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Treating Depression with CBT

Depressive disorders are the most common of the psychopathological disorders. Depression is accurately described as a ‘major affective disorder’ because it affects the way that people feel, as well as altering their moods and behaviour. Statistics indicate that depression affects 2.6 people in every 100 and, with approximately 60 million people in the UK, this means that there may be over 1.5 million sufferers. Many people mistakenly believe that depression is when a person simply feels a bit fed up and that the advice of ‘get over it’ or ‘pull yourself together’ might actually be of use when this is, of course, far from the truth.

Major affective disorder is separated into two different types, bipolar and unipolar.

Bipolar disorder

Bipolar disorder (once known as manic depression) mainly affects a person’s mood and involves individuals having episodes of mania, depression and sometimes even psychosis alternately. Men and women suffer from this disorder in equal measures. Episodes of mania can include sufferers feeling excited, elated and sometimes even delusional and these can go on for days or even weeks and are usually followed by a period of depression. The effects of the feelings of mania on sufferers can be overwhelming and they often find it difficult to cope with the huge change in mood. This disorder has come into the public eye recently with high profile celebrities acknowledging their struggle with it, particularly Stephen Fry who is a big advocate for trying to remove the stigma that surrounds it.

Unipolar disorder

Unipolar disorder is usually simply referred to as depression as there is no mania involved. The episodes of depression may be constant or intermittent for an indeterminate amount of time, varying with each one. More women than men suffer from unipolar disorder.

Symptoms of mania include:

  • Feeling extremely happy or overjoyed.
  • Speaking very quickly.
  • Having feelings of increased self-importance.
  • Being full of new ideas and plans.
  • Being easily distracted.
  • Extreme irritability.
  • Not wanting to sleep or eat.
  • Making decisions that appear out of character and often involve some level of risk.
  • Spending large sums of money on items that are not needed and often cannot really be afforded.

Symptoms of depression include:

  • Feeling sad and unworthy.
  • Crying frequently with no reasonable explanation.
  • Feeling pessimistic about everything.
  • Problems with insomnia or sleeping too much.
  • Suicidal thoughts.
  • Loss of interest in every day activities.
  • Loss of interest in sex.
  • Problems with bodily functions, such as having unexplained head aches and stomach aches.

There are many theories about the causes of depression and how it should be treated. In order to be well-informed about clients’ issues, it is always good practice to know about some of the background theories about the causes of as many disorders as possible. Here we will look at some biological and psychological explanations for depression, before moving on to treatments.

Depressed man sat lonely in a dark room with hands to head

Biological explanations for depression

We have already seen that lowered serotonin levels are a possible explanation for depression but there is also evidence that in people with depression, levels of cortisol are elevated. Cortisol is a hormone known to be released when someone undergoes a stressful experience, which has been known to trigger depression.

Having a first degree relative, i.e. a parent or sibling, who has depression appears to be a risk factor for depression. Research indicates that a child who has a parent with the disorder is three times more likely to get it than a child who does not and some studies have found depression now running through three generations of a family.

Finally, according to Coffey et al., (1993), the brain anatomy of individuals with depression is structurally different to those who do not have it. They indicated that there were marked differences in their frontal lobes, although not in any other areas.

As with all explanations, applying any of them to everyone who has depression is not prudent because there may be many other factors which bring about increased vulnerability to depression. Many of them are psychological and we shall consider these now.

Psychological explanations for depression

Many researchers argue that biological explanations are the only ones that are worth research support, because they believe that it simply must be brain chemistry, which is the underlying factor. However, others disagree, whilst maintaining that biological factors may cause depression, it could be psychological factors that maintain it. Comer (2003) states that it is likely to be a combination of the two, someone may have a biological predisposition to depression because of low levels of serotonin but then they may blame themselves for everything negative that happens to them.

Freud (1917) argued that sometimes, when a child loses a family member, their period of grieving never ends and this is what becomes depression once they become adults. He referred to this depression as melancholia and stated that it was a pathological illness.

