Cognitive Therapy of Depression and Suicide* A. J O H N A A R O N

R U S H , M.D.t

T . BECK, M.D.i

Oklahoma City, Okla. Philadelphia,

Pa.

This article reviews the cognitive therapy of depression. The psychotherapy based on this theory consists of behavioral and verbal techniques to change cognitions, beliefs, and errors in logic in the patient's thinking. A few of the various techniques are described and a case example is provided. Finally, the outcome studies testing the efficacy of this approach are reviewed. INTRODUCTION Beck r e f o r m u l a t e d the p h e n o m e n o n o f depression f r o m a cognitive viewpoint. T h i s f o r m u l a t i o n was d e s i g n e d t o p r o v i d e a m o d e l f o r u n d e r s t a n d i n g t h e r e l a t i o n s h i p s o f t h e signs a n d s y m p t o m s o f t h e depressive s y n d r o m e (e.g., g u i l t , d i f f i c u l t y c o n c e n t r a t i n g , l o w e n e r g y , etc.). I n a d d i t i o n , t h e c o g n i t i v e f r a m e w o r k was t o p r o v i d e a basis f o r a systematic p s y c h o t h e r a p y o f d e p r e s s i o n c a l l e d " c o g n i t i v e t h e r a p y . " T h i s paper will review briefly the cognitive theory o f depression. W e w i l l describe a f e w specific p s y c h o t h e r a p y t e c h n i q u e s u s e d i n t h e c o g n i t i v e t h e r a p y o f d e p r e s s i o n t o c h a n g e c o g n i t i o n s . A case e x a m p l e will illustrate the application o f cognitive therapy. Finally, we will r e v i e w t h e c o n t r o l l e d p s y c h o t h e r a p y r e s e a r c h studies d e s i g n e d t o test the efficacy o f c o g n i t i v e t h e r a p y w i t h d e p r e s s e d p a t i e n t s . 1

THE

COGNITIVE THEORY

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DEPRESSION

T h e c o g n i t i v e t h e o r y o f d e p r e s s i o n is a f o r m u l a t i o n w h i c h g r e w o u t o f careful clinical observation a n d experimental testing. T h i s interplay o f a c l i n i c a l a n d e x p e r i m e n t a l a p p r o a c h has a l l o w e d f o r c a r e f u l e v o l u t i o n o f this m o d e l a n d o f t h e p s y c h o t h e r a p y i t has s p a w n e d . 2

T h e c o g n i t i v e m o d e l postulates t h r e e specific n o t i o n s t o e x p l a i n d e p r e s s i o n : c o g n i t i v e t r i a d , schemas, a n d c o g n i t i v e e r r o r s . T h e c o g n i tive t r i a d consists o f t h r e e m a j o r c o g n i t i v e p a t t e r n s t h a t i n d u c e t h e patient t o r e g a r d himself, his f u t u r e , a n d his experiences i n a n i d i o s y n cratic m a n n e r . * P r e s e n t e d at t h e T h i r t e e n t h N a t i o n a l Scientific M e e t i n g o f t h e A s s o c i a t i o n f o r t h e A d v a n c e m e n t o f P s y c h o t h e r a p y , M a y 1, 1 9 7 7 , T o r o n t o , C a n a d a . tAssistant Professor, D e p a r t m e n t o f Psychiatry a n d Behavioral Sciences, University o f O k l a h o m a . Mailing address: U n i v e r s i t y o f O k l a h o m a , D e p t . o f P s y c h i a t r y a n d B e h a v i o r a l Sciences, P . O . B o x 26901, O k l a h o m a City, O k l a . 73190. ^Professor, Department o f Psychiatry, University o f Pennsylvania, Philadelphia, P e n n sylvania 19104.

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Cognitive Triad T h e first c o m p o n e n t o f t h e t r i a d revolves a r o u n d t h e p a t i e n t ' s n e g a tive v i e w o f h i m s e l f . H e sees h i m s e l f as d e f e c t i v e , i n a d e q u a t e , o r u n w o r t h y . H e t e n d s t o a t t r i b u t e his u n p l e a s a n t e x p e r i e n c e s t o a p h y s i c a l , m e n t a l , o r m o r a l d e f e c t i n h i m s e l f . T h e p a t i e n t believes h e is u n d e s i r able a n d w o r t h l e s s because o f his p r e s u m e d defects. H e tends to u n d e r e s t i m a t e o r c r i t i c i z e h i m s e l f because o f t h e m . F i n a l l y , h e believes h e lacks t h e a t t r i b u t e s h e t h i n k s a r e essential t o a t t a i n h a p p i n e s s a n d contentment. T h e s e c o n d c o m p o n e n t consists o f t h e d e p r e s s e d person's t e n d e n c y t o i n t e r p r e t his o n g o i n g e x p e r i e n c e s i n a n e g a t i v e w a y . H e sees t h e w o r l d as m a k i n g e x o r b i t a n t d e m a n d s o n h i m a n d / o r p r e s e n t i n g i n s u p e r a b l e obstacles t o r e a c h i n g his l i f e goals. H e m i s i n t e r p r e t s his i n t e r a c t i o n s w i t h t h e w o r l d a r o u n d h i m as e v i d e n c e f o r d e f e a t o r d e p r i v a t i o n . T h e s e n e g a t i v e m i s i n t e r p r e t a t i o n s a r e e v i d e n t by o b s e r v i n g t h a t t h e p a t i e n t n e g a t i v e l y c o n s t r u e s s i t u a t i o n s even w h e n less n e g a t i v e , m o r e plausible, alternative i n t e r p r e t a t i o n s are available. T h e depressed p e r s o n m a y realize t h a t his i n i t i a l n e g a t i v e i n t e r p r e t a t i o n s a r e biased i f he is p e r s u a d e d t o r e f l e c t o n these less n e g a t i v e a l t e r n a t i v e e x p l a n a t i o n s . I n t h i s w a y , he can c o m e t o realize t h a t h e t a i l o r e d t h e facts t o f i t his preconceived negative conclusions. T h e t h i r d c o m p o n e n t consists o f a n e g a t i v e v i e w o f t h e f u t u r e . A s t h e d e p r e s s e d p e r s o n l o o k s a h e a d , he a n t i c i p a t e s t h a t his c u r r e n t d i f f i c u l t i e s o r s u f f e r i n g w i l l c o n t i n u e i n d e f i n i t e l y . H e expects u n r e m i t t i n g h a r d s h i p , f r u s t r a t i o n , a n d d e p r i v a t i o n . W h e n he t h i n k s o f u n d e r t a k i n g a specific task, he expects t o f a i l . T h e c o g n i t i v e t h e o r y c o n s i d e r s t h e o t h e r signs a n d s y m p t o m s o f t h e depressive s y n d r o m e t o be consequences o f t h e a c t i v a t i o n o f t h e n e g a t i v e c o g n i t i v e p a t t e r n s . F o r e x a m p l e , i f t h e p a t i e n t i n c o r r e c t l y thinks he is b e i n g r e j e c t e d , he w i l l r e a c t w i t h t h e same n e g a t i v e a f f e c t (e.g., sadness, a n g e r ) t h a t occurs w i t h actual r e j e c t i o n . I f he e r r o n e o u s l y believes h e is a social o u t c a s t , he w i l l f e e l l o n e l y . T h e m o t i v a t i o n a l s y m p t o m s (e.g., paralysis o f w i l l , escape a n d a v o i d a n c e wishes, etc.) c a n be e x p l a i n e d as consequences o f n e g a t i v e c o n d i t i o n s . "Paralysis o f w i l l " r e s u l t s f r o m t h e p a t i e n t ' s p e s s i m i s m a n d h o p e lessness. I f he expects a n e g a t i v e o u t c o m e , h e w o n ' t c o m m i t h i m s e l f t o a g o a l o r u n d e r t a k i n g . S u i c i d a l wishes c a n be u n d e r s t o o d as a n e x t r e m e e x p r e s s i o n o f t h e d e s i r e t o escape f r o m w h a t appears t o be i n s o l v a b l e p r o b l e m s o r a n u n b e a r a b l e s i t u a t i o n . T h e d e p r e s s e d p e r s o n m a y see h i m s e l f as a w o r t h l e s s b u r d e n a n d c o n s e q u e n t l y believe t h a t e v e r y o n e , h i m s e l f i n c l u d e d , w i l l be b e t t e r o f f w h e n h e is d e a d . I n c r e a s e d d e p e n d e n c y is also e x p l i c a b l e i n c o g n i t i v e t e r m s . Because h e sees h i m s e l f as i n e p t a n d u n d e s i r a b l e , t h e d e p r e s s e d p e r s o n u n r e a l i s -

