbons, Shea, and Shaw

(1996) acknowledged Jacobson and Hollon’s

(1996) observation that the outcome resultsvaried across sites, with cognitive therapy per-forming as well as medication at one of thethree sites with severely depressed clients Ja-cobson and Hollon noted that the best resultswere obtained at the site with the most experi-enced therapists Hollon and colleagues (2002)

“suspect that the explanation is not that tive therapy cannot be effective with such pa-tients, but that the therapist’s expertise makes agreater difference the more difficult the depres-sion is to treat” (p 62) Additionally, a study

cogni-by Albon and Jones (2003) raises the question

of the distinctness of the two types of therapy treatments in the TDCRP In this study,Albon and Jones, expert therapists in CBT andinterpersonal psychotherapy, developed proto-types of ideal regimens of their own respectivetreatments Then, actual transcripts of treat-ment sessions from the TDCRP were compared

psycho-to these expert propsycho-totypes Albon and Jonesfound that both CBT and interpersonal psy-chotherapy sessions conformed most closely tothe cognitive-behavioral prototype, and thatcloser adherence to the cognitive-behavioralprototype produced more positive correlationswith outcome measures across both types oftreatment

The multisite TADS study (2004) for tion of depressive symptoms in adolescentsfound that the combination of medication(fluoxetine) and CBT produced the most posi-tive outcome, medication alone was superior topill-placebo but CBT alone did not signifi-cantly differ from pill-placebo However, asnoted by Weisz, McCarty, and Valeri (2006,

reduc-p 144) “the CBT ES (effect size) generated inTADS is not characteristic of most CBT,” rais-ing questions about the administration of CBT

in this study

Several studies have not found the tion of CBT and drugs to be superior to eithertreatment alone with depressed outpatients(Biggs & Rush, 1999; Evans et al., 1992;Hollon, Shelton, & Loosen, 1991; Scott,1996a; Shaw & Segal, 1999) The increment inefficacy appears to be modest in the acutephase of treatment at best, with increases in ef-ficacy from 10 to 20% (Conte, Plutchik, Wild,

combina-& Karasu, 1986) Studies regarding treatmentwith depressed inpatients suggest beneficial re-sults when CBT is combined with medication(Bowers, 1990; Miller, Norman, Keitner,Bishop, & Dow, 1989; Stuart & Bowers, 1995;Wright, 1996) Although cognitive therapy ap-

252 CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS

pears to be a useful adjunct to standard care

with inpatients, it remains unclear whether

cognitive therapy alone is sufficient (Hollon et

al., 2002)

Research on Relapse Prevention

Even though the vast majority of patients

re-cover from an episode of depression, they

nev-ertheless remain vulnerable to future

depres-sion.1

Recurrence is a major problem for many

individu-als suffering from depression: at least 50% of

in-dividuals who suffer from one depressive episode

will have another within 10 years Those

experi-encing two episodes have a 90% chance of

suffer-ing a third, while individuals with three or more

lifetime episodes have relapse rates of 40% within

15 weeks of recovery from an episode (Kupfer,

Frank, & Wamhoff, 1996, p 293)

Other investigators have estimated that 85% of

patients with unipolar depression are likely to

experience recurrences (Keller & Boland,

1998, p 350) As these numbers clearly show,

there is an urgent need for treatments capable

of minimizing and preventing relapse

What we consider a very exciting finding in

the treatment of depression with cognitive

ther-apy is the consistent observation that patients

treated with cognitive therapy alone or with a

combination of cognitive therapy and

medica-tion fare far better in terms of relapse than do

patients treated with medication alone (when

both treatments are stopped at termination)

Despite differences in sample characteristics

and methodologies across studies, cognitive

therapy appears to have important

prophylac-tic properties After a 1-year follow-up,

numer-ous studies have reported lower relapse rates

for patients treated with cognitive therapy than

for patients treated with antidepressants For

examples, Simons, Murphy, Levine, and Wetzel

(1986) found relapse rates of 12% with

cogni-tive therapy versus 66% with antidepressants;

Bowers (1990) found relapse rates of 20% with

cognitive therapy versus 80% with

antidepres-sants; Shea and colleagues (1992) reported 9%

relapse with cognitive therapy versus 28% with

antidepressants; Hollon and colleagues (2005)

reported rates of 31% relapse with cognitive

therapy versus 76% with antidepressants

Re-sults from the most extensive meta-analysis to

date revealed that “on average, only 29.5% of

the patients treated with cognitive therapy

relapsed versus 60% of those treated with depressants” (Gloaguen, Cottraux, Cucherat,

anti-& Blackburn, 1998, p 68) The prophylacticbenefits of cognitive therapy are all the moresignificant because “there is no evidence thatpharmacotherapy confers any protectionagainst the return of symptoms after treatmenthas been terminated.2Since the majority of de-pressed individuals will experience multiple ep-isodes, the capacity of an intervention to pre-vent the return of symptoms after treatmentmay be at least as important as its ability totreat the current episode” (Evans et al., 1992,

resid-p 820) Inevitably, patients who improve onantidepressants continue to manifest some ofthe symptoms of depression, and, as numerousinvestigators have concluded, unless patientsachieve full recovery, residual symptoms in-crease the risk of relapse (Evans et al., 1992;Fava et al., 1998b; Keller & Boland, 1998)

A group of investigators concerned aboutthe risk of relapse associated with residualsymptoms looked at the lingering symptoms af-ter treatment with fluoxetine (Prozac) Theyfound that

even among subjects who are considered full sponders to fluoxetine 20 mg for 5 weeks, more than 80% had 1 or more residual DSM-III-R symptoms of major depressive disorder, more than 30% had 3 or more symptoms, and 10.2% met formal criteria for either minor or sub- syndromal depression These findings imply that minimal depressive symptoms are prodromal and increase the risk of developing an initial full- blown episode of major depression (Nierenberg

re-et al., 1999, pp 224–225)

Cognitive therapy has been found to be fective in reducing both residual symptoms andrelapse after the termination of medication:

ef-“Short-term CBT after successful sant drug therapy had a substantial effect onrelapse rate after discontinuation of antidepres-sant drugs Patients who received CBT re-ported a substantially lower relapse rate (25%)during the 2-year follow-up than those as-signed to [clinical management] (80%)” (Fava

antidepres-Cognitive Therapy for Depression 253