Cognitive Therapy for Depression

Andrew C. Butler, Ph.D. and Aaron T. Beck, M.D.

Beck Institute for Cognitive Therapy and Research and
University of Pennsylvania School of Medicine

Reprinted from:
Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-5.

I. Description of Treatment

Cognitive therapy for depression has its roots in the cognitive theory of depression (Beck, 1967). It is an active, structured, problem-focused, and time-limited approach to treatment which is based on the premise that depression is maintained by negatively biased information processing and dysfunctional beliefs. Treatment is designed to help patients learn to think more adaptively and thereby experience improvements in affect, motivation, and behavior. The efficacy of cognitive therapy for depression has been demonstrated in over 30 clinical trials (Dobson, 1989).

The general approach in cognitive therapy for depression involves guiding patients through a number of structured learning experiences. Patients are taught to monitor and write down their negative thoughts and mental images to recognize the association between their thoughts, feelings, physiology, and behavior. They learn to evaluate the validity and utility of these cognitions, test them out empirically, and change dysfunctional cognitions to reflect a more adaptive viewpoint. As therapy progresses, patients learn to identify, evaluate, and modify underlying assumptions and dysfunctional beliefs that may have predisposed them to depressive reactions. The therapist also teaches (or reactivates) adaptive coping skills such as breaking down large problems into smaller, more manageable steps, and decision-making by cost-benefit analysis. Activity scheduling, self-monitoring of mastery and pleasure, and graded task assignments are commonly used early in therapy to help patients overcome inertia and expose themselves to potentially rewarding experiences.

Cognitive therapy for depression sessions follow a structure that includes a brief check on mood and symptoms, agenda setting, bridging from the previous session, reviewing homework (self-help assignments that patient does between sessions), discussing issues on agenda, setting new homework, and summarizing and getting feedback form the patient about the session. Cognitive therapists use a variety of strategies and techniques to help depressed patients address their thinking including psychoeducation, guided discovery, socratic questioning, role playing, imagery, and behavioral experiments.

Patients typically require about eight sessions to gain a reasonable level of mastery with the model and the skills involved. A significant reduction in symptoms often occurs during this initial stage of therapy. The remaining sessions are used to evaluate and modify dysfunctional beliefs that impair functioning and make the patient vulnerable to future depressive episodes, build relapse prevention skills, and discuss termination issues. Many patients show a remission of symptoms in 8-12 sessions. A full course of treatment is considered to be 14-16 sessions although severe cases can take longer. Maintenance of treatment gains is enhanced by occasional booster sessions during the first year after termination.

II. Summary of Studies Supporting Treatment Efficacy

The efficacy of cognitive therapy for depression has been studied extensively has been often been shown to be effective or superior to alternative interventions. Dobson (1989) conducted a meta-analysis of 28 controlled treatment outcome studies of unipolar depression. Based on patients' Beck Depression Inventory scores at the end of treatment, cognitive therapy for depression was superior to pharmacotherapy, behavior therapy, "other" psychotherapies, and a wait-list condition. Studies comparing cognitive therapy for depression with pharmacotherapy specifically have indicated that cognitive therapy is as effective as pharmacotherapy regardless of the severity of the depression (the psychiatric sample in Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Hollon, DeRubeis, Evans, et al., 1992; Murphy, Simons, Wetzel, & Lustman, 1984; see Elkin et al., 1989 for an exception). Follow-up studies of the patients treated in the major controlled trials suggest that cognitive therapy of depression is more effective than pharmacotherapy alone in preventing relapse (Blackburn, Eunson & Bishop, 1986; Evans, Hollon, DeRubeis, et al., 1992; Kovacs, Rush, Beck, & Hollon, 1981; Shea, Elkin, Imber et al., 1992; Simons, Murphy, Levine, and Wetzel, 1986). Responders to cognitive therapy in these studies were only half as likely to relapse or seek further treatment following termination than responders to pharmacotherapy alone (Hollon, Shelton, & Loosen, 1991).

III. Clinical References

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.

Freeman, A., Simon, K.M., Beutler, L.E., & Arkowitz, H. (Eds.) (1989). Comprehensive handbook of cognitive therapy. New York: Plenum Press.

IV. Resources for Training

On the east coast of the United States, the Beck Institute for Cognitive Therapy and Research provides on-site and off-site intensive training in cognitive therapy. There are additional formal and informal training opportunities throughout the United States and internationally. For more detailed information on training opportunities in the United States and internationally, contact:

International Association for Cognitive Psychotherapy
GSB Building, Suite 700, City Line and Belmont Aves
Bala Cynwyd PA 19004-1610
(Telephone 610-664-3020)

V. References

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Hoeber. Republished as Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press).

Blackburn, I.M. Eunson, K.M. & Bishop, S. (1986). A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy, and a combination of both. Journal of Affective Disorders, 10, 67-75.

Blackburn, I. M., Bishop, S., Glen, A.I.M., Whalley, L.J., & Christie, J.E. (1981). The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. British Journal of Psychiatry, 139, 181-189.

Dobson, K.S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57, 3, 414-419.

Elkin, I., Shea, M.T., Watkins, J.T., Imber, S.D., Sotsky, S.M., Collins, J.F., Glass, D.R., Pilkonis, P.A., Leber, W.R., Docherty, J.P., Fiester, S.J., & Parloff, M.B. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-982.

Evans, M.D., Hollon, S.D., DeRubeis, R. J., Piasecki, J.M., Grove, W.M., Garey, M.J., & Tuason, V. B., (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 49, 802-808.

Hollon, S.D., DeRubeis, R .J., Evan, M.D., Wiemer, M.J., Garvey, M.J., Grove, W.M., & Tuason, V. B., (1992). Cognitive therapy and pharmacotherapy for depression: Singly and in combination. Archives of General Psychiatry, 49, 774-781.

Kovacs, M., Rush, A.J., Beck, A.T., & Hollon, S.D., (1981). Depressed outpatients treated with cognitive therapy or pharmacotherapy. Archives of General Psychiatry, 38, 33-39.

Murphy, G .E., Simons, A. D., Wetzel, R .D., & Lustman, P. L. (1984). Cognitive therapy and pharmacotherapy, singly and together in the treatment of depression. Archives of General Psychiatry, 41, 33-41.

Shea, M. T., Elkin, I., Imber, S.D., Sotsky, S. M., Watkins, J. T., Collins, J.F., Pilkonis, P.A., Beckman, E., Glass, D. R., Dolan, R.T., & Parloff, M .B., (1992). Course of depressive symptoms over follow-up: Findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Archives of General Psychiatry, 49, 782-787.

Simons, A .D., Murphy, G. E., Levine, J. L., & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry, 43, 43-48.

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