Case study: The Treatment of Depression

“Although depression has been recognized as a clinical syndrome for over 2000 years, as yet, no completely satisfactory explanation of its puzzling and paradoxical features has been found. There are still major unresolved issues regarding its nature, its classification and its etiology”. (Beck and Alford, 2009, p3)

However, the importance of depression is recognised by everyone in the field of mental health. According to Kline, “more human suffering has resulted from depression than from any other single disease affecting mankind.” (Kline, 1964)

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Hammen (Hammen,1997,p3) states that “the term depression is used in everyday language to describe a range of experiences from a slightly noticeable and temporary mood decrease to a profoundly impaired and even life-threatening disorder”.

“The severity of depression is generally defined according to the number of symptoms present, the severity of the symptoms and the severity of the associated functional impairment or distress”. (Whisman, 2008, p66).

This is done by health professionals using the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-IV), a publication where each mood disorder is characterised by a unique set of symptoms or diagnostic criteria which are split into 4 areas:

Affective

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Behavioral

Cognitive

Somatic

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The Cost of Depression

Government advisor, Lord Layard, worked on a report back in 2004 that outlined mental illness as “the biggest social problem facing Britain today.” (Layard, 2004)

The report pointed to the Psychiatric Morbidity Survey, which suggested that one in six British people would be diagnosed with depression or anxiety at some point in their lives. Yet only one in four of people with emotional disorders receive proper treatment.

“It imposes heavy costs on the economy (some 2% of GDP) and on the Exchequer (again some 2% of GDP). There are now more mentally ill people drawing incapacity benefits than there are unemployed people on Jobseeker’s Allowance.

Mental illness matters because it causes massive suffering to patients and their families, because it prevents them contributing fully to society, and because it imposes heavy costs on taxpayers”. (Layard, 2004).

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A UK wide strategy to help people with depression was required. The vehicle for this was through the NHS.

In September 2007, “the UK government launched the biggest state-funded mental health initiative ever. It pledged £170 million to create “a ground-breaking therapy service in Britain”, according to health minister Alan Johnson. The service was to include 3,500 extra psychological therapists trained in CBT to be found and trained by 2011.” (Evans, 2007).

What is CBT?

CBT (Cognitive Behavioral Therapy) is the treatment of choice within the NHS for depression.

According to The Royal College of Psychiatrists (2010); CBT is a form of psychotherapy which involves:

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How you think about yourself, the world and other people

How what you do affects your thoughts and feelings

CBT was developed by Dr Beck, a psychiatrist at the University of Pennsylvania in the early 1960s. Dr Beck had previously studied and practiced psychoanalysis.

“He designed and carried out a number of experiments to test psychoanalytic concepts on depression. Fully expecting research would validate these fundamental precepts, he was surprised to find the opposite”. Beck Institute website (1999-2009)

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“This research led him to begin to look for other ways of conceptualizing depression. Working with depressed patients, he found that they experienced streams of negative thoughts that seemed to pop up spontaneously.

He termed these cognitions “automatic thoughts,” and discovered that their content fell into three categories: negative ideas about themselves, the world and the future. He began helping patients identify and evaluate these thoughts and found that by doing so, patients were able to think more realistically, which led them to feel better emotionally and behave more functionally”. (Beck Institute 1999 – 2009).

According to the NHS Choice website (2010) “Cognitive Behavioral Therapy differs from most other types of psychotherapies because it is:

Pragmatic

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Highlight structured

Focused on current problems

Collaborative

“Cognitive behavioral treatments are developed with particular cognitive contents in mind they are disorder specific.” (Scott, 2009, p2)

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Depression:

Cognitive Therapy

“For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:

Individual guided self-help based on the principles of cognitive behavioural therapy (CBT)

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Computerised cognitive behavioural therapy (CCBT)

A structured group physical activity programme

Drug treatment

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk-benefit ratio is poor, but consider them for people with:

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a past history of moderate or severe depression or

initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or

subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

For Those with Moderate or Severe Depression:

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For people with moderate or severe depression, medical practitioners are advised to “provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT or IPT)”. (NICE Guidelines 2009)

The Royal College of Psychiatrists (2010) highlight the medication used within the NHS for the treatment of depression to include:

Tricyclics

MAOIs

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SSRIs

SNRIs

NASSAs

Although medication can help lift the patient’s mood, it does not tackle any underlying problems they may be experiencing. There are also various known side effects to the medication including abdominal pain, nausea, headache, suicidal thoughts, constipation, blurred vision – to name but a few. People react differently to different drugs, so until they try them they are unable to know if they will have a negative impact on them.

“Psychological therapies can help patients to explore what may have contributed to their depression in the first place, and what might be keeping them depressed”. (Depression Alliance UK, 2010)

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CBT can be done individually or with a group of people. It can also be done from a self-help book or computer programme.

