Is It Necessary to Evaluate Thoughts in Cognitive Behavioral Therapy for Depression - Research Paper Example

Is it necessary to evaluate thoughts in Cognitive Behavioral Therapy for Depression Introduction: All of us have some negative automatic thoughts every day but when we are depressed we tend to have lots more of them. If we have lots of these kinds of thoughts each day we could end up feeling depressed and once we are depressed, the negative automatic thoughts take over. Negative automatic thoughts not only make us feel bad or depressed, but they can also stop us from doing right things. We may find ourselves thinking "I'll not be able to do it, what's the point in trying" and finally we get depressed. Depression is a chronic illness that requires long-term treatment but most of the antidepressant drugs possess severe adverse. Moreover, antidepressants need to be used cautiously in children because one out of fifty children becomes more suicidal (Richard et al., 2006). Cognitive Behavioral Therapy (CBT) can be a very effective alternative to treat depression in long-term benefits. CBT helps identifying the negative automatic thoughts that may be leading to feelings of depression and helps us to come up with alternative ways of thinking that reduces the feelings of depression. It aims to influence dysfunctional emotions, behaviors and cognitions through a goal-oriented and systematic procedure by using a number of psychological techniques, behavioristic learning and cognitive psychology. This psychological therapy has been proved to help the people with depression and is based on the idea that how we feel is affected by the way we think and what we believe in. It helps people to see how their thoughts and behavior relate to their problems and how Behavioral Activation changes our behavior and emotional state. Behavioral activation encourages patients to approach activities that they are avoiding and the patients are thus refocused on their goals and valued directions in life. There are many advantages of behavioral activation over traditional CBT for treating depression. As the emotional difficulties often pose significant obstacles to pleasurable activities, simple intervention of behavioral activation is potentially ideally suited to improve both emotional and functional outcomes. Our own unrealistic beliefs are directly responsible for generating dysfunctional emotions and their resultant behaviors, like stress, depression, anxiety, and social withdrawal. Cognitive restructuring advises to change such irrational beliefs and substitute more rational thoughts. There are a number of theories and mechanisms about the usefulness and working of Behavior Activation. Most of the theories suggest that It gives our mind something else to think about - a different focus, and the patient finds pleasure and enjoyment in the activities. It helps us to feel less tired and take a different perspective on particular problems in our life. As a result of the Behavioral Activity, our thoughts become clearer and make good sense to do fun and pleasurable things which make us feel better. Depression: Depression is a serious condition that affects how a person is able to function in his or her everyday life. It is characterized by the persistence of frustration, feelings of sadness and hopelessness, and feelings of having no control over life situations. The two most common types of depression are major depression and dysthymia (chronic depression). Less common are postpartum depression, psychotic depression, and seasonal affective disorder. It is a complex illness that is caused by multiple factors. Some environmental causes include emotional distress, a traumatic event, grief, physical or sexual abuse while biological causes include chemical imbalances of the brain, medical conditions and genetics. Stress can also exacerbate depression. Major depression and mania are two extremes of affective disorders which refer to a pathological change in mood state. Major depression is characterized by symptoms like sad mood, loss of interest and pleasure, low energy, worthlessness, guilt, psychomotor retardation or agitation, change in appetite or sleep, melancholia, suicidal thoughts, etc. (Tripathi, 2003). Depression is one of the most common health conditions in the world. Depression, formally called major depression, major depressive disorder or clinical depression, is a medical illness that involves the mind and body. It is a serious disorder that afflicts approximately 14 million adults in the United States each year. The lifetime prevalence rate of depression in the United States has been estimated to include sixteen percent of adults or more than 32 million people (Richard, 2006). Studies suggest that depression may affect 2-8% of children and adolescents, with a peak incidence around puberty. It may be self-limiting, but about 40% of affected children experience a recurrent attack, a third of affected children will make a suicide attempt, and 3-4% will die from suicide (Hazell, 2009). Depression typically begins in the late 20s, but it can arise at any age, affecting everyone from young children to older adults. Data indicates that twice as many women are diagnosed with a history of depression as men, but this may be due in part because women are more likely to seek treatment for depression. Causes: As with many mental illnesses it is not known specifically what causes depression. It is thought that there are a number of factors including biochemical, genetic and environmental factors that may cause depression. Some evidences indicate that people with depression have physical changes in their brains. The naturally