Cognitive Behavioral Therapy as a Treatment for Major Depressive Disorder
According to The Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM-5; American Psychiatric Association, 2013), Major Depressive Disorder (MDD) is diagnosed when the following criteria are met. The first, being the most expansive, is that 5 of the following symptoms are present during a 2-week period, constantly, either daily and most of the day or nearly every day: depressed mood for most of the day, feelings of hopelessness, sadness, emptiness, significant weight loss or weight gain or noticeable changes in appetite, insomnia or hypersomnia nearly every day, fatigue or loss of energy, recurrent thoughts of death or suicide, diminished ability to concentrate, diminished interest in all activities even favorite, psychomotor agitation or retardation (American Psychiatric Association, 2013).
The second category needed to be fulfilled for MDD is that the previously stated 5 or more symptoms need to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013). Another criterion needed for MDD to be properly diagnosed is that the depressive episode cannot be attributed to the physiological effects of a substance or other medical condition (American Psychiatric Association, 2013). In addition to the previous criterion, MDD cannot be properly diagnosed if the depressive episodes are better explained by schizophrenia or other psychotic disorders and there must not be a manic or hypomanic episode (American Psychiatric Association, 2013).
The possible causes for MDD and other depressive disorders are thought to be a combination of genetic, biological, environmental, and psychological factors (National Institute for Mental Health, 2018). Depressive disorders can occur at any age but most often occur in early adulthood, physical ailments such as diabetes, Parkinson’s, cancer, heart disease and more can be attributed to causing MDD or other depressive disorders to occur (National Institute for Mental Health, 2018). Other factors such as a family history of depression can also be an influence and major life changes, traumas, or stressors can also contribute to depressive disorders (National Institute for Mental Health, 2018). Major life changes such as moving or the loss of a job can be seen as examples. As for stressors and trauma, the loss of a loved one, constant failures, deployment in war or life in war can also be major stressors that can cause depressive disorders among other psychological disorders.
A Major Depressive Episode (MDE) is also characterized by the same criteria as MDD, the difference being that MDD is the recurrence of several MDEs both do need to persist for at least 2 weeks as well. MDD is one of the most common mental health disorders in the world with 7.1% of all adults in the U.S have had at least one MDE, this accounts for roughly 17.3 million adults aged 18 and older (National Institute for Mental Health, 2019). While MDEs may be common among the U.S population females are statistically more likely to suffer from MDEs at 8.7% compared to males 5.3% with the highest prevalence rate occurring at ages 18-25 for adults at 13.1% (National Institute for Mental Health, 2019). For adolescents these numbers change significantly, 13.3% aged 12-17 have had at least one MDE with 20.0% being female as opposed to 6.8% male (National Institute for Mental Health, 2019). Research has also shown that MDD and MDEs tend to decrease as family income increases (Brody, Pratt, Hughes, 2013-2016). It is also seen that minority groups also experience more MDEs than white Americans in the U.S, especially if of mixed-race descent (Brody, Pratt, Hughes, 2013-2016).
With the commonality of MDD and MDEs in the U.S the expectation, one would assume, is that there would be a high rate of those affected seeking treatments. However, this is not the case as 35% of adults and 60% of adolescents do not seek treatment for MDEs despite facing impairment or loss of functioning (National Institute for Mental Health, 2019). Despite these high rates of no treatment, there is still 59% of adults who do seek Health professionals for treatment and ~27% for adolescents, these numbers include not only professional psychologists or psychiatrists but also case managers and other health professionals, listing of treatments also varies on a case by case, but Cognitive Behavioral Therapy is among the ranks of successful mental health treatment options available (National Institute for Mental Health, 2019).
Cognitive-behavioral therapy or CBT began in the 1960s with Aaron Beck coining the term ‘cognitive therapy,’ which is synonymous with CBT. Beck defined cognitive therapy as ‘a structured, short-term, present-oriented psychotherapy for depression, directed toward solving current problems and modifying dysfunctional thinking and behavior,” (Beck, 2011). The essence of CBT is to have the patient identify the problematic or dysfunctional behavior and alter it for the bettering of the patient. While it may seem that the therapist must do this task, the work truly lies with the patient as they must be the ones to change their behavior and practice outside of the therapy session. CBT is something that takes time as behavior is not an easy thing to change, nor is it easy to fall out of the rut of dysfunctional behavior that a patient may be used to. While each client diagnosed with MDD may have the same mental health issue, each situation is different, and this is where CBT excels. It is a psychotherapy approach that is very versatile as it adapts to the patients’ needs, level of education and income and time constraints. This flexibility allows patients of all types to receive the proper and individualized treatment best suited for their conditions.
In initially developing CBT Aaron Beck sought to test the concept that depression is a result of hostility turned inward towards the self, a need to suffer in a way (Beck, 2011). After testing Beck concluded that this initial theory was incorrect as he found that depressed patients had occasionally expressed two streams of thought: one being a free association and the other being quick evaluative thoughts about themselves, mostly negative (Beck, 2011). This observation led Beck to believe that patients expressed automatic negative thoughts to which their emotions were then connected to and bringing a new target for therapy (Beck, 2011).