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tically o v e r e s t i m a t e s t h e d i f f i c u l t y o f n o r m a l tasks a n d expects t h i n g s t o t u r n p u t b a d l y . T h e p a t i e n t t e n d s t o seek h e l p a n d r e a s s u r a n c e f r o m o t h e r s w h o m he c o n s i d e r s m o r e c o m p e t e n t a n d c a p a b l e . F i n a l l y , t h e c o g n i t i v e m o d e l m a y also e x p l a i n t h e p h y s i c a l s y m p t o m s . A p a t h y a n d l o w e n e r g y m a y r e s u l t f r o m t h e p a t i e n t ' s b e l i e f t h a t he is d o o m e d t o f a i l u r e i n a l l his e f f o r t s . A n e g a t i v e view o f t h e f u t u r e (a sense o f f u t i l i t y ) m a y l e a d to " p s y c h o m o t o r i n h i b i t i o n . " Schemas A s e c o n d m a j o r i n g r e d i e n t i n t h e c o g n i t i v e m o d e l consists o f t h e n o t i o n o f schemas. T h i s n o t i o n is u s e d t o e x p l a i n w h y a d e p r e s s e d p a t i e n t clings t o p a i n f u l a t t i t u d e s d e s p i t e o b j e c t i v e e v i d e n c e o f p o s i t i v e factors i n his l i f e . A n y s i t u a t i o n is c o m p o s e d o f a p l e t h o r a o f s t i m u l i . A n i n d i v i d u a l selectively a t t e n d s t o specific s t i m u l i , c o m b i n e s t h e m i n a p a t t e r n a n d c o n ceptualizes t h e s i t u a t i o n . A l t h o u g h d i f f e r e n t p e r s o n s m a y c o n c e p t u a l i z e t h e same s i t u a t i o n i n d i f f e r e n t ways, a p a r t i c u l a r p e r s o n t e n d s t o be consistent i n his responses t o s i m i l a r types o f events. R e l a t i v e l y stable c o g n i t i v e p a t t e r n s f o r m t h e basis f o r t h e r e g u l a r i t y o f i n t e r p r e t a t i o n s o f a p a r t i c u l a r set o f s i t u a t i o n s . T h e t e r m " s c h e m a " designates these stable c o g n i t i v e p a t t e r n s . W h e n a p e r s o n faces a p a r t i c u l a r c i r c u m s t a n c e , a s c h e m a r e l a t e d t o t h e c i r c u m s t a n c e is a c t i v a t e d . T h e s c h e m a is t h e basis f o r m o l d i n g d a t a i n t o c o g n i t i o n s ( d e f i n e d as a n y m e n t a l a c t i v i t y w i t h v e r b a l c o n t e n t ) . T h u s , a s c h e m a constitutes t h e basis f o r s c r e e n i n g o u t , d i f f e r e n t i a t i n g , a n d c o d i n g t h e s t i m u l i t h a t c o n f r o n t t h e i n d i v i d u a l . H e categorizes a n d evaluates his e x p e r i e n c e s t h r o u g h a m a t r i x o f schemas. T h e k i n d s o f schemas e m p l o y e d d e t e r m i n e h o w a n i n d i v i d u a l w i l l s t r u c t u r e d i f f e r e n t e x p e r i e n c e s . A s c h e m a m a y be i n a c t i v e at o n e t i m e b u t can be a c t i v a t e d by specific e n v i r o n m e n t a l i n p u t s . T h e schemas act i v a t e d i n a specific s i t u a t i o n d i r e c t l y d e t e r m i n e h o w t h e p e r s o n a f f e c tively responds to the circumstance. F o r e x a m p l e , i f a p e r s o n is c o n c e r n e d o v e r w h e t h e r o r n o t he is c o m p e t e n t a n d a d e q u a t e , he m a y be assuming the validity o f the schema, "Unless I do e v e r y t h i n g perfectly, I ' m a f a i l u r e . " I n t h i s case, he w i l l be c o n s t r u i n g s i t u a t i o n s i n t e r m s o f t h e q u e s t i o n o f a d e q u a c y e v e n w h e n t h e q u e s t i o n is not r e l a t e d t o t h e s i t u a t i o n . F o r i n s t a n c e , w h i l e s w i m m i n g at t h e beach (an a p p a r e n t l y f u n a c t i v i t y not r e l a t e d t o p e r s o n a l c o m p e t e n c e ) , t h i s p e r s o n m a y be t h i n k i n g , " I s m y s w i m m i n g g o o d e n o u g h ? D o I l o o k as g o o d as t h e o t h e r s ? , " a n d so f o r t h . T h u s , t h e d e p r e s s e d p a t i e n t ' s c o n c e p t u a l i z a t i o n s o f specific s i t u a t i o n s are d i s t o r t e d t o fit t h e schemas. T h e o r d e r l y m a t c h i n g o f s t i m u l u s a n d a p p r o p r i a t e s c h e m a is u p s e t by t h e i n t r u s i o n o f o v e r l y active i d i o s y n -

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cratic schemas w h i c h displace m o r e a p p r o p r i a t e ones. As these i d i o s y n cratic schemas b e c o m e m o r e active, t h e y are e v o k e d by a w i d e r r a n g e o f s t i m u l i w h i c h are less l o g i c a l l y r e l a t e d t o t h e m . T h e p a t i e n t loses c o n t r o l o f his t h i n k i n g processes a n d is u n a b l e t o i n v o k e o t h e r m o r e a p p r o p r i a t e schemas. I n m i l d e r d e p r e s s i o n s t h e p a t i e n t is able t o v i e w his n e g a t i v e t h o u g h t s w i t h some o b j e c t i v i t y . As t h e d e p r e s s i o n w o r s e n s , his t h i n k i n g is i n c r e a s i n g l y d o m i n a t e d by n e g a t i v e ideas, a l t h o u g h t h e r e m a y be n o logical connection between actual situations a n d negative i n t e r p r e t a t i o n s . T h e p a t i e n t is less able t o e n t e r t a i n t h e n o t i o n t h a t his n e g a t i v e i n t e r p r e t a t i o n s are e r r o n e o u s , possibly because t h e s t r o n g e r i d i o s y n cratic schemas i n t e r f e r e w i t h r e a l i t y t e s t i n g a n d r e a s o n i n g . These h y p e r v a l e n t schemas l e a d t o d i s t o r t i o n s o f r e a l i t y a n d c o n s e q u e n t l y t o systematic e r r o r s i n t h e d e p r e s s e d person's t h i n k i n g . Cognitive

Errors

T h e s e systematic e r r o r s i n t h e logic o f t h e d e p r e s s e d p e r s o n ' s t h i n k i n g i n c l u d e a r b i t r a r y i n f e r e n c e , selective a b s t r a c t i o n , o v e r g e n e r a l i z a t i o n , magnification or minimization and personalization. 1. Arbitrary inference r e f e r s t o t h e process o f d r a w i n g a c o n c l u s i o n i n t h e absence o f e v i d e n c e t o s u p p o r t t h e c o n c l u s i o n o r w h e n t h e e v i d e n c e is c o n t r a r y t o t h e c o n c l u s i o n . 2. Selective abstraction consists o f f o c u s i n g o n a d e t a i l t a k e n o u t o f c o n t e x t , i g n o r i n g o t h e r m o r e salient f e a t u r e s o f t h e s i t u a t i o n , a n d c o n c e p t u a l i z i n g t h e w h o l e e x p e r i e n c e o n t h e basis o f t h i s e l e m e n t . 3. Overgeneralization r e f e r s t o t h e p a t t e r n o f d r a w i n g a g e n e r a l c o n c l u s i o n o n t h e basis o f a single i n c i d e n t . 4. Magnification and minimization is r e f l e c t e d i n e r r o r s i n e v a l u a t i o n t h a t a r e so gross as t o c o n s t i t u t e a d i s t o r t i o n . 5. Personalization r e f e r s t o t h e p a t i e n t ' s p r o c l i v i t y t o r e l a t e e x t e r n a l events t o h i m s e l f w h e n t h e r e is n o basis f o r m a k i n g s u c h a c o n n e c t i o n . T h e cognitive theory offers a hypothesis about f o r m i n g a predisposition to depression. B r i e f l y , t h e n o t i o n is t h a t e a r l y e x p e r i e n c e s c o n s t i t u t e a basis f o r f o r m i n g a n e g a t i v e view a b o u t one's self, t h e f u t u r e , a n d the w o r l d a r o u n d . These negative concepts are f o r m u l a t e d i n t e r m s o f schemas. Schemas m a y be l a t e n t b u t t h e y can be a c t i v a t e d by specific c i r c u m s t a n c e s w h i c h a r e a n a l o g o u s t o e x p e r i e n c e s i n i t i a l l y responsible f o r e m b e d d i n g the negative a t t i t u d e . F o r e x a m p l e , d i s r u p t i o n o f a m a r i t a l s i t u a t i o n m a y activate t h e c o n cept o f i r r e v e r s i b l e loss associated w i t h d e a t h o f a p a r e n t i n c h i l d h o o d . A l t e r n a t i v e l y , d e p r e s s i o n m a y be t r i g g e r e d b y a p h y s i c a l a b n o r m a l i t y o r disease t h a t activates t h e n o t i o n h e is d e s t i n e d f o r a l i f e o f s u f f e r i n g . W h i l e these a n d o t h e r events m i g h t be p a i n f u l t o m o s t p e o p l e , t h e y

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w o u l d n ' t necessarily p r o d u c e a d e p r e s s i o n unless t h e p e r s o n is p a r t i c u l a r l y sensitive t o t h e s i t u a t i o n because o f p r e v i o u s e x p e r i e n c e a n d c o n sequent predepressive cognitive o r g a n i z a t i o n . I n response t o s u c h t r a u m a s t h e average p e r s o n w i l l still m a i n t a i n i n t e r e s t i n a n d realistically a p p r a i s e o t h e r n o n t r a u m a t i c aspects o f his life. H o w e v e r , t h e t h i n k i n g o f t h e d e p r e s s i o n - p r o n e p e r s o n becomes m a r k e d l y c o n s t r i c t e d a n d n e g a t i v e ideas d e v e l o p a b o u t e v e r y aspect o f his l i f e . T h e r e is s u b s t a n t i a l e m p i r i c a l s u p p o r t f o r t h e c o g n i t i v e t h e o r y o f depression. Naturalistic studies, clinical observations a n d e x p e r i m e n t a l studies have r e c e n t l y b e e n r e v i e w e d . Studies have d o c u m e n t e d t h e presence a n d i n t e r c o r r e l a t i o n o f the constituents o f the "cognitive t r i a d " i n association w i t h d e p r e s s i o n . Several studies d o c u m e n t t h e p r e s e n c e o f specific c o g n i t i v e deficits (e.g., i m p a i r e d abstract r e a s o n i n g , selective attention) i n depressed o r suicidal persons. T h e presence o f dysfunct i o n a l a t t i t u d e o r schemas has r e c e n t l y b e e n f o u n d w i t h d e p r e s s e d patients. H o w e v e r , m o r e e x p e r i m e n t a l s u p p o r t is n e e d e d . This t h e o r y has l e d to a specific p s y c h o t h e r a p y for' d e p r e s s e d , s u i c i d a l patients. 2