Seligman, (1974) believes that depression is learnt; it comes about because people try and control negative experiences in their lives and when they fail to do so, depression is the result. They then have a ‘learned helplessness’, which impairs their performance in situations that they can control. This is important for CBT because people who fall into this category fail to initiate even basic coping strategies, which, as we have seen, is fundamental to successful CBT application.

Beck’s ABC model is something we have already discussed but here it is worth mentioning the fact that he argued that depression is caused by negative schema, which means that current situations will be based on previous experiences. So, if a child doesn’t do well in a test then they will expect the same thing to happen when they are older. This leads to a continuous pessimistic view of the self and the world and an inability to deal with the demands of what may happen in the future.

Treatments for depression

Treatments for depression include drug therapies (also known as chemotherapy) with a quarter of all medication prescribed in the UK consisting of ‘psychiatric’ drugs, those which modify the working of the brain and so affect mood and behaviour.

Antipsychotic drugs were discovered in the 1950s and these were initially used to treat symptoms of schizophrenia. At around the same time, another type of drug, ‘tricyclic’ was also discovered and this lead to widespread prescription for those suffering from depression.

Drugs for treating depression can now be categorised into three main types:

  • Monoamine oxidase inhibitors (MAOIs).
  • Tricyclics.
  • Selective serotonin reuptake inhibitors (SSRIs)

Monoamine oxidase inhibitors

This is a widely used group of drugs, which boosts neurotransmitters such as serotonin and as such, can help to relieve the symptoms of depression for those whose serotonin levels are low. Examples of this type of drug include Nardil and Parnate, both of which must be prescribed by a health professional because the dosage for individuals is crucial. If the dose of this type of antidepressant is too high, it can induce mania as well as bringing about other, more common, side effects such as headaches and nausea.

Tricyclics

This type of drug works in a very similar way to MAOIs but the chances of side effects are greatly increased and are much more unpleasant. For this reason, this type of anti-depressant is not a first choice for most patients, except those for whom other types of medication have been ineffective. Examples of tricyclics include amitriptyline.

Selective serotonin reuptake inhibitors

As the name suggests, this works only on serotonin as opposed to other neurotransmitters as well. When taken, SSRIs allow serotonin to remain for longer within cells and so the quantity available to the body is higher. Examples of SSRIs include, fluoxetine (Prozac) and citalopram. Side effects of these types of drugs can vary from very mild to severe so the monitoring of patients who are prescribed it should be regular. Severe side effects include suicidal thoughts, which have been more prevalent in younger users.

Drug treatment is effective for most people who are suffering from depression but it is not always useful for those whose symptoms are mild. Many believe that drugs will have an instant effect when they take the first one but this is not the case. Most of the time, it will take up to four weeks to feel the full effects, although some may be felt within seven days.

Other types of treatment

As well as drug treatments, there are other types available for those suffering from depression. One which is considered, even now, to be extremely controversial is electro-convulsive therapy (ECT), which is used in cases of severe depression when all other avenues of treatment have been exhausted. The use of ECT fell out of favour towards the end of the 20th century, as many thought it to be barbaric, but it now appears to be making a comeback with more than 4,000 patients being treated by this method in the UK in the last year.

ECT works by passing a small electric current of about 0.6 amps through two electrodes placed on the scalp, which induces a seizure. Prior to the application of the current, the patient will be given a drug to make them unconscious and a nerve-blocking agent, which prevents the muscles contracting during the seizure, which can lead to fractures. The seizure will usually last for approximately one minute and it will affect the entire brain. The exact way in which it works is unknown but professionals have likened it to ‘restarting a car’s battery’. By doing this, it is thought that chemicals, which were previously slow to release, or not released in enough quantity, will reset themselves and their function will return to levels more like normal.

