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Cognitive therapy for persistent depression


									Psychological treatment for
  persistent depression
              Richard Moore
           Clinical Psychologist
    South Intake and Treatment Team
          Cambridgeshire and Peterborough
              NHS Foundation Trust
   Forms of persistent depression


Double depression

Major depression with residual symptoms

Recurrent depression with incomplete remission

Chronic major depression
        CT is an effective treatment for
                    …is it?!

In recent „gold standard‟ RCT for moderate to severe

Remission at 16 weeks of ADM (46%) or CT (40%)
(DeRubeis et al, 2005, Arch Gen Psychiat)

CT responders less relapse (31%) than ADM (76%) or
ADM-continuation (47%)

Sustained response over 12 months was 27% in ADM-
cont and 37% in CT (Hollon et al, 2005, Arch Gen Psychiat)
The Challenge for our Services
In „gold standard‟ studies of acute treatment,
under half sustain response over 12 months
     Hollon et al, 2005, Arch Gen Psychiat

At least 15% of individuals with first onset
depression will follow a chronic course
     eg 23 year follow-up, Eaton et al, 2008, Arch Gen Psychiat

In a naturalistic study of treatment of resistant
depression, the remission rate at 12 months was
3.6% and at 24 months 7.8%
     Dunner et al, 2006, J Clin Psychiat
Evidence meeting NICE criteria for
 treatment of chronic depression
     NICE Guidelines for Depression
           (Updated 2009)

For a person whose depression has failed to respond to
  pharmacological or psychological interventions:

   – Consider combining them
   – Consider referral to a practitioner with a specialist
   – Conduct full assessment
   – Develop a multidisciplinary care plan
   – Re-introduce treatments that have been inadequately
 Cognitive Therapy for Residual
    Depressive Symptoms
           (Paykel et al, 1999, Arch Gen Psychiat)

Significant residual symptoms following adequate
medication (N=158)

CT+ADM vs ADM over 20 wks

At 20wks, CT more remission (26% vs 12%); less
guilt/hopelessness; better social function

Over 68wks follow-up, CT reduced relapse (29% vs

Benefits extended to 3½ years after Tx
Chronic Depression: the CBASP
                 (Keller et al, 2000, NEJM)

681 patients with „chronic depression‟

CBASP vs ADM vs Combination at 12 weeks

Combination greater response (73%) vs either
treatment alone (48%)

„Small print‟:
     Remission rates lower (42% vs 22% vs 24%)
     Most patients had „double depression‟
     Treatment resistance excluded
             Length of therapy
No evidence on longer courses of CT

In responders to CT, monthly continuation CT reduced
recurrence compared to control over 8 months (10% vs
31%) and 24 months (37% vs 62%) (Jarrett et al, 2001, Arch
Gen Psychiat)

In CBASP responders, recurrence rates lower with
monthly CBASP (11%) than assessment only (32%)
(Klein et al, 2004, J Cons Clin Psychol)

Maintenance treatments also resulted in continuing
improvements in residual symptoms
           Relapse prevention
A number of approaches now shown to be
effective in preventing recurrence in remitted
high risk patients:

     Mindfulness-Based Cognitive Therapy (Teasdale et
     al, 2000, J Cons Clin Psychol)

     Cognitive therapy (Fava et al, 1998, Arch Gen Psychiat)

     Group CBT (Bockting et al, 2005, J Cons Clin Psychol)
Chronic depression not a „specialist issue‟

Services need to be based on assumptions of
long-term symptoms/risk

Psychological treatments can reduce persistent
symptoms and relapse

Maintenance therapy of significant additional
        Adapting therapy
Develop model of factors contributing to

Adapt and develop interventions

Adapt treatment delivery to maximise
    Audio excerpt: Patient A
How does his presentation differ from someone
with acute depression?

How does it make you react?