The functioning behind CBT can be explained by the cognitive model, which proposes that dysfunctional thinking after one misstep can lead to believing that you are bad at everything and a failure, which causes you to retreat to bed. After further examining the issue however, you may conclude that you may have overgeneralized and realized you excel at many different things (Beck, 2011). CBT works in this way in that therapists seek to do this to clients, but instead of one behavior or thought, the therapist works at a more basic level with a patient’s basic beliefs about themselves and their surroundings (Beck, 2011). This modification leads to a more lasting change, because of the removal of the dysfunctional beliefs a patient may have and the ability to reason through a more realistic light, such as instead of seeing one’s self as a failure at a specific task, the patient can now see themselves as someone who may not be good at one specific task but still possess strengthens in other aspects (Beck, 2011).
CBT works in many great ways as it incorporates a wide range of treatment strategies that use a current understanding of different mental disorders to provide proper care (Leichsenring, Hiller, Weissberg, & Leibing, 2006). Like other treatment types, CBT incorporates using goals to motivate patient change and behavior, the patient and therapist work together to identify and understand the problems the patient faces via thoughts, feelings, and behaviors (Leichsenring, Hiller, Weissberg, & Leibing, 2006). CBT “directly targets symptoms, reduce distress, re-evaluate thinking and promote helpful behavioral responses.” (Leichsenring, Hiller, Weissberg, & Leibing, 2006). A unique but important aspect of CBT is its use of “homework” between sessions. The “homework” that patients are given is to use what has been learned in each session outside of therapy and to practice in the day to day. This constant practice is key in CBT as it allows the client to attribute improvement based on their efforts and view the therapist as more of a guide and support, not the sole reason for their betterment.
Other techniques that cognitive-behavioral therapists use in treatment often include some or most of the following: systematic desensitization, exposure prevention, relaxation, positive and negative reinforcement, cognitive modification, assertiveness training, stress management and problem-solving (Leichsenring, Hiller, Weissberg, & Leibing, 2006). Systematic desensitization is used to teach the patient to not experience distress when subject to anxious situations, by exposing the patient to an anxious situation (either real or imaginative) from a rested calm state. Exposure/response prevention is similar in that the patient is exposed to anxiety or stress-provoking situation that they cannot escape, this will hopefully lead to the patient experiencing peak anxiety followed by a drop where the patient begins to calm and learn emotional habituation. Relaxation is used to calm the patient physically, which in turn helps to calm a patient mentally.
Positive and negative reinforcement is used to establish new beneficial behavior and weaken harmful negative behaviors a patient may show. Assertiveness training is used to teach patients how to manage interpersonal situations more efficiently, negotiate needs in a relationship, become assertive to avoid fear or sad responses to social situations (Leichsenring, Hiller, Weissberg, & Leibing, 2006). Stress management is used to reduce tension and distress in a patient’s life by managing life goals, anger, interpersonal conflicts and to improve time management (Leichsenring, Hiller, Weissberg, & Leibing, 2006). Problem-solving is used to identify problems a patient faces in the day to day and to improve decision making and find possible outcomes for situations (Leichsenring, Hiller, Weissberg, & Leibing, 2006).
CBT has been shown to be quiet an effective treatment for many different kinds of disorders, especially that of MDD. A meta-analysis of the effects of CBT and its modifications for relapse prevention in MDD showed that CBT showed much greater success in a 12-month period as opposed to control conditions (Zhang, Zhang, Zhang, Jin, & Zheng, 2018). This study examined 16 trials containing an overall 1945 participants of varying backgrounds. The conclusion of the meta-analysis found that the use of CBT for MDD patients in remission have an expected lower chance of falling into relapse via another MDE (Zhang, Zhang, Zhang, Jin, & Zheng, 2018).
The researchers do however caution against believing that CBT does this for everyone with at least 3 or more previous MDEs and acknowledge that further research into previous psychological interventions should be explored (Zhang, Zhang, Zhang, Jin, & Zheng, 2018). Another aspect that should be taken into account is that medication with the use of CBT is found to be much more effective than CBT alone or medication alone, this can, however, vary based on a patient by patient basis (Zhang, Zhang, Zhang, Jin, & Zheng, 2018). Other modified versions of CBT have also been found to be more effective than basic unmodified CBT, an example would be mindfulness-based CBT (Zhang, Zhang, Zhang, Jin, & Zheng, 2018).
A study examining the evaluation of CBT in a treatment trial of comorbid MDD/AUD adolescents found that adolescents who were placed in the CBT group responded much better and improved better overall than the naturalistic treatment group who were also given placebo medication (Cornelius, et al., 2011). The researchers found that CBT showcased great use in the treatment of comorbid disorders in adolescence specifically MDD and an alcohol use disorder (Cornelius, et al., 2011). The researchers do caution against drawing any solid conclusions to clarify the efficacy of CBT among adolescents with comorbid disorders as more research is needed to analyze the population and efficacy of treatment (Cornelius, et al., 2011). The effectiveness of CBT cannot be overlooked as it has been shown to help many suffering from MDD and has been able to keep MDE from reoccurring. The flexibility of CBT as a therapy allows it to help a plethora of patients suffering not only from MDD but other disorders as well, even those potentially suffering from comorbid disorders as well.
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