A Behavioral Treatment for Depression

David O. Antonuccio, Ph.D.

University of Nevada School of Medicine and Reno V. A. Medical Center

Reprinted from:
Antonuccio, D.O. (1998). The coping with depression course: A behavioral treatment for depression. The Clinical Psychologist, 51 (3), 3-5.

I. Description of Treatment

A classic behavioral model of unipolar depression (Lewinsohn, Youngren, & Grosscup, 1979) postulates that depression can result from a stressor which disrupts normal behavior patterns causing a low rate of response contingent positive reinforcement. The rate of reinforcement is functionally related to the availability of reinforcing events, personal skills to act on the environment, or the impact of certain types of events. If an individual cannot reverse the negative balance of reinforcement, a heightened state of self-awareness will follow that can lead to self-criticism and behavioral withdrawal (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985). This model also suggests that there may be a negative feedback loop of social reinforcement for depressive behaviors when family members and social networks are mobilized to provide support for the depressed individual. The resulting behavioral psychotherapy involves helping patients increase their frequency and quality of pleasant activities. It has been found that depressed patients have low rates of pleasant activities and obtained pleasure; their mood covaries with rates of pleasant and aversive activities; their mood improves with increases in pleasant activities, and they lack social skills, at least during the depressed phase, all of which contribute to the depression (Lewinsohn, Sullivan, & Grosscup, 1980).

The Coping With Depression (CWD) Course was derived from this theoretical perspective. The course was designed as a psychoeducational group or small seminar, teaching people techniques and strategies to cope with the problems that are assumed to be related to their depression. These strategies include improving social skills, addressing depressogenic thinking, increasing pleasant activities, and relaxation training.

The CWD course for adults consists of 12 two-hour sessions conducted over 8 weeks. Sessions are held twice weekly for the first four weeks. Groups typically consist of six to ten adults, with a single group leader. One- and six-month follow-up sessions ("class reunions") are held to encourage maintenance of treatment gains and to collect information on improvement or relapse. Booster sessions can be built in as needed to prevent relapse. All sessions are highly structured, and make use of a text, Control Your Depression (Lewinsohn, Munoz, Youngren, & Zeiss, 1986) and a Participant Workbook (Brown & Lewinsohn, 1984). In addition, an instructor's manual (Lewinsohn, Antonuccio, Steinmetz-Breckenridge, & Teri, 1984) provides scripts, exercises and guidelines.

The CWD course has been adapted to adolescents (CWD-A; Clarke, Lewinsohn, & Hops, 1990). In addition to the skill areas included in the adult CWD course, the CWD-A was expanded to incorporate the teaching of basic communication, negotiation, and conflict-resolution skills. A parallel course for the parents of depressed adolescents (Lewinsohn, Rhode, Hops, & Clarke, 1991) has also been developed.

The CWD Course has also been modified for use with the elderly (Breckenridge, Zeiss, Breckenridge, & Thompson, 1985; Gallagher & Thompson, 1981), for frail or demented elderly persons and their caregivers (Lovett & Gallagher, 1988; Teri & Gallagher-Thompson, 1991), for prevention of depression in high risk low income, minority medical outpatients (Munoz, Ying, Armas, Chan, and Gurza, 1987), for prevention with mid and late life American Indians, (Manson, 1988), for prevention of more serious depression in mildly depressed adolescents (Clarke et al., 1990), and for prevention of depression in smokers who are trying to quit cigarettes (Hall, Munoz, & Reus, 1994).

II. Summary of Studies Supporting Treatment Efficacy

The acute and long-term efficacy of the CWD course or its variations has been demonstrated in several outcome studies with adults (Brown & Lewinsohn; 1984; Steinmetz, Lewinsohn, & Antonuccio; 1983; Hoberman, Lewinsohn, & Tilson, 1988; Teri & Lewinsohn, 1986), adolescents (Lewinsohn, Clarke, Hops, and Andrews, 1990), elderly depressed patients (Teri, Logsdon, Uomoto, & McCurry, 1997; Thompson, Gallagher, Nies, & Epstein, 1983) and in prevention efforts (Clarke et al., 1990; Munoz et al., 1988; Munoz & Ying, 1993). The CWD course has achieved comparable acute outcome and better long-term outcome than antidepressant medication (de Jong-Meyer & Hautzinger, 1996). Group format, individual treatment, and minimal phone contact have all fared equally well, providing therapists many convenient and cost-effective options that can be tailored to the needs of the patient.

III. Clinical References

Breckenridge, J.S., Zeiss, A.M., Breckenridge, J., & Thompson, L. (1985). Behavioral group therapy with the elderly: A psychoeducational model. In D. Upper & S. Ross (Eds.), Handbook of behavioral group therapy (pp. 275-302).

Brown, M.A., & Lewinsohn, P.M. (1984). Participant workbook for the Coping with Depression Course. Eugene, OR: Castalia Publishing.

Clarke, G.N., Lewinsohn, P.M., & Hops, H. (1990). Adolescent coping with depression course. Eugene, OR: Castalia Publishing.

