CBT for Depression                                               (August 2009)

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The August lecture in the 2009 Monthly Lecture Series was given by Craig Chigwedere, Cognitive Behavioural Therapist & Clinical Lecturer, St. Patrick’s Hospital. In this talk the lecturer discusses the merits of CBT and, more specifically, focuses on how it can be of benefit to those suffering in particular with unipolar depression.

Contents

1. Introduction: the different types of depression
2. Unipolar depression
3. Cognitive model for depression
4. Beliefs to assumptions
5. Maintenance of depression
6. Getting over depression

According to Craig, depression is prevalent in 15%-20% of adults at any one time, with 12% of the population requiring treatment at some point in their lifetime. It also accounts for 75% of psychiatric hospitalisations. As the American psychologist Seligman described it: “Depression... the common cold of psychiatry” (1975).

There are many different types and the condition is subclassified in a number of ways including:
- Bipolar vs unipolar disorders
- Endogenous vs non-endogenous (reactive)
- Primary vs secondary.

Although CBT has benefits for different types of depression, Craig specified that he would be focusing on the specific benefits for unipolar and non-psychotic depression during this talk.

Unipolar Depression
Looking specifically to symptoms of unipolar depression Craig identified some key differences between non-clinical and clinical depression, stating that a period of low mood in non-clinical depression which manifests in reaction to loss can be considered normal.  Clinical depression, on the other hand, can disturb many aspects of a person's day-to-day living with symptoms including:

• Guilt
• Tearfulness
• Sadness
• Low energy
• Irritability
• Emotional numbing
• Affected sleep
• Inability to enjoy life
• Affected concentration
• Affected memory
• Affected appetite.

Unipolar depression can be either endogenous  or non-endogenous:

Endogenous – melancholic, seen as having biological causes
Non-endogenous – reactive, seen as having psychosocial causes.

Research suggests potential links between psychological and biological functions in depression and it is necessary to go beyond these basic categorical differences to understand how biological and psychosocial factors interact.

Craig identifies two major approaches to understanding and treating depression:
- Biological
- Psychological (cognitive behavioural approaches).

Biological
- First major theory: relates depression to altered neuro-biology
- Research studies: patients who are depressed show alterations in neurotransmitters such as norepinephrine, serotonin, acetylcoline, dopamine
- Treatment: major support for the biological theory from the successful treatment of depression with antidepressant medication & ECT.

Bio-psycho-social
There is also evidence that there are changes in neuro-endocrine system (the stress response system) in patients with depression suggesting a link between psychosocial factors and biological factors.

Psychological
- Second major theory: psychological
- Different ‘cognitive models’: for the understanding and treatment of depression, including:
Learned Helplessness (Seligman, 1975)
Behavioural activation (Jacobson et al., 1996; 1998)
Mindfulness (Segal Teasdale and Williams)
Cognitive Model of emotional disorders (Beck 1967, 1979)
In this talk: Beck’s model (1979), though we may touch on one or two others.

Cognitive model
Craig wenton to discuss the cognitive model for depression, stating that the condition is characterised by a negative cognitive triad.  This triad is made up of negative views regarding:
(A) Self
(B) The world (others)
(C) The future.

And these negative views are the result of formative experiences, particularly in early life. According to Craig, early experiences leads to the formation of ways people see themselves, the world/other people and the future.  These early experiences (interactions with family, friends, school etc) form ones core beliefs (schemata).

Experience of abuse, neglect and criticism can lead to a person having unconditional and rigid core-beliefs such as:
Self: I am worthless.
The future: is lonely.
Others: are rejecting.

Beliefs to Assumptions
Such negative core beliefs create distress for a person and threaten one's 'social/interpersonal survival', which in turn can lead to what the speaker describes as assumptions (rules for living).

For example:
- If I am not loved, then life is not worth living.
- I must...
- I should...
- I must/should always be accepted or else I am worthless.

Beliefs and assumptions alone are not sufficient to cause depression. Compensatory strategies may be employed:

Rule – If I am not loved, then life is not worth living.
Compensation – If I hide away and don’t upset anyone, I will not risk being rejected.

Rule Breaking
What happens if in spite of all our efforts, the rules we set ourselves fail? Regardless of our best attempts to avoid being rejected, the worst occurs and we experience rejection, criticism, failure.

A critical event challenges the rules and makes them insufficient to protect against the negative core belief stored deep within, thus allowing the belief to rise to the surface and before we know it...

"I am a failure... I’m worthless."


 

Maintenance of Depression Untreated depression usually resolves within 3-6 months but might relapse. In 15-20% of people it becomes chronic. If it continues, hopelessness and a longing for death can occur and 15% of severe cases may eventually take their own lives (Fennell, 1989).

According to Craig CBT offers a coherent and well-researched explanation for the maintenance of depression.

 

While untreated depression usually resolves within 3-6 months but might relapse, in 15% - 20% of cases, depression can become a chronic problem. The Aim of CBT is to alleviate current distress and reduce the chances of relapse.

Craig describes CBT as essentially a self help approach, which aims to teach individuals to become their own therapist.  The rationale here being that an individual’s mood and behaviour are largely determined by the way in which he/she structures the world in which they live.  Therefore, if one changes the way he/she perceives this world, the mood and behaviour will also change. Of course, this can be difficult to do.

Getting Over Depression
Craig explains that the starting point with CBT is the identification of Negative Automatic Thoughts (NATs) which include:

• Situational: specific to events
• Negative: associated with unpleasant emotions
• Automatic: uninvited and occur spontaneously
• Believable: based on misinterpretations of current and/or past activities
• Varied: interpretations of current events, predictions of the future, images or thoughts.

Craig states that these NATs are most easily identified via emotions, and that a change of feeling can be enough to indicate that a NAT is at play.



Conclusion
Craig concluded by saying that the aim is not to be positive but to be more balanced and less biased towards the negative.

The fact that cognitions influence mood does not imply that negative thinking causes depression.

"Depression may be seen as a final common pathway for a range of biological, developmental, social and psychological, predisposing and precipitating variables. Depressive thinking does not cause depression, it is part of it” (Fennell, 1989).