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O V E R V I E W OF T H E T E C H N I Q U E S OF C O G N I T I V E T H E R A P Y T h e c o g n i t i v e t h e o r y f o r m s t h e basis f o r " c o g n i t i v e t h e r a p y . " T h i s t h e r a p y consists o f a n u m b e r o f specific t e c h n i q u e s f o r t r e a t i n g d e p r e s s e d p a t i e n t s . T h e s e t e c h n i q u e s have b e e n c o m p i l e d i n a T r e a t ment Manual. T h i s section w i l l r e v i e w a f e w o f these t e c h n i q u e s t o p r o v i d e a f l a v o r f o r h o w this t r e a t m e n t is c o n d u c t e d . T h e n a n i l l u s t r a t i v e case e x a m p l e f o l l o w s . 4

C o g n i t i v e t h e r a p y is a s h o r t - t e r m , t i m e - l i m i t e d p s y c h o t h e r a p y u s u a l l y i n v o l v i n g a m a x i m u m o f t w e n t y sessions o v e r t e n t o t w e l v e weeks. T h e t h e r a p i s t actively d i r e c t s t h e discussion t o f o c u s o n selected p r o b l e m areas p r e s e n t e d by t h e p a t i e n t . Q u e s t i o n i n g is f r e q u e n t l y u s e d t o elicit specific t h o u g h t s , i m a g e s , d e f i n i t i o n s , a n d m e a n i n g s . For e x a m p l e , t h e t h e r a p i s t m i g h t say, " W h a t was i t a b o u t t h e t e l e p h o n e call w h i c h m a d e y o u m o s t u p s e t ? " " W h a t d i d t h e p h o n e call m e a n t o y o u ? , " o r " W h a t w e r e y o u t h i n k i n g j u s t as y o u h u n g u p t h e t e l e p h o n e ? " I n a d d i t i o n , q u e s t i o n i n g is u s e d t o e x p o s e i n n e r c o n t r a d i c t i o n s , i n c o n s i s tencies, a n d flaws i n logic o f t h e p a t i e n t ' s t h i n k i n g o r c o n c l u s i o n s . Skill a n d tact a r e r e q u i r e d , h o w e v e r , t o assure t h a t this q u e s t i o n i n g is n o t c o n s t r u e d as a n i n t e r r o g a t i o n o r c r o s s - e x a m i n a t i o n , w h i c h m i g h t l e a d t h e d e p r e s s e d p e r s o n t o c o n c l u d e t h a t his r e a s o n i n g p o w e r s a r e d e f e c tive. T h e t h e r a p i s t a n d p a t i e n t c o l l a b o r a t e t o use a n e m p i r i c a l m e t h o d o l o g y t o focus o n specific p r o b l e m areas. T h e therapist must

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c l e a r l y u n d e r s t a n d t h e p a t i e n t ' s co n c e r i t u a l i z a t i o n s o f h i m s e l f a n d t h e w o r l d a r o u n d h i m . I n essence, he m u s t be able to see t h e w o r l d " t h r o u g h t h e p a t i e n t ' s eyes." I f t h e p a t i e n t ' s c o n c e p t u a l i z a t i o n s d i f f e r f r o m t h e t h e r a p i s t ' s views o f r e a l i t y , the c o l l a b o r a t o r s t e n d t o r e c o n c i l e the differences w i t h a logical e m p i r i c a l approach. I n essence, t h e p a t i e n t ' s t h o u g h t are t r e a t e d as i f t h e y w e r e hypotheses r e q u i r i n g v a l i d a t i o n , D u r i i k g this v a l i d a t i o n process ( o f t e n c o n d u c t e d as h o m e w o r k ) , t h e p a t i e n t needs t o c l e a r l y u n d e r s t a n d w h a t beliefs o r ideas (hypotheses) a r e b e i n g t e s t e d a n d , t h e r e f o r e , m u s t u n d e r s t a n d t h e p u r p o s e o f each h o m e i v o r k a s s i g n m e n t . T e c h n i c a l l y , a scientific i n v e s t i g a t i o n : (1) c o g n i t i v e t h e r a p y m a y be c o m p a r e d c o l l e c t i n g d a t a t h a t are as r e l i a b l e a n d v a l i d as possible; (2) f o r m u l a t i n g hypotheses based o n t h e d a t a ; a n d (3) t e s t i n g a n d , i f i n d i c a t e d , r e v i s i n g hypotheses based o n n e w i n f o r m a t i o n . T h e d a t a consist o f t h e p a t i e n t ' s ";a u t o m a t i c t h o u g h t s , " f e e l i n g s , a n d wishes. T h e s e a u t o m a t i c t h o u g h t s o r c o g n i t i o n s a r e c o l l e c t e d as o r a l o r w r i t t e n r e p o r t s f r o m t h e p a t i e n t . T h e t h e r a p i s t accepts these c o g n i t i o n s as t r u t h f u l ( a l t h o u g h n o t necessarily accurate) r e p r e s e n t a t i o n s o f r e a l i t y , since t h e basic p r e m i s e o f t h e c o g n i t i v e t h e o r y is t h a t t h e d e p r e s s e d p e r s o n n e g a t i v e l y m i s c o n s t r u e s his expediences. F i r s t , t h e t h e r a p i s t tries t o elicit a u t o m a t i c t h o u g h t s s u r r o u n d i n g each u p s e t t i n g e v e n t . H e tries t o o b t a i n specific e v i d e n c e f o r o r against t h e p a t i e n t ' s p o t e n t i a l l y d i s t o r t e d o r dys :Fi i n c t i o n a l t h i n k i n g b y q u e s t i o n i n g the patient about the total circumstances o f a particular event, Secondly, the cognitive therapist helps the patient to i d e n t i f y o r i n f e r the assumptions o r themes i n the r e c u r r e n t negative automatic t h o u g h t s . F o r e x a m p l e , s u c h a t h e m e m i g h t be " e x p e c t i n g t o f a i l " o r T h e therapist helps the " r e a d i n g rejection into personal situations p a t i e n t t o see t h a t such a b e l i e f m a y n o t necessarily r e f l e c t r e a l i t y . F o r e x a m p l e , t h e t h e r a p i s t w o u l d use l o g i c , p e r s u a s i o n , a n d e v i d e n c e f r o m t h e p a t i e n t ' s c u r r e n t a n d past f u n c t i o n i n g to get t h e p a t i e n t t o v i e w a b e l i e f (e.g., " I a m u n a b l e t o l e a r n " ) as an i d e a o r h y p o t h e s i s r e q u i r i n g v a l i d a t i o n r a t h e r t h a n as a b e l i e f . T h i r d l y , t h e c o g n i t i v e t h e r a p i s t teachjes t h e p a t i e n t t o i d e n t i f y specific e r r o r s o f logic i n his t h i n k i n g (e.g., a r b i t r a r y i n f e r e n c e , o v e r g e n e r a l i z a t i o n , etc.). L e a r n i n g t o r e c o g n i z e a n d c o r r e c t these e r r o r s h e l p s t h e p a t i e n t t o r e p e a t e d l y assess t h e d e g r e e t o w h i c h his t h i n k i n g m i r r o r s 5

reality. T h e p a t i e n t a n d t h e r a p i s t c o l l a b o r a t e t o i d e n t i f y basic a t t i t u d e s , b e l i e f s , a n d a s s u m p t i o n s , w h i c h ( a c c o r d i n g t o t h e m o d e l ) shape m o m e n t t o - m o m e n t t h i n k i n g . S o m e t i m e s , a n a t t i t u d e m a y be so d o m i n a n t o r p e r v a s i v e t h a t d e s p i t e changes i n e n v i r o n m e n t a l events, t h e c o n c l u s i o n n e v e r varies (e.g., " I c a n ' t be h a p p y unless I ' m l o v e d " ) . B y a r t i c u l a t i n g

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these a t t i t u d e s , t h e t h e r a p i s t h e l p s t h e p a t i e n t n o t o n l y t o d e v e l o p a basis f o r e m p i r i c a l v a l i d a t i o n , b u t also t o r e c o g n i z e s u b s e q u e n t c o g n i t i o n s based o n these a t t i t u d e s . Cognitive t h e r a p y techniques are designed to facilitate changes i n specific t a r g e t s y m p t o m s f o u n d i n d e p r e s s i o n (e.g., i n a c t i v i t y , selfc r i t i c i s m , lack o f g r a t i f i c a t i o n , s u i c i d a l wishes.) T h e specific t e c h n i q u e s are described i n detail elsewhere. H e r e w e w i l l describe j u s t a f e w o f these t e c h n i q u e s t o i l l u s t r a t e t h e n a t u r e o f t h e t r e a t m e n t . I n g e n e r a l , a t h e r a p y session b e g i n s w i t h a discussion o f t h e f o r m e r l y assigned h o m e w o r k . T h i s h o m e w o r k g e n e r a l l y focuses o n t h e p a t i e n t ' s t h i n k i n g . T h e l a t t e r p a r t o f each session is s p e n t d e v e l o p i n g a n d p l a n n i n g the subsequent h o m e w o r k assignment. 4