Gallagher, D. & Thompson, L.W. (1981). Depression in the elderly: A behavioral treatment manual. Los Angeles, CA: University of Southern California Press.

Lewinsohn, P.M., Antonuccio, D.O., Steinmetz-Breckenridge, J.L., & Teri, L. (1984). The Coping with Depression course: A psychoeducational intervention for unipolar depression. Eugene, OR: Castalia Publishing.

Lewinsohn, P.M., Munoz, R.F., Youngren, M.A., & Zeiss, A.M. (1986). Control your depression (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall.

Lewinsohn, P.M., Rhode, P., Hops H., & Clarke, G.N. (1991). Leader's manual for parent groups: Adolescent coping with depression course. Unpublished manuscript.

IV. Resources for Training

Training in the various versions of the Coping With Depression Course is offered by Dr. Lewinsohn and his current staff at:

Oregon Research Institute
1715 Franklin Blvd.
Eugene, OR 97403-1983
Phone: (503) 484-2123

Training opportunities are also available from many of Dr. Lewinsohn's former students and colleagues who are scattered across the country and the world. They include David Antonuccio, Julia Breckenridge, Rick Brown, Greg Clarke, Martin Hautzinger, Harry Hoberman, Ricardo Munoz, Paul Rhode, Linda Teri, Maryanne Youngren, and Toni Zeiss, among others.

V. References

Brown, R.A., & Lewinsohn, P.M. (1984). A psychoeducational approach to the treatment of depression: Comparison of group, individual, and minimal contact procedures. Journal of Consulting and Clinical Psychology, 52, 774-783.

de Jong-Meyer, R., & Hautzinger, M. (1996). Results of two multicenter treatment studies among patients with endogenous and nonendogenous depression: Conclusions and prospects. Zeitschrift fuer Linische Psychologie, 25(2), 155-160.

Hall, S., Munoz, R.F., & Reus, V.I. (1994). Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers. Journal of Consulting and Clinical Psychology, 62, 141-146.

Hoberman, H.M., Lewinsohn, P.M., & Tilson, M. (1988). Group treatment of depression: Individual predictors of outcome. Journal of Consulting and Clinical Psychology, 56, 393-398.

Lewinsohn, P.M., Clarke, G.N., Hops, H., & Andrews, J. (1990). Cognitive-behavioral treatment for depressed adolescents. Behavior Therapy, 21, 385-401.

Lewinsohn, P.M., Hoberman, H.M., Teri, L., & Hautzinger, M. (1985). An integrated theory of depression. In S. Reiss & R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331-359). New York: Academic Press.

Lewinsohn, P.M., Sullivan, J.M., & Grosscup, S.J. (1980). Changing reinforcing events: An approach to the treatment of depression. Psychotherapy: Theory, Research, and Practice, 47, 322-334.

Lewinsohn, P.M., Youngren, M.A., & Grosscup, S.J. (1979). Reinforcement and depression. In R. A. Dupue (Ed.), The psychobiology of depressive disorders: Implications for the effects of stress (pp. 291-316). New York: Academic Press.

Lovett, S., & Gallagher, D. (1988). Psychoeducational interventions for family caregivers: Preliminary efficacy data. Behavior Therapy, 19, 321-330.

Manson, S.M. (1988). American Indian and Alaska Native mental health research. The Journal of the National Center, 1, 1-64.

Munoz, R.F., & Ying, Y.W. (Eds.), (1993). The prevention of depression: Research and practice. Baltimore, MD: The Johns Hopkins University Press.

Munoz, R.F., Ying, Y.W., Armas, R., Chan, F., & Gurza, R. (1987). The San Francisco depression prevention research project: A randomized trial with medical outpatients. In R. F. Munoz (Ed.), Depression prevention: Research directions (pp. 199-215). Washington DC: Hemisphere Press.

Steinmetz, J.L., Lewinsohn, P.M., & Antonuccio, D.O. (1983). Prediction of individual outcome in a group intervention for depression. Journal of Consulting and Clinical Psychology, 51, 331-337.

Teri, L., & Gallagher-Thompson, D. (1991). Cognitive-behavioral interventions for treatment of depression in Alzheimer's patients. Gerontologist, 31, 413-416.

Teri, L., & Lewinsohn, P.M. (1986). Individual treatment of unipolar depression: Comparison of treatment outcome and identification of predictors of successful treatment outcome, Behavior Therapy, 17, 215-228.

Teri, L, Logsdon, R.G., Uomoto, J., & McCurry, S.M. (1997). Behavioral treatment of depression in dementia patients: A controlled clinical trial. Journal of Gerontology: Psychological Sciences, 52B, 159-166.

Thompson, L.W., Gallagher, D., Nies, G., & Epstein, D. (1983, November). Cognitive-behavioral vs. other treatments of depressed alcoholics and inpatients. Paper presented at the 17th Annual Convention of the Association for the Advancement of Behavior Therapy, Washington, DC.

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