Unfortunately, in many parts of the country, there are long waiting lists for CBT and sometimes people end up going to private therapists instead of waiting to see an NHS appointed therapist.

The Benefits of CBT in the Treatment of Depression

The Royal College of Psychiatrists (2009) state that: “CBT is one of the most effective treatments for conditions where anxiety or depression is the main problem. It can help patients break the vicious cycle of altered thinking, feeling and behaviour. It is the most effective psychological treatment for moderate and severe depression. It is as effective as antidepressants for many types of depression”.

This is also supported by Townend, Grant, Mulhern and Short (2009, p 254) who state that “CBT remains the psychological therapy with the widest and broadest evidence base.”

This is also backed by (Gabbard, Beck and Holmes, 2007, p115), “CBT has been demonstrated to be an effective treatment for depression in the large number of studies that have accumulated since the original study by Rush et al (1977).”

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They go on to say that “CBT produces a greater improvement in symptoms than no treatment or waiting list controls (Dobson 1989) and demonstrates equivalent efficacy as pharmacotherapy for depression”.

This is also further supported by (Freeman and Power, 2007, p30) who state, “There have been numerous randomised clinic trials that support the efficacy and effectiveness of cognitive therapy for depression, across a variety of clinical settings and populations (for review, see Clark, Beck and Alford 1999; De Rubeis and Crits-Christophe 1998; Dobson 1999; Robinson,Berman and Neimeyer 1990)” (Freeman and Power, 2007,p30).

According to (Ingram, 2009, p174) “In the acute treatment phase, combination therapy, consisting of medication and CBT, has been found to be superior to either medication or CBT used alone for patients with more severe, recurrent or chronic forms of depression”.

(Gabbard, Beck and Holmes, 2007, p115), state that “One of the main potential benefits of CBT for depression is that it reduces relapse / recurrence to a greater extent than antidepressant medication”.

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“Today, CBT remains the gold standard for the treatment of depression with psychotherapy” (Wasmer-Andrews, 2009, p3).

The Limitations of CBT in the Treatment of Depression

However, although highly praised, CBT does have its limitations and indeed its critics.

In terms of limitations, these are set out below:

To benefit from CBT, the patient needs to commit themselves to the process. A therapist can help and advise, but cannot make someone’s problems go away without the patient’s co-operation (NHS Choices, 2010). Therefore, the patient needs to be open to CBT and play their part in their recovery, including taking a full part in each therapy and doing their ‘homework’ in order to recover from depression.

This is also highlighted by the Royal College of Psychiatrists (2009) who state that “CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages – but cannot ‘do’ it for a patient.

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If a patient is feeling low, it can be difficult for them to concentrate and get motivated. (Royal College of Psychiatrists,2009)

Because of the structured nature of CBT, it may not be suitable for people who have more complex mental health needs or learning difficulties. (NHS Choices, 2010)

This is further supported by (Wasmer-Andrews, 2009, p3) who states that “CBT has limitations for treating certain groups, including people with treatment-resistant depression and those with both depression and a personality disorder”.

Critics of CBT argue that because the therapy only addresses current problems and focuses on very specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood. (NHS Choices, 2010). This is something that could be achieved using a Diagnostic Scan under hypnosis, if hypno-psychotherapy could be used instead.

CBT focuses on the individual’s capacity to change themselves (their thoughts, feelings and behaviours), and does not address wider problems in systems or families that often have a significant impact on an individual’s health and wellbeing. (NHS Choices, 2010)

The Royal College of Psychiatrists (2009) state that “For severe depression, CBT should be used with antidepressant medication. When a patient is very low, they may find it hard to change the way they think until the antidepressants have started to make them feel better”.

Critics of CBT in the Treatment of Depression

Critics of CBT, as with all clinical theories, vary depending on the thoughts of the analyst.

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Townend, Grant, Mulhern and Short (2009, p 254) point to many of these discussions. “Specific issues have been raised over the necessity of, for example, challenging thoughts in CBT (Longmore and Worrell, 2007); and cognitive interventions in severe depression (Dimidjian et al, 2006).

Additionally, there is still ongoing discussion (e.g. Gilbert and Leahy, 2007) about the nature an impact of the therapeutic alliance as causes of the changes seen in CBT.”

Weiner, Freedheim and Stricker (2003) point out that “Although the scope and efficacy of CBT are impressive, much work needs to be done. In particular, future efforts of CBT clinical researchers must demonstrate the effective of treatments outside research centres as well as turn more attention towards disorders overlooked by CBT (e.g. personality disorder).”

Kotler and Shepard (2008) highlight that “human beings are multi-faceted, with feelings as well as thoughts. It is suggested that CBT puts undue emphasis on thought processes to the exclusion of many legitimate feelings, thereby contributing to repression and the denial of feeling.”