I n t h e i n i t i a l sessions, t h e r a p y t e n d s t o e m p h a s i z e i n c r e a s e d a c t i v i t y a n d e n v i r o n m e n t a l i n t e r a c t i o n (i.e., b e h a v i o r a l changes). I n t h e c o u r s e o f s u c h changes, t h e p a t i e n t l e a r n s t o m o n i t o r a n d r e c o g n i z e his t h i n k i n g i n r e g a r d to his b e h a v i o r o r a c t i v i t y . T h i s e a r l y e m p h a s i s o n b e h a v i o r a l objectives is based o n o u r r e c o g n i t i o n t h a t t h e severely d e p r e s s e d p a t i e n t is o f t e n u n a b l e t o e n g a g e i n c o g n i t i v e tasks because o f d i f f i c u l t y i n abstract r e a s o n i n g . A s t h e d e p r e s s i o n lessens, c o n c e n t r a t i o n i m p r o v e s a n d t h e i n t e n s i t y o f t h e a f f e c t decreases. T h e p a t i e n t is t a u g h t t o collect, e x a m i n e , a n d test his a u t o m a t i c t h o u g h t s (e.g., T r i p l e C o l u m n T e c h n i q u e b e l o w ) . I n s u b s e q u e n t sessions, t h e a s s u m p t i o n s s u p p o r t i n g these c o g n i t i o n s a r e identified a n d subjected to e m p i r i c a l validation t h r o u g h h o m e w o r k assignments. These cognitive-change techniques r e q u i r e a greater a b i l i t y t o abstract a n d use l o g i c . T h e r e f o r e , t h e y are e m p l o y e d a f t e r t h e d e p r e s s i o n lessens i n s e v e r i t y . H o w e v e r , t h e t h e r a p i s t m a y e m p l o y these c o g n i t i v e - c h a n g e t e c h n i q u e s f r o m t h e o u t s e t i f t h e p a t i e n t is o n l y moderately depressed. W e w i l l describe a t e c h n i q u e w i t h a p r i m a r y b e h a v i o r a l o b j e c t i v e (the G r a d e d Task Assignment) a n d one w i t h a p r i m a r y cognitive objective (the T r i p l e C o l u m n T e c h n i q u e ) . H o w e v e r , a task d e s i g n e d t o a l t e r m a i n l y b e h a v i o r , w i l l also i n f l u e n c e t h e p a t i e n t ' s t h i n k i n g . S i m i l a r l y , a c o g n i t i v e c h a n g e m a y r e s u l t i n a b e h a v i o r a l c h a n g e as w e l l . Graded Task Assignment T h e G r a d e d T a s k A s s i g n m e n t is based o n t h e a s s u m p t i o n t h a t t h e d e p r e s s e d p a t i e n t has d i f f i c u l t y c o m p l e t i n g tasks w h i c h h a d b e e n r e l a t i v e l y s i m p l e , p r i o r t o t h e d e p r e s s i o n . A l t h o u g h t h e p a t i e n t has t h e s k i l l a n d i n f o r m a t i o n necessary t o p e r f o r m t h e task, he e x p e r i e n c e s d i f f i c u l t y w i t h i t because he t h i n k s " I c a n ' t d o a n y t h i n g " o r " I t ' s useless t o t r y . " T h e e n d r e s u l t o f s u c h t h i n k i n g is decreased a c t i v i t y a n d f u r t h e r n e g a tive s e l f - e v a l u a t i o n . T h i s r e a c t i o n is a l o g i c a l r e s u l t o f a n o v e r -

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g e n e r a l i z e d b e l i e f t h a t "because a n activity is n o l o n g e r s i m p l e , t h e r e f o r e , i t is i m p o s s i b l e . " T h e c o g n i t i v e t h e r a p i s t a p p r o a c h e s this p r o b l e m f r o m a n e m p i r i c a l v i e w p o i n t ( " W o u l d y o u be w i l l i n g t o test y o u r belief?") r a t h e r t h a n t r y i n g t o t a k e a n o p p o s i n g s t a n d ("Yes, y o u c a n d o i t i f y o u t r y . " ) since t h i s l a t t e r s t r a t e g y m a y a l i e n a t e t h e p a t i e n t . T h e G r a d e d T a s k A s s i g n m e n t consists o f s u b d i v i d i n g t h e m a j o r task i n t o m i n i - t a s k s w h i c h a r e w i t h i n t h e p a t i e n t ' s c a p a b i l i t y . T h u s , this t e c h n i q u e n o t o n l y increases a c t i v i t y by i n d u c i n g t h e p a t i e n t t o u n d e r t a k e m o r e tasks b u t i t also h e l p s t h e p a t i e n t recognize a n d c o r r e c t u n r e a l i s tically n e g a t i v e c o g n i t i o n s w h i c h m a i n t a i n i n a c t i v i t y . O t h e r t e c h n i q u e s d e s i g n e d t o c h a n g e b e h a v i o r i n c l u d e Activity Scheduling (the p a t i e n t a n d t h e r a p i s t c o l l a b o r a t e t o s c h e d u l e h o u r l y a s s i g n m e n t s ) ; t h e Mastery and Pleasure Technique ( s c h e d u l e d activities a r e rated according to the a m o u n t o f mastery or pleasure obtained w i t h each); a n d Cognitive Rehearsal (the p a t i e n t i m a g i n e s each step i n t h e seq u e n c e l e a d i n g to c o m p l e t i o n o f t h e a s s i g n m e n t ) . E a c h o f these t e c h n i q u e s is u s e d t o h e l p t h e p a t i e n t r e e v a l u a t e his i n i t i a l n e g a t i v e beliefs i n h o p e s o f m a k i n g a n a p p r o p r i a t e c o g n i t i ve c h a n g e (e.g., " I thought t h a t I c o u l d n ' t d o a n y t h i n g b u t t h e e v i d e n c e is t h a t t h e tasks are h a r d to d o b u t n o t i m p o s s i b l e . " ) . I n u s i n g these t e c h n i q u e s t h e t h e r a p i s t emphasizes the i m m e d i a t e goal o f r e l i e v i n g the patient's self-debasement. Triple Column Technique A n u m b e r o f specific t e c h n i q u e s a r e d e s i g n e d to h e l p t h e p a t i e n t i d e n t i f y a n d r e e v a l u a t e his t h i n k i n g . F o r e x a m p l e , t h e T r i p l e C o l u m n T e c h n i q u e is o f t e n used to h e l p t h e p a t i e n t t o i d e n t i f y a n d r e a l i t y test u p s e t t i n g c o g n i t i o n s . T h e p a t i e n t r e c o r d s t h e events associated w i t h u n pleasant a f f e c t as w e l l as t h e a c t u a l c o g n i t i o ns o r a u t o m a t i c t h o u g h t s associated w i t h t h e d y s p h o r i a . N e x t tfhe p a t i e n t a t t e m p t s t o a n s w e r these c o g n i t i o n s u s i n g c o n c r e t e e v i d e n c e ("facts") t o test t h e v a l i d i t y a n d reasonableness o f each c o g n i t i o n . T h e e v i d e n c e f o r a n d against each specific t h o u g h t (e.g., " I ' m a c o m p l e t e f a i l u r e , " o r " E v e r y o n e is d i s g u s t e d w i t h m e . " ) is e x a m i n e d . I n this w a y , t h e p a t i e n t l e a r n s to see his c o g n i t i o n s as p s y c h o l o g i c a l events o r responses r a t h e r t h a n as a n accurate reflection o f reality. T h e t h e r a p i s t h e l p s t h e p a t i e n t c a t e g o r i z e his c o g n i t i o n s u n d e r r e l e v a n t t h e m e s s u c h as s e l f - b l a m e , i n f e r i o r i t y , o r d e p r i v a t i o n . T h e p a t i e n t l e a r n s t h a t o f t(he m a n y ways t o i n t e r p r e t l i f e experiences he tends to persevere i n a few stereotyped, self-defeating patterns. As t h e p a t i e n t distances h i m s e l f f r o)rti his a u t o m a t i c t h i n k i n g a n d as he l e a r n s t o a n s w e r his d i s t o r t e d n e g a t i v e t h o u g h t s w i t h c o n c r e t e e v i d e n c e , he begins t o r e c o n c e p t u a l i z e p r o b l ems a n d t o d e v e l o p a l t e r n a t i v e m e t h o d s o f p r o b l e m s o l v i n g . T h i s p r o b l e m s o l v i n g i n v o l v e s a search f o r