occurring brain chemicals called neurotransmitters, which are linked to mood, and hormonal imbalances play a role in causing depression. Our surroundings and Environment is also thought to play a causal role in some way. Environmental causes, such as the loss of a loved one, financial problems and high stress, are some of the situations in our life that are difficult to cope with. Such situations are also responsible for causing depression. Western antidepressants and their side effects: Most health professionals today consider depression a chronic illness that requires long-term treatment, much like diabetes or high blood pressure. Most of the antidepressant drugs possess severe adverse effects which include weakness, sexual dysfunction, sleep disturbances and drug interactions. Antidepressants need to be used cautiously in children because one out of fifty children becomes more suicidal as a result of SSRI (Selective Serotonin Re-uptake Inhibitors) treatment, commonly given for the treatment of depression. Moreover, larger intakes of SSRI may cause seizures also (Richard et al., 2006). Many western antidepressant drugs such as Effexor, Paxil, Elavil, Zoflot, Prozac, Celexa, Lexapro, Wellbutrin,etc. can be beneficial by focusing on maintaining the serotonin levels in the brain. But, in addition to the side effects, the patients need to take them all the time. Cognitive Behavioral Therapy (CBT) can be a very effective alternative to treat depression and anxiety in long-term benefits. CBT helps identifying the negative automatic thoughts, and once we are able to identify the thoughts that may be leading to feelings of depression, it helps us to come up with alternative ways of thinking that reduces the feelings of depression. The CBT approach focuses on how we think and interpret things. The therapy taught how to think differently about the situations we are in, so that we may cope with it. Cognitive Behavioral Therapy (CBT): A psychotherapeutic approach that aims to influence dysfunctional emotions, behaviors and cognitions through a goal-oriented and systematic procedure is known as Cognitive behavioral therapy. This umbrella term is used for a number of psychological techniques that share a theoretical basis in behavioristic learning theory and cognitive psychology. CBT is a psychological therapy that has been proved to help the people with depression and anxiety and is based on the idea that how we feel is affected by the way we think and what we believe which, in turn, affects our emotions and behavior. CBT involves helping people to see how their thoughts and behavior relate to their problems. CBT is an action oriented form of psychosocial therapy that assumes that faulty thinking patterns cause maladaptive behavior and 'negative' emotions. Maladaptive behavior is a behavior that interferes with everyday living. The treatment focuses on changing the individual's thoughts (cognitive patterns) in order to change their behavior and emotional state. Behavioral Activation: Behavioral activation, a formal therapy for depression, focuses on activity scheduling to encourage patients to approach activities that they are avoiding and on analyzing the function of cognitive processes that serve as a form of avoidance. Patients are thus refocused on their goals and valued directions in life. The main advantage of behavioral activation over traditional CBT for depression is that it may be easier to train staff in it and it can be used in both in-patient and out-patient settings. Veale (2008) outlines the utility of behavioral activation in the management of depression and asserts that complex problems often require therapists to perform simple interventions well. He highlights overcoming avoidance, setting goals and teaching patients to disengage with the content of thoughts, as effective strategies within behavioral activation. These points are of direct relevance to psychotherapeutic approaches to depression, where patients may have cognitive impairment in addition to depression and other emotional or behavioral difficulties. The emotional difficulties following depression, often pose significant obstacles to re-engagement with meaningful and pleasurable activities. While complex psychotherapeutic interventions may result in unsatisfactory outcomes or poor generalization because of patients' cognitive impairment behavioral activation, a relatively simple intervention, is potentially ideally suited to improve both emotional and functional outcomes, in this population. Cognitive restructuring: In cognitive therapy, cognitive restructuring is the process of learning to fundamental 'faulty thinking' with the goal of replacing our irrational, counter-factual beliefs with more accurate and beneficial ones. The cognitive restructuring theory holds that our own unrealistic beliefs are directly responsible for generating dysfunctional emotions and their resultant behaviors, like stress, depression, anxiety, and social withdrawal. We humans can get rid of such emotions and their effects by dismantling the beliefs that give them life. Cognitive restructuring advises to change such irrational beliefs and substitute more rational thoughts. Mechanism by which Behavioral Activation works: Increasing our Activity Level is one of the ways of overcoming depression. There are a lot of evidences that shows that the more people do, and the more pleasant activities they get involved in, the better they feel. There are a number of theories and mechanisms about the usefulness and working of Behavior Activation. Most of the theories suggest that It gives our mind something else to think about - a different focus, and the patient