ECT procedures are usually given three times a week with patients usually needing between 3 and 15 treatments. Side effects are common, with headaches being most reported. However, many patients suffer from irrational fear and distress after their first few sessions, which do subside but can be extremely disturbing. Temporary memory loss is also a common side effect, with much less common ones including serious injury or even death, although this only occurs 1 in every 50,000 treatments.

The success of ECT is highly dependent on the reason for which it was given but research indicates that it is effective in approximately 50% of cases for those who were treated for depression, (Dierckx, et al., 2012).

One final treatment for depression is one that is used even less frequently than ECT and that is neurosurgery. In the past, this would have meant carrying out a ‘lobotomy’, where a surgical procedure involved destroying nerve fibres on the frontal lobe of the brain, with the hope that this would improve mood regulation. However, a pioneering new technique known as ‘deep brain stimulation’ (DBS) involves the implantation of a device that, like the lobotomy before it, hopes to regulate mood activity. The way in which the device works mimics the pacemaker- both are regulators of activity. It is too soon to know whether or not this surgery will become commonplace for those whose depression does not respond to any other kind of treatment and neurosurgery is currently extremely rare within the UK. However, many clinicians hope its usage will be more widespread in the future.

Research and effectively treating depression with CBT

Research indicates that CBT is effective in treating mild and moderate depression. It works to change negative thought patterns and replace them with more positive, healthy ones, to prevent cognitive biases and to help clients to overcome any shame and hopelessness that they may feel on a persistent basis. It should also help them to restore their activity levels, especially those, which had previously brought about a sense of achievement or pleasure for the client.

Some aspects of depression may be experienced as part of life, for example, following bereavement or divorce but it is when these feelings become the norm rather than the exception that their impact on someone’s life becomes significant.

Unipolar disorder can be treated more effectively than bipolar disorder with use of CBT because for some, the issues behind their bipolar disorder are unresolvable by this method. The symptoms of unipolar disorder can be relieved through full discussion with the client of their issues and then collaboration between therapist and client as to how to proceed with strategies to help facilitate changes in client behaviour.

The therapist will firstly try and identify resolvable issues by exploring the reasons the client has stated have brought them to therapy. After which, a programme of therapy will be devised based on each individual client’s needs. The therapist’s assessment of the client’s problem will likely be based on exploration of the following:

Current problems and issues

  • What is the client’s current frame of mind? Are they sad? Anxious? Withdrawn? Irritable? Bear in mind that clients may have one, two or sometimes even all of these characteristics.
  • Are they using any self-coping mechanisms such as drugs or alcohol to try and deal with their depression?
  • Have their sleeping patterns changed? Do they have problems falling asleep, staying asleep or sleeping too much?
  • Has their self-esteem been affected?
  • What is their social situation? Are they living with family or are they more isolated?
  • Is there attitude always negative or can they see some positives in everyday life?

Problems should be put into context

  • Are there any triggers or situations that make any of the problems that the client has identified worse?

Triggers

  • Once triggers have been identified, does this mean that certain situations can make triggers happen? For example being in a certain place, hearing some type of music, even seeing a certain person?

Client history

  • Are there any other things in the client’s life that might be a factor in the depression?
  • Is there an individual or a family history?
  • Is there any other type of event happening in the client’s life that may be a factor, such as loss of a job, bereavement, diagnosis of a serious illness etc.

Coping strategies

  • Does the client already have any kind of method to deal with events when they occur? If so, what are they and are they useful?

All of the information collected from the assessment should be enough to get started with a programme of treatment straight away. The therapist should not have any questions that have been unanswered because when this happens, a crucial bit of information might be missed. For example, if the therapist fails to ask if there are any specific situations that might cause negative feelings to occur, then they will miss the opportunity to explore this and possibly find out an important trigger in other areas as well. Depression is seen as an undesirable state and so its resolution is key in helping clients to amend their behaviour.