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alternative interpretations a n d s o l u t i o n s t o p r o b l e m a t i c events. T h e r a p y is n o t s i m p l y t h i n k i n g p o s i t i v e l y b u t r a t h e r t h i n k i n g realistically a n d logically. T h e l a t t e r stages o f c o g n i t i v e t h e r a p y i n v o l v e i d e n t i f i c a t i o n o f chronic attitudes a n d assumptions by w h i c h t h e patient constructs a n d o r d e r s his e x p e r i e n t i a l w o r l d . T h e c o n t e n t o f these a t t i t u d e s is i n f e r r e d f r o m the r e c u r r e n t themes present i n t h e patient's cognitive response to specific s i t u a t i o n s . S o m e o f t h e a t t i t u d e s f o u n d t o be associated w i t h d e p r e s s i o n i n c l u d e n o t i o n s s u c h as: " I m u s t be successful i n w h a t e v e r I u n d e r t a k e " ; " M y v a l u e as a p e r s o n d e p e n d s o n w h a t o t h e r s t h i n k o f m e " ; a n d " I c a n ' t live w i t h o u t l o v e . " T h e p a t i e n t learns t o e x a m i n e a n d assess t h e reasonableness o f these basic a t t i t u d e s b y c o n s i d e r i n g t h e e v i d e n c e f o r a n d against e a c h b e l i e f . H e is o f t e n a s k e d t o u n d e r t a k e h o m e w o r k to test o u t t h e v a l i d i t y o r t h e g e n e r a l a p p l i c a b i l i t y o f a specific a t t i t u d e . T h e f o l l o w i n g case e x a m p l e serves t o i l l u s t r a t e a n u m b e r o f t h e specific i n g r e d i e n t s i n c o g n i t i v e t h e r a p y . T h e case h i s t o r y is p r e s e n t e d to e x e m p l i f y p r a c t i c a l issues i n d i f f e r e n t i a l diagnosis a n d t r e a t m e n t planning. I n a p p l y i n g c o g n i t i v e t h e r a p y t o a specific p a t i e n t , t h e t h e r a p i s t j u d i c i o u s l y selects t e c h n i q u e s f r o m a v a r i e t y o f possibilities. T h e basic g u i d e l i n e s f o r t h e selection o f t h e m o s t p e r t i n e n t t e c h n i q u e s are d e t a i l e d e l s e w h e r e . T h i s case e x a m p l e i l l u s t r a t e s t h e use o f a f e w o f the many techniques o f cognitive therapy. 6

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years

previously

c o v e r e d his wife's e x t r a m a r i t a l affair w i t h a fellow officer. the affair w h e n M r . L . f o u n d out.

when

H i s wife

h e dis-

terminated

A year later h e h a d resigned f r o m the service

as a c o n s e q u e n c e o f his d e p r e s s i o n . H e b e l i e v e d h e h a d f o r c e d h i s wife to stay w i t h h i m b y h i s d i s c o v e r y , a l t h o u g h there w a s n o e v i d e n c e , e v e n after several interviews w i t h h e r that this w a s a valid belief.

S h e stated s h e c h o s e to stay w i t h h i m b e c a u s e s h e l o v e d h i m .

the affair as a s y m p t o m o f difficulties i n t h e r e l a t i o n s h i p . waking moments

S h esaw

H e spent most o f his

thinking about the affair w h i c h h e interpreted i n terms o f per-

sonal failure a n d inadequacy. H e h a d h a d two other episodes o f the depressive s y n d r o m e i n the past.

Each

episode lasted o n e year, each remitted without formal treatment, a n d each was

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associated with the failure to get p r o m o t e d c n time.

OF

PSYCHOTHERAPY

E a c h o f these events was

c o n s t r u e d by the patient as testimony to his in< : o m p e t e n c e . T h e r e was also suggestive e v i d e n c e o f h y p o m a n i c episodes w i t h i n c r e a s e d activity, e u p h o r i a , e n e r g y a n d feelings o f ere ativity, but these episodes failed to meet criteria for h y p o m a n i a . T h e patient p r e s e n t e d e v i d e n c e by history a n d 6

mental

status o f obsessive-compulsive p e r tonality.

H e showed

significant

c o n c e r n over issues o f respect, c o n t r o l , a n d tir ne. Treatment administered

consisted

of

simultaneously.

both

chemotherapy

H o u r l y ses lions

c o n d u c t e d o n c e weekly for a total o f 16 sess ions.

a n d cognitive

o f cognitive

therapy

therapy

were

C h e m o t h e r a p y consisted o f

a m i t r i p t y l i n e m a i n t a i n e d at 1 0 0 - 1 5 0 mg/da} until t h e 16th w e e k o f t r e a t m e n t T

T h e t h e r a p y s issions initially i n c l u d e d only the

w h e n it was d i s c o n t i n u e d .

patient b u t subsequently i n c l u d e d his spouse as well.

T h e patient's r e s p o n s e to

this c o m b i n a t i o n a p p r o a c h , a c c o r d i n g to the B e c k D e p r e s s i o n I n v e n t o r y , ( B D I ) is s h o w n i n T a b l e 1. T A B L E 1: Week No.

Initial

2

5

6

8

10

BDI

19

10

7

4

5

1

12 0

16

24

2

7

C h e m o t h e r a p y was u s e d i n h o p e s o f p r o v i d i n g r a p i d s y m p t o m a t i c r e l i e f as the patient a p p e a r e d very s u i c i d a l a n d h o p e ess at t h e b e g i n n i n g o f t r e a t m e n t . Hospitalization a p p e a r e d i m m i n e n t i f symptq >matic r e l i e f c o u l d not be p r o v i d e d rapidly. indeed,

W e also h o p e d , by r e s p o n d i n g to the patient's e x p e c t a t i o n f o r , a n d near

insistence

on drug

treatme i t ,

to create

a milieu in which

psychological t r e a t m e n t might be a c c e p t e d at east as a n a d j u n c t t r e a t m e n t , C o g n i t i v e t h e r a p y was d e s i g n e d to h e l p t tie patient: (1) identify a n d r e c o r d his negative automatic t h i n k i n g ; (2) identify < t i m u l i w h i c h t r i g g e r e d these n e g a tive t h o u g h t s ; (3) p r o v i d e m e t h o d s to coii t r o l these t h o u g h t s ; (4) p r o v i d e m e t h o d s for the patient to refute a n d c o r r e ct these t h o u g h t s ; a n d (5) identify c o r r e c t the silent a s s u m p t i o n s o r themeis w h i c h r a n t h r o u g h o u t a n d s u p -

and

p o r t e d his negative t h i n k i n g . Step 1: T h e patient r e c o r d e d his negativ< i thoughts a n d associated e n v i r o n m e n t a l events i n his notebook. thoughts o r cognitions.

H e r e p o r t e c a p r o f u s i o n o f negative automatic

T h e s e cognitions we r e repetitious, u p s e t t i n g , d i s t o r t e d ,

a n d generally reflected a very negative view o f h i m s e l f .

T h e content consisted

o f statements s u c h as, " I a m a failure i n m y o c c u p a t i o n .

M y wife has s h o w n m e

I ' m a failure i n m a r r i a g e .

I can't get a j o b ir i civilian life. N o o n e respects m e . W h y botl ler to a p p l y f o r a j o b , they'll n e v e r h i r e s o m e o n e as old as I a m . I can't e v e n pla> tennis a n y m o r e , " a n d so forth, I've n e v e r s u c c e e d e d at a n y t h i n g .

Step 2: B y r e c o r d i n g the e n v i r o n m e n t a l ev ents associated w i t h negative t h i n k i n g , the patient identified s t i m u l i for this ti l i n k i n g .

Exacerbating stimuli i n -

e l u d e d p l a y i n g t e n n i s , h a v i n g d i n n e r w i t h hii wife, a n d l o o k i n g at o l d N a v y p i c tures.

D r i n k i n g alcohol o r w a l k i n g i n the wc ods alone d e c r e a s e d the f r e q u e n c y

o f the thoughts.

T h e patient's c o n c e n t r a t i oi was severely i m p a i r e d because o f

this r e c u r r e n t s t r e a m o f self-critical t h i n k i n g .

C O G N I T I V E

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S U I C I D E

T h e patient u s e d a wrist c o u n t e r to m o n i t o r the f r e q u e n c y o f these

thoughts a n d the s t i m u l i associated with t h e m .

O n the a v e r a g e , these thoughts

o c c u r r e d about 60 times p e r h o u r d u r i n g most o f the day. T h e patient was i n s t r u c t e d to r e c o r d a n d g r a p h the exact n u m b e r o f negative thoughts p e r m i n u t e for f o u r days for every w a k i n g m i n u t e u s i n g a stopwatch and counter. hour.

W i t h this t e c h n i q u e he r e d u c e d the thoughts to as few as 3 to 7 p e r

H e g a i n e d some c o n t r o l o v e r his thoughts with this t e c h n i q u e .

I n addi-

tion, he b e g a n to look at his t h i n k i n g m o r e objectively (i.e., to r e g a r d these thoughts as u p s e t t i n g yet repetitious psychological events, r a t h e r t h a n a c c u r a t e reflections o f reality). Step 4: A f t e r he l e a r n e d to c o n t r o l a n d to b e c o m e m o r e objective about his negative t h o u g h t s , he was able to begin to c o r r e c t , validate, a n d / o r refute e a c h thought.

W h e n a s k e d for e v i d e n c e that these thoughts w e r e t r u e , he r e p e a t e d

the p r e v i o u s e x p e r i e n c e s o f d e l a y e d p r o m o t i o n , f a i l u r e to m a k e A d m i r a l , a n d his c u r r e n t difficulty w i t h s e x u a l p e r f o r m a n c e . o f h e r affair to seek a d i v o r c e .

H e felt his wife was too a s h a m e d

T h i s i n f e r e n c e e x p l a i n e d w h y she was still l i v i n g

w i t h h i m w h e n he believed she still loved h e r f o r m e r p a r a m o u r . the p a r a m o u r h a d b e e n o f a h i g h e r r a n k t h a n the patient.

Furthermore,

T h i s fact was seen by

the patient as e v i d e n c e that he wasn't g o o d e n o u g h for h e r .