What does the therapist do well? What could be
      The chronic cognitive triad

Low self-esteem: lacking/fragile

Helplessness:     “there‟s nothing I can

Hopelessness:     “things can never
              Cases from CN study
1.   Declined further therapy after one session

2.   Symptoms worsened at session 3: “therapist

3.   Chaotic course: hard to identify central beliefs

4.   No clear evidence of belief change despite

5.   Patient unforthcoming: little material to present
Three important factors in
  persistent depression



               Types of avoidance

                 Cognitive/    Emotional
                 Behavioural   Suppression

Behaviour        active        passive

Affect           labile        flat

Presentation     certain       confused
                 problems +    no problems
           A typical suppressor

         Depression          Problems

         ?2.5 yrs/ ?15yrs    ?brain disorder
58 yrs   ? 1st episode       ?redundancy

         „out of the blue‟   ?mother-in-law

                             ?no hobbies
               A typical avoider
         Depression            Problems

         9 Months              “Fine” but…
32 yrs   8th episode           …no job

         break-up of           financial
                               lost friend

                               can‟t keep



Effects on emotional experience
  -lowers tolerance of distress
  -prevents development of coping/regulation
  -prevents experience of pleasure

Effects on cognition
  -prevents disconfirmation of negative beliefs
  -often confirms/maintains beliefs
  Overt thinking in
persistent depression





Core beliefs in persistent depression

Fundamental view of self and world

Cognitive maintenance: „translation
  device‟, prejudice

Behavioural maintenance: avoidance,
  compensation, maintenance
 Common themes in chronic depression

Core beliefs

   Bad                                 Weak                 Worthless
   Useless                             Inadequate           Don‟t count
   Unacceptable                        Helpless             Nuisance

Conditional beliefs
                            I must always stay in control
                            Emotions are a sign of weakness

It is terrible ever to be criticised                I must put others first
My value depends on                                 I am responsible
gaining approval
                  Beliefs about depression
Identity- “It‟s just me”

   -depression shows how inadequate I am
   -there‟s no point trying to get better
   -if I get better, I won‟t know how to act/think


   -it‟s in my genes
   -I can‟t change the chemicals in my brain
   -talking is very nice but can not work

“It‟s them”

   -I can‟t change until they do
   -It‟s their fault I‟m depressed- why should I try to get better?
                        Early experiences

Unconditional beliefs                       Conditional beliefs

                        Triggering events


   Biological              LOW MOOD             Avoidance
   changes                                      strategies

 Beliefs about                               Environmental
 depression                                  consequences
Cognitive model in chronic depression

Underlying beliefs are rigid/unconditional

Vulnerability results in avoidance/compensation

Experiences provide evidence to confirm beliefs

Beliefs about depression develop

Low self-esteem, helplessness, hopelessness
become entrenched
   Cognitive model of persistent

“Behind this frustration, though, there was something more:
 a terrible sadness and a feeling of vulnerability he did not
 wish to investigate, though it lapped against his immediate
concerns… He would not, could not, consider this. To think
of such things, he was sure, would mean drilling holes in his
  watertight heart; all sorts of doubts would pour in and he
                    would be a lost man.”

  (from Hullabaloo in the Guava Orchard by Kiran Desai)
         Top tips for CT with persistent
1.   Be realistic- play the „long game‟, consolidate small gains

2.   Be prepared- develop and share a formulation that
               helps to explain the problems

3.   Be flexible- regulate the emotion in session to facilitate
                 experiential change

4.   Be patient- help the patient to recognise unhelpful thoughts and
                beliefs and their effects

5.   Be positive- foster the processing and retention of positive

6.   Be personal- get in there with kindness and humour
                 Working with avoidance
Identifying and labelling   -playing it safe
                            -blanking out
                            -pushing down

Consequences                -avoid unpleasant feelings
                            -links to problems

Graded exposure             -tasks

Explanation                 -feeling worse expected
                            -thoughts/beliefs not facts

Experiments                 -predictions
                            -accessing feelings
                   Problems for therapy

Active avoidance                   Emotional suppression

Therapy triggers intense emotion   Hard to specify problems

Withdrawal from/within therapy     Hard to identify NATs/beliefs

Hard to focus on central issues    Many techniques „blunted‟

Much evidence for NATs             Questioning leads to
  Audio excerpt: Patient B
How does her presentation differ from the
previous patient?

How does it make you react?