As with other therapies, the relationship between client and therapist must be established as quickly as possible with the next priority being to define what the most concerning problems are for the client and how they will be fitted into session planning in the future. Collaboration between both therapist and client must occur at the initial stages, this will promote self-reliance for the client and reduce the risk of them becoming too dependent on the therapist in providing answers. It is also critical that the client is aware of their involvement in the maintenance of strategies by practicing them at home and then reporting back to the therapist as to their usefulness so that the programme can be amended if required.

Therapist using CBT to help depressed client within a counselling session.

Core beliefs

Core beliefs of depressed clients are usually negative and follow patterns of negativity, regardless of their situation. These types of thoughts have an impact on daily relationships with others and it is for this reason that, when a client’s negative core belief is identified in conversation, the therapist should try and challenge this such as in this example:

Here, the therapist is prompting the client to explore their irrational core beliefs about why, potentially, someone does not like them. They will be looking for things in the client’s thought processes that might suggest that the client:

  • Seeks approval
  • Fears failure
  • Has a desire to be accepted
  • Feels out of control

These thought processes are very common with depressed clients whose self-esteem and confidence will probably be very low. Strategies should be worked on with the client that will promote positive thinking and so statements that they would usually fall back on are challenged and changed. Let us use the activating event of a divorce to look at some alternative coping thoughts:

Irrational thought or belief Alternate coping thought or belief
My looks are not good enough for anyone new to find me attractive. Although I am currently single, I am still likeable and attractive enough to start a new relationship.
I cannot cope with this by myself. I am stronger than I think and I have friends and family who will help me through bad times.
It is completely unfair that this has happened to me. Not all relationships are infinite.
I will never be happy again. I have had periods of unhappiness in the past and have overcome them. This one should not be any different.

Some clients will not be able to amend their thought processes immediately but with persistence and practise, this should become easier for them. This is why it is really important that consistent reviews take place as the relationship progresses. This can be done with the use of standardised assessment criteria, with which the therapist will be familiar. Reviews should take the form of evaluating techniques being used both in sessions and as homework, regular feedback and adjustment of the programme if required.

Women following therapists advise by writing a journal of daily activity's

Journals and activity scheduling

Many clients with depression find that they find it difficult to cope with even the most simple of tasks and so presenting for a CBT session can be a massive achievement for which they should be commended. Being unable to cope with daily tasks can sometimes make clients unmotivated to even try them and so encouraging them to schedule some daily activities and keep a journal can both be very useful techniques.

Initially, the client should be encouraged to note down what they do in a day; this will give the therapist the chance to see the scale of the problem and so look at how activities can be brought in bit by bit so as not to make the client feel overwhelmed.

The daily activity log should include a key to show how much pleasure or achievement the client felt when doing each thing within it. It should also note if the client found the task to be boring or if they were supposed to do something and didn’t and why this was the case, for example they felt too tired.

This sounds like it has the potential to be very complicated but it is actually very straightforward to maintain. An entry in a journal may look like this:

Time of day Monday
7-8 Got out of bed, got dressed A-4 P-1
8-9 Children breakfast and to school A- 8 P – 5
9-10 Supposed to take dog out. T

Key:

A – achievement

P – pleasure

T – too tired

Numbers indicate strength of emotion, 1 is low and 10 high.

The client can make their own key so it is easier for the therapist to interpret.  The client who completed this journal appears to be able to complete some tasks but then finds others out of reach because of tiredness. Keep in mind that some clients will be unable to complete any tasks at first and so making them simple and keeping other activities to an absolute minimum is important. It is better that they complete some small tasks successfully than a bigger one unsuccessfully because they will likely see this as an indicator that they have failed, which will feed into their depressed state. Activities that clients can be encouraged to take part in alongside their daily tasks include:

  • Exercise.
  • Reading.
  • Watching TV or films.
  • Meeting with friends.

Really, anything that a client indicates has previously brought them pleasure should be introduced to their daily schedule but again, do remember that this should be done gradually and all attempts to do this whether successful or not should be praised and the client encouraged to continue because it is an indicator that their behaviours are starting to change.

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