They go on to highlight some other criticism leveled at CBT as follows: “CBT is less effective with some kinds of clients – those who have a problem with overintellectualising or those who don’t have the capacity to reason logically, or clients with minimal intelligence (e.g. young children, very old people, schizophrenics and those with other personality disorders).

Many CBT therapists complain of boredom and burnout from continuously repeating the same arguments and processes with all clients.

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CBT is difficult for some people for some professionals to practice if they are not outgoing and assertive and don’t enjoy vigorous debate and confrontation.

Because the therapists role is so verbal, active and direct, the client may feel overpowered, dominated and not responsible for the outcome.” (Kotler and Shepard, 2008)

The Debate

There is much debate on the subject of CBT as a treatment for depression within the NHS.

Oliver James’ article (James, 2006) sumarises much of this debate. He indicates that “Depression and anxiety costs the (British) economy £17 billion per year. Being cheap, quick (15 – 20 sessions) and simplistic, CBT appeals to the Government”.

In fact, in June 2006, Professor Richard Layard – labeled the government’ happiness ‘tsar’ – claimed that CBT can lift at least half of those affected out of their depression or their chronic fear”. (James, 2006)

Another attraction for the government is that “CBT aims to get you to a point where you can do all this on your own and tackle problems without the help of a therapist”. (NHS Choices, 2010). Thereby, it is argued that using CBT could reduce the future costs of treatment in current users.

In addition, there are also now computerised CBT approved for use by the NHS – Beating the Blues which has been approved for the treatment of depression. (NHS Choices, 2010).

Again, this is a cost effective treatment for some people who find they prefer using a computer rather than talking to a therapist about their private feelings. (NHS Choices, 2010)

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In a follow up article, in March 2009 (James, 2009) resurrected the debate when he reported that “CBT is not a real cure, just a form of personal spin.”

He went on to argue that work by “eminent US psychologist, Professor Drew Weston found that after two years, two thirds of those who had CBT for depression has relapsed or sought further help”.

It is important for patients to keep practicing their CBT skills, even after they are feeling better. There is some research that suggests CBT may be better than antidepressants at preventing depression coming back. (The Royal College of Psychiatrists, 2009)

James (2009) went on to argue that “If given no treatment, most people with depression drift in and out of it. After 18 months, those given CBT have no better mental health than ones who have been untreated.”

On the other hand, in the same article by James (2009), Derek Draper a CBT practitioner and author states that CBT “draws on the obvious truth that how we feel is inextricably linked to the way we think and behave. It isn’t remotely sinister and is rather simple – and it works. Many of my patients have been helped by CBT”.

New Research

According to the Royal College of Psychiatrists website (2009) “Cognitive behavioural therapy (CBT) is most effective in patients who have had four or more prior episodes of depression, according to new research from The Netherlands.

The study, published in the December issue of the British Journal of Psychiatry, suggests GPs could use the number of prior episodes to determine which patients are likely to benefit most from therapy and prescribe treatment accordingly).

In another recent study, a comparison of a cognitive behavioural therapy (CBT) website with an information website for depression has found that after 6 months only the CBT website was significantly effective in reducing symptoms. After 1 year, both interventions were significantly better than no intervention (control condition).

Research has shown that internet-delivered brief CBT may be effective in reducing depression, but it has not been clear whether these gains are maintained over time.

The aim of this Australian study, published in the February 2008 issue of the British Journal of Psychiatry, was to see whether the benefits of internet-delivered brief psychoeducation and CBT were still there 6 and 12 months later, compared with a control condition, in which participants were asked questions about their lifestyle.

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Summary

In summary, CBT is the treatment of choice in the NHS for moderate to severe depression and having reviewed all of the benefits and limitation, read from the critics and the ambassadors, the writer feels that there is still much to learn and evaluate in the treatment of depression.

Whilst the results so far have appeared to show that CBT is very effective in the treatment of moderate to severe depression, there are large groups of people that will not benefit from this treatment, e.g. young children, those with personality disorders, late-life depression suffers.

The writer suggests that there is not a universally acceptable treatment for all – that some treatments will work for some people with some therapists and other treatments will work for others with another therapist – the willingness of the client to seek help, play their part in their recovery alongside their chosen therapy will help some of the people, some of the time. But what about in the longer term ? Is this a sticking plaster over a gaping wound ? CBT can help in the here and now, but relapses can occur as the root of the problem if it is in the past is not usually discussed in a CBT session, which is focussed on the present.

While the costs of depression to individuals, families and businesses are huge, the writer feels that the government, through the NHS has made very positive steps to try to assist people living with depression by welcoming the use the “talking therapies”.

As more studies are commissioned in the future, new information will be gained and new decisions made based on this. For the moment, embracing the “talking therapies” is a very good step in the right direction and it is hoped that other therapies will continue to be evaluated so that patients of the future would have a choice of “talking therapies”, including CBT, but also others like life coaching, NLP and hypno-psychotherapy.

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