What does the therapist do differently to
manage the emotion? Is it helpful?
               Adaptations of therapy

Active avoidance            Emotional suppression

Pre-emptive style           Provocative style

Preparation/explanation     Concrete examples

Coping plans                Setting goals

Reactions to therapy        Reactions to therapy
Role play: adjusting the heat
Patient: persistently depressed patient
coming to session 3 after a week with
several spells of feeling low

Therapist: try to focus on a low spell and
begin to identify and question any NATs…

…using 1 statement + 1 question
     Supervision Role Play
Supervisee: Think about a patient with
whom identifying/questioning NATs has
been difficult. Describe your efforts and
how they don‟t seem to be working.

Supervisor: Try to help the supervisee to
clarify the nature of the problem: what is
„going wrong‟ and what to do about it?
      Working with automatic thoughts

Common problem          Possible strategies

No thoughts             Constant vigilance
                        Provoke via tasks
                        Focus on avoidance

No decrease in mood     Small changes… great!
                        If act on this, what to do?
                        Highlight the bias

Loads of evidence       Validate!
                        Relate to themes… beliefs
                        Causal vs consequential
        Cambridge Newcastle Study of
           Residual Depression
         (Paykel et al, Arch. Gen. Psychiat., 1999)

Outcomes: In addition to adequate medication…

   – CT significantly reduced guilt and hopelessness and improved
     social functioning
   – CT reduced rate of relapse into major depression by 40%

Mechanisms: Outcome predicted by…

   – extremity of responses on standard questionnaires, but not
   – meta-awareness of negative thoughts in memories of upsetting
           How CT really works
       (1) Extremity of responses
     (Teasdale et al, J Cons Clin Psych, 2001)

•   extremity = total number of extreme (positive and
    negative) responses to 5 questionnaires

•   extremity predicts relapse

•   CT patients less extreme post-treatment
            How CT really works
              2) Meta-awareness
      (Teasdale et al, J Cons Clin Psych, 2002)

meta-awareness = ability to see negative thoughts as
thoughts rather than reality („I can see it‟)

measured by complicated semi-structured interview
about cued autobiographical memories

meta-awareness predicts relapse

CT patients showed increased meta-awareness post-
 Developing awareness of schemas


Understanding patterns in life history

Prejudice model (Padesky, 1990)

Maintenance cycles (Self-fulfilling
            Explaining schemas

Schemas as „all you need to know about…‟

Something isn‟t true just because it feels true

Schemas can be rooted in early experiences

Maintained by processes of thinking and

Schemas can be changed
              The Prejudice Model
                     (Padesky, 1990)
Think of someone who holds a prejudice you disagree

What beliefs do they hold?

What if they see something that fits with their prejudice?

What if they see something that doesn‟t fit?
      Not notice
      Make an exception

How would you help them overcome their prejudice?
Schemas as self-fulfilling prophecies
                  I am weak

    If I say what I want, I will be ridiculed

            Don‟t say what I want

             Others take control

                Feel stressed
 Audio excerpt: Patient A (2)
How does this differ from “standard CT”?

How does the therapist manage the (lack of)

What is helpful?

What could be improved?
              Modifying beliefs
Identifying and monitoring
Explore development of beliefs

Weigh up advantages and disadvantages
Behavioural experiments
Acting against the assumption
Examine the logical basis

Historical test of schema
Restructure childhood imagery
Discussing adaptive alternative belief
Scaling on adaptive belief
Log of evidence supporting adaptive belief
   Behavioural Experiments
Make explicit the assumption to be tested

Clarify the predictions about task/situation

Test what happens in practice

Review implications for beliefs
  Procedure for imagery re-scripting
Identify content of core schema through themes

Identify early memory that is typical of feelings of core schema

Replay memory in details to identify core meanings

In present, develop alternative viewpoints

Replay memory incorporating new interpretations via new outcome
or „messenger‟

Assess impact of alternative view on core meanings in the image

Debriefing in present to draw new conclusions and discuss how to
apply in current situation
         Developing adaptive beliefs

Old belief:     I am weak

New belief:     I am able %

  I took pleasure from something
  I decided to do something
  I expressed a positive feeling
  I acknowledged being unhappy
  I went into company
  Someone took notice of what I said
                    Treatment delivery
       Discharge planning


       Multidisciplinary team: CPN, Social Worker, OT…

Therapist issues
      The final showdown
DoH/NHS hierarchy demands
    Fewer sessions
    Less experienced therapists
    Evidence of benefit

Successful therapy requires
    More sessions
    More experienced therapists
    Tolerance of uncertainty

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