finds pleasure and enjoyment in the activities. It helps us to feel less tired and take a different perspective on particular problems in our life. As a result of the Behavioral Activity, our thoughts become clearer and make good sense to do fun and pleasurable things which make us feel better. Becoming more active has a number of advantages: It helps you to feel better: when you start engaging in some kind of activity, it gives your mind something else to think about - a different focus. You may even find pleasure and enjoyment in the activities you do. It helps you to feel less tired: Usually, when you are physically tired, you need rest. However, when you are depressed, the opposite is true. Sleeping more and sitting around doing nothing will only cause you to feel more lethargic and tired. Also, doing nothing leaves room for your mind to ruminate on depressive thoughts, which will make your feel even more depressed. Activity can help you think more clearly. Once you get started, you may find that you take a different perspective on particular problems in your life. Also, because your mind takes a different focus as a result of the activity, your thoughts may become clearer. Fun & Achievement: It makes good sense to do fun and pleasurable things to make you feel better. Start Simple: Even though there are a number of advantages in increasing your activity level, it may not be easy to get started. Often, this is because when you are depressed, you think negative thoughts such as "I won't enjoy doing this," or "It's too hard," or "I'll probably fail at this too." These thoughts may stop you from getting started. Often the big mistake people make is trying to do too much too soon. Start with small steps and slowly build yourself up to the large tasks that seem unmanageable right now In the present communication, the evidence base for cognitive-behavioral therapy (CBT) for depression is discussed. The history of psychological therapies has been marked by a lack of well designed outcome studies accompanied by the reluctance of many psychotherapists to adopt ideas such as diagnosis and disagreements about the nature or importance of outcome measures and, sometimes, of the benefits of evidence-based approaches. This situation has altered radically with the increased use of cognitive-behavioral therapy (CBT) treatments, which are based on the scientist-practitioner model and routinely gather outcome data. Theoretically, CBT can be employed in any situation in which there is a pattern of unwanted behavior accompanied by distress and impairment. It is a recommended treatment for a number of mental disorders, social phobia, obsessive compulsive disorder, eating disorder, substance abuse, anxiety or panic, agoraphobia, post traumatic stress disorder and attention deficit hyperactivity disorder. Cognitive Therapy is also frequently used as a tool to deal with chronic pain for patients with illnesses such as rheumatoid arthritis, back pain, and cancer. Patients with sleep disorders may also find cognitive behavior therapy a useful tool treatment for insomnia. CBT was primarily developed through a merging of behavior therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the "here and now" and symptom removal (Rachman et al., 1997). Many CBT treatment programs for specific disorders have been developed and evaluated for efficacy and effectiveness; the health-care trend of evidence-based treatment, where specific treatments for specific symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments (Lambert et al., 2004). Major depression is expected to become the second leading contributor to disease burden worldwide by 2020. The combined therapy of antidepressant drugs with CBT increased the rate of successfully treated patients. The combined therapy appeared to be cost-effective and more beneficial from the health-care system perspective and the dominant strategy from the social perspective (Sado et al., 2009). Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy. The present study tested the efficacy of behavioral activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder (N = 241). In addition, it examined the importance of initial severity as a moderator of treatment outcome. Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy (Dimidjian et al. 2006). Konarski et al. (2009) studied predictors of non-response to cognitive behavioral therapy or venlafaxine using glucose metabolism in major depressive disorder. The results suggested that CBT is very useful in the treatment of depression as compared to the antidepressant therapy (Konarski et al., 2009). Analyses were carried out using patients of a 10-weeks randomized, placebo-controlled trial comparing the effectiveness of sertraline and cognitive-behavioral therapy (CBT) in patients with mild major, minor or sub-syndromal depression. The findings suggests that the identification of early improvement might be useful in clinical decision making in the early course of treatment of patients with mild major, minor and sub threshold depression (Tadic et al., 2009). Relapse rates for children and adolescents with major depressive disorder have also been noticed which range from 30% to 40% within 1 to 2 years after acute treatment. The findings suggest that Cognitive Behavioral Therapy Prevent Depressive Relapse in Youth (Betsy et al., 2008). A Pilot Study was carried out to study and to evaluate a culturally adapted cognitive-behavioral treatment (CBT) for major depression among Hispanics in primary care. Findings of acceptable treatment retention rates and clinically meaningful reductions in depressive symptoms showed promise for this intervention to treat