H e saw his wife as a

b r i g h t , attractive, t a l e n t e d , artistic, a n d m u c h a d m i r e d a n d r e s p e c t e d w o m a n . I n c o m p a r i s o n , he saw h i m s e l f as a n o c c u p a t i o n a l , m a r i t a l , s e x u a l , a n d social f a i l u r e . H e attributed his m a n y military h o n o r s to " t h e s y s t e m , " w h i l e he attributed occupational

failures to

himself.

I n r e v i e w i n g these thoughts

he

l e a r n e d to identify a n d c o r r e c t the cognitive distortions o f o v e r g e n e r a l i z a t i o n , a r b i t r a r y i n f e r e n c e , a n d magnification. H e l e a r n e d to identify specific t h e m e s w h i c h w e r e i n f e r r e d f r o m the negative automatic thoughts he r e c o r d e d .

H e l e a r n e d to evaluate these t h e m e s w i t h logic

a n d , at times, with e x p e r i m e n t a l testing.

E x a m p l e s o f these t h e m e s are " U n l e s s

I do e v e r y t h i n g perfectly, I ' m a f a i l u r e .

I f I a m not r e w a r d e d a n d r e s p e c t e d ,

I'm a failure.

I f I m a k e a mistake, it m e a n s I ' m defective.

an affair, she no l o n g e r loves o r respects m e .

B e c a u s e my wife h a d

I can't enjoy a n y t h i n g i f I ' m not

the best." Initially, the patient e n u m e r a t e d a p l e t h o r a o f specific events f r o m his past, e a c h o f w h i c h he c o n s t r u e d as s u p p o r t i n g these t h e m e s . w e n t back five to twenty-five years p r i o r to t r e a t m e n t .

O f t e n his e v i d e n c e B y r e v i e w i n g the e v i -

d e n c e point by point a n d suggesting alternative i n t e r p r e t a t i o n s o f the events reported, enough consider

doubt developed

r u n n i n g an experiment

consideration.

i n the patient's t h i n k i n g , that he w o u l d to

test the a s s u m p t i o n

or theme

under

F o r e x a m p l e , he was d i r e c t e d to intentionally lose at s e v e r a l sets

o f tennis with a m e d i o c r e p l a y e r , w h i l e t r y i n g to identify w h a t else he m i g h t be enjoying

while playing.

He

reported

enjoying

the e x e r c i s e , c o n v e r s a t i o n ,

w e a t h e r , a n d o t h e r players at the c l u b , thereby d i s e n t a n g l i n g the issues o f achievement and enjoyment. H e l e a r n e d to see his wife's affair m o r e as a reflection o f h e r view o f h e r s e l f and

the m a r r i a g e r a t h e r t h a n c o n c l u s i v e p r o o f o f some p e r m a n e n t defect i n

himself.

B y l e a r n i n g how he h a d i n a d v e r t e n t l y b l o c k e d c o m m u n i c a t i o n (at least

f r o m his wife's v i e w p o i n t ) , he c o u l d take corrective action to discuss a n d solve

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problems rather than c o n c l u d i n g that he

J OU R N A L 1

OF

P S Y C H O T H E R A P Y

5 a total failure by o v e r g e n e r a l i z i n g

f r o m a few complaints f r o m his wife. At

s i x - m o n t h follow-up, the patient's B e c k

H e was taking no medication. drinking

excessively.

He

D e p r e s s i o n Inventory was six.

H e w a s e m p l o y e d f u l l t i m e , still m a r r i e d a n d n o t

a n d his wife r e p o r t e d a d r a m a t i c i m p r o v e m e n t in

marital satisfaction.

T h i s case i l l u s t r a t e s t h e use o f c o m b i n e d c h e m o t h e r a p y a n d c o g n i t i v e therapy. T h e c o m b i n a t i o n t r e a t m e n t may have certain advantages. C h e m o t h e r a p y m a y p r o v i d e r a p i d s y m p t o m a t i c r e l i e f (e.g, f o r i n s o m n i a ) a n d i t m a y s u f f i c i e n t l y m a t c h t h e p a t i e m ;'s e x p e c t a t i o n s , so t h a t c o g n i t i v e a n d b e h a v i o r a l c h a n g e t e c h n i q u e s can be a p p l i e d . C o g n i t i v e t h e r a p y m a y have r e s u l t e d i n s u f f i c i e n t c o r r e c t i o n o f h o w t h i s p a t i e n t c h r o n i c a l l y gives d i s t o r t e d n e g a t i v e m e a n i n g s t o events b o t h past a n d p r e s e n t , t o p r o v i d e p r o p h y l a x i s against f u t u r e depr^ssio ns. F u r t h e r m o r e , this case i l l u s t r a t e s h o w a c o g n i t i v e o r b e h a v i o r a l a p p r o a c h can i n v o l v e t h e c o u p l e o r f a m i l y system. O f t e n t h e spouse can F u r t h e r m o r e , as p r o v i d e i n f o r m a t i o n to correct cognitive d i s t o r t i o n s . t h e spouse becomes a w a r e o f t h e p a t i e n t s n e g a t i v e t h i n k i n g , h e o r she can r e s o r t t o v e r b a l a n d n o n v e r b a l b e h a v i o r s t o c o n s i s t e n t l y " d i s " c o n f i r m the patient's negative automatic t h i n k i n g 7

O U T C O M E S T U D I E S OF C O G N I T I V E T H E R A P Y W e have b r i e f l y p r e s e n t e d t h e c o g n i t i v e m o d e l o f d e p r e s s i o n . This m o d e l has b e e n a basis f o r d e v e l o p i n g a specific c o g n i t i v e t h e r a p y f o r depression. T h e r a t i o n a l e f o r t h e co; ^nitive t h e r a p y o f d e p r e s s i o n is d e r i v e d f r o m this f o r m u l a t i o n : i f t h e s o u r c e o f t h e d e p r e s s i o n is a h y p e r v a l e n t set o f n e g a t i v e c o n c e p t s , t h e n t h e c o r r e c t i o n a n d d a m p i n g d o w n o f these schemas m a y be e x p e c t e d to alleviate t h e depressive s y m p t o m a t o l o g y . I n c o g n i t i v e t h e r a p y , t h e the r a p i s t a n d p a t i e n t w o r k t o g e t h e r t o i d e n t i f y d i s t o r t e d c o g n i t i o n s , d e r i v e f r o m his d y s f u n c t i o n a l beliefs, T h e s e d i s t o r t e d n e g a t i v e c o g n i t i o n s a n d d y s f u n c t i o n a l beliefs a r e s u b j e c t e d to l o g i c a l analysis a n d e m p i r i c a l t e s t i n g . M o r e o v e r , t h r o u g h t h e a s s i g n m e n t o f b e h a v i o r a l tasks, t h e p a t i e n t l e a r n s t o m a s t e r p r o b l e m s a n d life situations w h i c h he previously considered insuperable, a n d cons e q u e n t l y , h e learns t o r e a l i g n his t h i n k i n g w i t h r e a l i t y . Studies o f t h e efficacy o f c o g n i t i v e t h e r a p y have i m p l i c a t i o n s f o r t h e cognitive model. I f t e c h n i q u e s t o cor|rect c o g n i t i o n s o f f e r n o specific a d v a n t a g e o v e r n o t r e a t m e n t o r n o n specificc t r e a t m e n t c o n t r o l s , we m i g h t c o n c l u d e t h a t n e g a t i v e c o g n i t i o n , a l t h o u g h p r e s e n t i n association w i t h a d e p r e s s e d m o o d , m a y s i m p l y be ; s e c o n d a r y e f f e c t o f t h e m o o d i t self, a n e p i p h e n o m e n o n , r a t h e r t h a n h k v i n g a causal r e l a t i o n s h i p to t h e disorder. Secondly, i f d y s f u n c t i o n a l attitudes c o n t r i b u t e to a predis-

C O G N I T I V E

T H E R A P Y

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S U I C I D E

213

p o s i t i o n t o d e p r e s s i o n a n d i f these a t t i t u d e s are c o r r e c t e d w i t h c o g n i t i v e t h e r a p y , t h e n p a t i e n t s t r e a t e d w i t h c o g n i t i v e t h e r a p y m a y be a f f o r d e d some p r o p h y l a x i s against relapse c o m p a r e d to n o t r e a t m e n t o r p e r h a p s to other treatments. A n u m b e r o f o u t c o m e studies c o m p a r i n g t h e efficacy o f c o g n i t i v e t h e r a p y w i t h o t h e r t r e a t m e n t s f o r d e p r e s s i o n are n o w available. To date t h r e e c o n t r o l l e d o u t c o m e studies w i t h d e p r e s s e d s t u d e n t s h a v e been c o n d u c t e d , two o f w h i c h used a g r o u p - t r e a t m e n t f o r m a t . Cognit i v e t h e r a p y e x c e e d e d t h e results o b t a i n e d i n w a i t i n g - l i s t , s u p p o r t i v e treatment, or positive-experience control groups. S h i p l e y a n d F a z i o t r e a t e d t w e n t y - f o u r subjects w i t h a n i n d i v i d u a l approach w h i c h p r o v i d e d functional problem-solving alternatives. T w e n t y - f i v e depressed controls received a nonspecific interest-support treatment. T h e experimental treatment resulted i n significantly greater i m p r o v e m e n t t h a n t h e c o n t r o l t r e a t m e n t . I n a d d i t i o n , these effects w e r e i n d e p e n d e n t o f the subjects' i n i t i a l expectancies. Taylor and Marshall conducted a controlled-treatment comparison a m o n g g r o u p s w h i c h r e c e i v e d c o g n i t i v e m o d i f i c a t i o n , b e h a v i o r m o d i f i c a t i o n , c o g n i t i v e and b e h a v i o r m o d i f i c a t i o n , as w e l l as a w a i t i n g list g r o u p . T h e y f o u n d t h a t p a t i e n t s i n a l l active t r e a t m e n t g r o u p s s h o w e d s i g n i f i c a n t i m p r o v e m e n t i n d e p r e s s i o n c o m p a r e d to t h e w a i t i n g - l i s t c o n t r o l subjects. T h e c o m b i n a t i o n t r e a t m e n t was s u p e r i o r to t h e c o g n i t i v e a n d the behavioral treatments alone. Gioe compared a modified cognitive-modification treatment in combination w i t h a "positive g r o u p experience," a cognitive-modification t r e a t m e n t , a treatment consisting o f a "positive g r o u p experience" alone a n d a waiting-list c o n t r o l . U s i n g a g r o u p - t h e r a p y m o d a l i t y w i t h t e n d e p r e s s e d s t u d e n t s i n each g r o u p , he r e p o r t e d t h a t t h e c o m b i n a t i o n t r e a t m e n t p a c k a g e was clearly s u p e r i o r i n a l l e v i a t i n g depressive s y m p tomatology. 8