Hispanics with major depression (Alejandro et al., 2008). Depression, have been reported in 25-50% of all patients with COPD, a common progressive and debilitating medical condition. Interventions that reduce anxiety and depressive symptoms may affect COPD outcomes. In this non-randomized study, a programme of individualized CBT in patients with COPD resulted in marked improvements in psychosocial impairment and a significant reduction in service use (Haslpo et al., 2009). The differentiation between postnatal depression and other types of depression is often unclear, but there are treatment issues in nursing mothers that do not apply in other situations. Overall, the prevalence of depression in postpartum women is the same as the prevalence in women generally, at about 12-13%. Suicide is a major cause of maternal mortality in resource-rich countries, but rates are lower in women postpartum than in women who have not had a baby. On this issue, Craig et.al. (2009) studied the effectiveness and safety of the cognitive behavioral therapy which was found to be very effective in the treatment of postnatal depression (Craig et al., 2009). Similarly, Simon (2009) studied the effect of CBT on maternal perinatal depression and found it effective in the management of depression (Simon, 2009). Stanley et al., (2009) performed a pilot studies to observe the effects of CBT relative to enhanced usual care (EUC) in older adults with generalized anxiety disorder (GAD) and depression in primary care. Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care (Stanley et al., 2009). Most of the findings suggest that the CBT plays a very important role in treating depression but some of the findings suggest a clear bias favoring CBT as there was no evidence that the complete treatment with CBT produced better outcomes. In one study, Jacobson NS studied an experimental test to explain the efficacy of cognitive-behavioral therapy (CT) for depression. The comparison involved randomly assigning 150 outpatients with major depression to a treatment focused exclusively on the behavioral activation (BA) component of CT, a treatment that included both BA and the teaching of skills to modify automatic thoughts (AT), but excluding the components of CT focused on core schema, or the full CT treatment. Four experienced cognitive therapists conducted all treatments. Despite excellent adherence to treatment protocols by the therapists, a clear bias favoring CT, and the competent performance of CT, there was no evidence that the complete treatment produced better outcomes, at either the termination of acute treatment or the 6-month follow-up, than either component treatment. Furthermore, both BA and AT treatments were just as effective as CT at altering negative thinking as well as dysfunctional attribution styles. Finally, attribution style was highly predictive of both short- and long-term outcomes in the BA condition, but not in the CT condition (Jacobson et al., 1996). Conclusion: All of us have some negative automatic thoughts every day but when we are depressed we tend to have lots more of them which end up feeling depressed. Once we are depressed, the negative automatic thoughts take over and finally we get depressed. Depression is a chronic illness that requires long-term treatment but most of the antidepressant drugs possess severe adverse effects. Cognitive Behavioral Therapy (CBT), which focuses on how we think and interpret things, can be a very effective alternative to treat depression in long-term benefits. The present review brings together much of the best available evidences for the effectiveness of psychological therapies. The publication highlights the extensive evidence for the effectiveness of CBT for depression, Behavioral activation which is a formal therapy for depression, Cognitive restructuring and the mechanism by which the behavioral activation works. CBT may not be suitable for some patients, particularly those who do not have a specific behavioral issue. Though some researchers suggest a clear bias favoring CBT, but the Patients must also be wiling to take a very active role in order to be treated. For severely psychotic patients and for cognitively impaired patients cognitive behavioral intervention may be very useful depending on their level of severity. Most of the research findings also suggest that CBT plays a very important and dominating role in treating depression. References 1. Alejandro Interian, Lesley A. Allen, Michael A. Gara and Javier I. Escobar (2008 February). A Pilot Study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression', Cognitive and Behavioral Practice, 15(1), 67-75 2. Betsy D. Kennard, , Sunita M. Stewart, Jennifer L. Hughes, Robin B. Jarrett and Graham J. Emslie, (2008 November). 'Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth', Cognitive and Behavioral Practice, 15(4), 387-99. 3. Craig M, Howard LM., (2009 Jan) 'Postnatal depression' Clin Evid (Online), 26, 1407 4. 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Stanley MA, Wilson NL, Novy DM, Rhoades HM, Wagener PD, Greisinger AJ, Cully JA, Kunik ME., (2009 Apr). 'Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial', JAMA, 38 15. Tripathi K.D. (2003). Essentials of Medical Pharmacology, (5th ed.), Jaypee Brothers Medical Publishers (P) Ltd. New Delhi, , p. 4 16. Tadic A, Helmreich I, Mergl R, Hautzinger M, Kohnen R, Henkel V, Hegerl U, (May 2009). 'Early improvement is a predictor of treatment outcome in patients with mild major, minor or subsyndromal depression', J Affect Disord, 8. 17. Veale, D. (2008). 'Behavioral activation for depression', Advances in Psychiatric Treatment, 14 (1): 29 - 36. Read More