9

1 0

T u r n i n g t o studies o f c o g n i t i v e t h e r a p y i n d e p r e s s e d p s y c h i a t r i c p a t i e n t s , we find a t o t a l o f f o u r c o n t r o l l e d o u t c o m e studies a n d t h r e e case r e p o r t s . C o g n i t i v e t h e r a p y has e x c e e d e d t h e results o f w a i t i n g - l i s t g r o u p , insight therapy, behavior therapy, nondirective therapy, and pharmacotherapy. S h a w treated depressed patients r e f e r r e d f r o m a University H e a l t h Service. Psychometric ratings, self-reports, a n d i n d e p e n d e n t clinical e v a l u a t i o n s w e r e u s e d . A g r o u p - t h e r a p y f o r m a t was e m p l o y e d w i t h o n e t h e r a p i s t t r e a t i n g e i g h t subjects i n each g r o u p . A l l active t r e a t m e n t s p r o d u c e d s i g n i f i c a n t l y b e t t e r results t h a n a w a i t i n g - l i s t c o n t r o l . Cognit i v e t h e r a p y was f o u n d t o be m o r e efficacious t h a n b e h a v i o r t h e r a p y ( i n t e r p e r s o n a l skills t r a i n i n g ) , n o n d i r e c t i v e t h e r a p y , a n d a w a i t i n g - l i s t c o n trol. 1 1

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Rush a n d c o w o r k e r s r e p o r t e d o n cognitive therapy o f three patients w i t h chronic relapsing depression. T h e main behavioral modality consisted o f t h e use o f a c t i v i t y schedules. T h e c o g n i t i v e a p p r o a c h was d i r e c t e d at e x p o s i n g a n d c o r r e c t i n g t h e p a t i e n t ' s n e g a t i v e m i s e v a l u a t i o n s o f his activities. T h e s e p a t i e n t s , a l t h o u g h n o t p r e v i o u s l y h e l p e d by d r u g t h e r a p y , s h o w e d p r o m p t a n d s u s t a i n e d i m p r o v e m e n t w i t h t h e r a p y acc o r d i n g to c l i n i c a l a n d s e l f - r e p o r t measures. Morris compared a "didactic cognitive behavioral p r o g r a m , " an " i n s i g h t - o r i e n t e d t h e r a p y " (an e x p e r i e n t i a l a n d u n s t r u c t u r e d p r o g r a m w h i c h focused o n self-understanding), a n d a waiting-list c o n t r o l g r o u p w i t h d e p r e s s e d f e m a l e o u t p a t i e n t s . T w e n t y - t w o subjects w e r e t r e a t e d i n t h e c o g n i t i v e - b e h a v i o r a l g r o u p , seventeen i n t h e i n s i g h t g r o u p a n d t w e l v e served as c o n t r o l s . T h e c o g n i t i v e - b e h a v i o r a l p r o g r a m was s u p e r i o r . F u r t h e r m o r e , t h e c o g n i t i v e - b e h a v i o r a l t r e a t m e n t was as e f f e c t i v e i n a t h r e e - w e e k p e r i o d as i n a six-week p e r i o d w h e n t h e n u m b e r o f sessions r e m a i n e d c o n s t a n t . T h i s l a t t e r f i n d i n g emphasizes a n o t a b l e f e a t u r e o f t h e c o g n i t i v e a p p r o a c h (i.e., s i g n i f i c a n t c h a n g e can o c c u r d u r ing a brief time period). 7

1 2

4

U s i n g a single-subject d e s i g n , S c h m i c k l e y , r e p o r t e d significant i m p r o v e m e n t i n eleven c l i n i c a l o u t p a t i e n t s as a d i r e c t r e s u l t o f f o u r o n e h o u r sessions o f c o g n i t i v e - b e h a v i o r a l t r e a t m e n t i n t e r v e n t i o n . A t t e r m i n a t i o n , i m p r o v e m e n t was f o u n d w i t h eleven o f t w e l v e p s y c h o m e t r i c a n d b e h a v i o r a l measures. 13

W e r e c e n t l y u n d e r t o o k a n i n t e n s i v e p i l o t s t u d y at t h e U n i v e r s i t y o f Pennsylvania. W e c o m p a r e d t h e r e l a t i v e efficacy o f c o g n i t i v e t h e r a p y w i t h a tricyclic antidepressant d r u g ( i m i p r a m i n e h y d r o c h l o r i d e ) i n the t r e a t m e n t o f f o r t y - o n e d e p r e s s e d o u t p a t i e n t s . C o g n i t i v e t h e r a p y was f o u n d t o be m o r e e f f e c t i v e t h a n i m i p r a m i n e . 14

W e have r e c e n t l y e x t e n d e d o u r s t u d y to f o r t y - f o u r d e p r e s s e d o u t p a t i e n t s , a n d f o l l o w - u p d a t a a r e n o w available. A l l p a t i e n t s w e r e selfr e f e r r e d p s y c h i a t r i c o u t p a t i e n t s w h o satisfied r e s e a r c h d i a g n o s t i c c r i t e r i a f o r t h e depressive s y n d r o m e . A l l h a d a diagnosis o f d e p r e s s i v e n e u r o s i s a c c o r d i n g t o t h e D i a g n o s t i c Statistical M a n u a l - I I . As a g r o u p t h e y w e r e g e n e r a l l y w h i t e , p a r t i a l l y college e d u c a t e d , a n d i n t h e i r m i d thirties. T h e i r past h i s t o r i e s a n d M i n n e s o t a M u l t i p h a s i c P e r s o n a l i t y I n v e n tories indicated a substantial degree o f psychopathology. I n general, the patients h a d been i n t e r m i t t e n t l y o r chronically depressed almost n i n e years, a n d o n e - f o u r t h o f these p a t i e n t s h a d b e e n h o s p i t a l i z e d f o r d e p r e s s i o n i n t h e past. T h e a v e r a g e p a t i e n t h a d seen o v e r t w o therapists p r i o r to the study. O n the average, the c u r r e n t episode o f d e p r e s s i o n h a d b e e n p r e s e n t f o r j u s t less t h a n t w e l v e m o n t h s at t h e t i m e o f e n t e r i n g the study. A t t h e start o f t r e a t m e n t , a l l p a t i e n t s w e r e 6

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m o d e r a t e - s e v e r e l y d e p r e s s e d by s e l f - r e p o r t (Beck D e p r e s s i o n I n v e n t o r y ) , o b s e r v e r e v a l u a t i o n ( H a m i l t o n R a t i n g Scale), a n d t h e r a p i s t r a t i n g (Raskin Scale). Seventy-five p e r c e n t o f these p a t i e n t s r e p o r t e d s i g n i f i c a n t s u i c i d a l i d e a t i o n at t h e start o f t r e a t m e n t . I n essence, o u r u n i p o l a r depressed patients generally h a d a substantial degree o f p s y c h o p a t h o l o g y and a h i s t o r y oí poor r e s p o n s e t o o t h e r p s y c h o t h e r a p i e s . Patients w e r e r a n d o m l y assigned to e i t h e r i n d i v i d u a l c o g n i t i v e therapy o r p h a r m a c o t h e r a p y ( i m i p r a m i n e h y d r o c h l o r i d e ) f o r twelve weeks o f t r e a t m e n t . P r e s c r i b e d p s y c h o t h e r a p y consisted o f t w i c e ^weekly h o u r - l o n g c o g n i t i v e t h e r a p y sessions f o r a m a x i m u m o f t w e n t y visits. P h a r m a c o t h e r a p y consisted o f n o t less t h a n 100 m g / d a y , b u t n o t m o r e t h a n 250 mg/day o f i m i p r a m i n e prescribed i n t w e n t y - m i n u t e , once w e e k l y visits f o r a m a x i m u m o f t w e l v e weeks. 1 6

7

18

T h e r a p i s t s consisted m a i n l y o f p s y c h i a t r i c r e s i d e n t s w h o h a d t r e a t e d o n l y t w o " p r a c t i c e " cases w i t h s u p e r v i s i o n p r i o r t o t r e a t i n g r e s e a r c h cases. T h e m e t h o d o l o g y o f c o g n i t i v e t h e r a p y was specified i n a t r e a t ment manual. T h e t h e r a p i s t s w e r e systematically s u p e r v i s e d o n a w e e k l y basis b y t h r e e e x p e r i e n c e d c l i n i c i a n s . A l l sessions w e r e a u d i o r e c o r d e d a n d spot c h e c k e d f o r a d h e r e n c e t o p r o t o c o l . 4

B o t h t r e a t m e n t g r o u p s w e r e e q u i v a l e n t w i t h respect t o d e m o g r a p h i c c h a r a c t e r i s t i c s , h i s t o r i e s o f illness, t r e a t m e n t a n d m e a n severity o f d e p r e s s i o n at t h e start o f t r e a t m e n t . O f n i n e t e e n p a t i e n t s assigned t o cognitive therapy, eighteen completed treatment over a mean p e r i o d o f eleven weeks. O f t w e n t y - f i v e p a t i e n t s assigned to p h a r m a c o t h e r a p y , seventeen c o m p l e t e d t r e a t m e n t o v e r t h e same m e a n p e r i o d o f t i m e . By t h e e n d o f active t r e a t m e n t , b o t h t r e a t m e n t g r o u p s s h o w e d statistically s i g n i f i c a n t decreases (p < .001) i n depressive s y m p t o m a t o l o g y acc o r d i n g to self-reports, observer evaluations, a n d therapist ratings. By the e n d o f t r e a t m e n t , cognitive t h e r a p y resulted i n significantly greater i m p r o v e m e n t t h a n d i d p h a r m a c o t h e r a p y o n self-reports a n d observerbased c l i n i c a l r a t i n g s o f d e p r e s s i o n ( < .01). T h e r e s p o n s e rates t o b o t h p h a r m a c o t h e r a p y a n d cognitive t h e r a p y exceeded the usually r e p o r t e d degree o f response to placebo i n depressed o u t p a t i e n t s . I n addition, b o t h t r e a t m e n t s r e s u l t e d i n s u b s t a n t i a l decreases i n subjective r e p o r t s and interviewer-based ratings o f anxiety. 1 9

I n t e r e s t i n g l y , t h e d r o p o u t r a t e d u r i n g active t r e a t m e n t was significantly greater w i t h p h a r m a c o t h e r a p y t h a n w i t h cognitive therapy (p < .05). H o w e v e r , e v e n w h e n these d r o p o u t s w e r e e l i m i n a t e d f r o m t h e d a t a analysis, c o g n i t i v e t h e r a p y p a t i e n t s s h o w e d a s i g n i f i c a n t l y g r e a t e r i m p r o v e m e n t i n depressive s y m p t o m a t o l o g y t h a n t h e p h a r m a c o t h e r a p y p a t i e n t s (p < .05). F o l l o w - u p d a t a at t h r e e a n d six m o n t h s a f t e r t e r m i n a t i o n o f t r e a t m e n t f o r those w h o c o m p l e t e d c o g n i t i v e t h e r a p y a n d p h a r m a c o t h e r a p y

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a r e s h o w n i n F i g u r e 1. T r e a t m e n t gains w e r e m a i n t a i n e d f o r b o t h groups. A greater n u m b e r o f the d r u g - t r e a t m e n t g r o u p r e t u r n e d to t r e a t m e n t d u r i n g this p e r i o d c o m p a r e d t o c o g n i t i v e - t h e r a p y p a t i e n t s . T h e c o g n i t i v e - t h e r a p y p a t i e n t s s h o w e d s i g n i f i c a n t l y l o w e r levels o f d e p r e s s i o n at t h r e e m o n t h s (p < .05) a n d a t r e n d t o w a r d l o w e r levels at six m o n t h s (p < .10). A l s o those p a t i e n t s w h o h a d d r o p p e d o u t o f b o t h c o g n i t i v e t h e r a p y a n d p h a r m a c o t h e r a p y w e r e f o l l o w e d u p at t h r e e a n d six m o n t h s a f t e r t h e y w o u l d have c o m p l e t e d t r e a t m e n t . W h e n b o t h those w h o c o m p l e t e d a n d those w h o d r o p p e d o u t o f t h e r a p y a r e c o m b i n e d i n a c o m parison o f cognitive therapy and pharmacotherapy groups, cognitive t h e r a p y r e s u l t e d i n statistically s i g n i f i c a n t l o w e r levels o f d e p r e s s i o n at b o t h t h r e e m o n t h s (p < .05) a n d six m o n t h s o f f o l l o w - u p (p < .05). T h i s is t h e first s t u d y t o s h o w t h a t a n y p s y c h o t h e r a p y was e q u i v a l e n t t o o r e x c e e d e d t h e efficacy o f p h a r m a c o t h e r a p y i n t h e r e l i e f o f t h e acute s y m p t o m s o f t h e depressive s y n d r o m e . O f c o u r s e , o u r results a w a i t c o n f i r m a t i o n . I n a d d i t i o n , o u r f o l l o w - u p data indicated that t r e a t m e n t gains are m a i n t a i n e d o v e r t i m e . O u r p r e l i m i n a r y d a t a suggest t h a t

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c o g n i t i v e t h e r a p y m a y e x c e e d p h a r m a c o t h e r a p y i n p r e v e n t i n g relapse o r n e e d f o r f u r t h e r t r e a t m e n t , o n c e b o t h t r e a t m e n t s are d i s c o n t i n u e d since a g r e a t e r n u m b e r o f p h a r m a c o t h e r a p y p a t i e n t s r e t u r n e d t o t r e a t m e n t d u r i n g f o l l o w - u p c o m p a r e d t o t h e c o g n i t i v e t h e r a p y cases. Several o t h e r s t u d i e s ' have c o m p a r e d d i f f e r e n t p s y c h o t h e r a p i e s directly or indirectly w i t h antidepressant pharmacotherapy i n the treatm e n t o f depressed outpatients. T h e psychotherapies studied i n c l u d e d interpersonal t h e r a p y , marital t h e r a p y , a n d supportive-expressive group treatments. These psychotherapies d i d not compare w i t h the efficacy o f a n t i d e p r e s s a n t m e d i c a t i o n i n t h e r e l i e f o f t h e acute s y m p t o m s o f t h e depressive s y n d r o m e . T h e s e studies also i n d i c a t e t h a t t h e increased a m o u n t o f therapist contact t i m e f o r patients i n cognitive t h e r a p y i n i t s e l f is i n s u f f i c i e n t t o a c c o u n t f o r t h e g r e a t e r efficacy o f cognitive therapy i n symptomatic relief. 2 0

2 0

2 2

2 1

2 2

I n g e n e r a l , p s y c h o t h e r a p y o u t c o m e studies o f b o t h d e p r e s s e d s t u d e n t s a n d p s y c h i a t r i c o u t p a t i e n t p o p u l a t i o n s have s h o w n t h a t c o g n i t i v e t h e r a p y is m o r e e f f e c t i v e t h a n w a i t i n g - l i s t a n d o t h e r a c t i v e t r e a t m e n t c o n t r o l s , i n c l u d i n g p h a r m a c o t h e r a p y (the m o s t e f f e c t i v e t r e a t m e n t k n o w n t o d a t e f o r t h e depressive s y n d r o m e ) . S e c o n d l y , t h e p o t e n t i a l p r o p h y l a c t i c v a l u e o f c o g n i t i v e t h e r a p y is i m p l i e d by p r e l i m i n a r y f o l l o w - u p d a t a . T h e s e f i n d i n g s are consistent w i t h t h e n o t i o n t h a t c o g n i t i o n s a n d schemas p l a y a m a j o r r o l e i n t h e i n d u c t i o n o r maintenance o f depression. A d d i t i o n a l studies are n e e d e d to i d e n t i f y t h e p r e d i c t o r s o f r e s p o n s e t o t h i s t r e a t m e n t a n d to d e t e r m i n e t h e a p p l i c a b i l i t y o f this p s y c h o t h e r a p y t o o t h e r p o p u l a t i o n s .

SUMMARY T h e c o g n i t i v e t h e o r y o f d e p r e s s i o n o f f e r s a testable set o f h y p o t h e s e s t o e x p l a i n t h e s y m p t o m a t o l o g y a n d t h e p r e d i s p o s i t i o n o f relapse i n p a t i e n t s w i t h t h e depressive s y n d r o m e . T h e c o g n i t i v e t r i a d ( n e g a t i v e views o f self, f u t u r e , a n d w o r l d ) , specific t h i n k i n g e r r o r s d e f i c i e n t i n l o g i c , a n d t h e existence o f h y p e r v a l e n t schemas f o r m t h e c o r n e r s t o n e s o f this m o d e l . T h i s c o g n i t i v e t h e o r y is t h e basis f o r a specific p s y c h o t h e r a p y f o r d e p r e s s i o n — c o g n i t i v e t h e r a p y . T h i s t r e a t m e n t consists o f a n u m b e r o f t e c h n i q u e s , a few o f w h i c h are d e s c r i b e d a n d i l l u s t r a t e d above. Seven c o n t r o l l e d o u t c o m e studies i n d e p r e s s e d s t u d e n t s o r p s y c h i a t r i c o u t p a t i e n t s s h o w c o g n i t i v e t h e r a p y t o e x c e e d t h e efficacy o f w a i t i n g - l i s t , nondirective, supportive a n d behavioral-therapy controls. O u r recent s t u d y i n m o d e r a t e - s e v e r e l y d e p r e s s e d o u t p a t i e n t s shows t h a t c o g n i t i v e t h e r a p y was m o r e e f f e c t i v e t h a n i m i p r a m i n e h y d r o c h l o r i d e i n p r o v i d i n g acute s y m p t o m a t i c r e l i e f a n d i n d e c r e a s i n g p r e m a t u r e d r o p o u t s f r o m

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treatment. A d d i t i o n a l studies o f t h e acute a n d p r o p h y l a c t i c effects o f t h i s p s y c h o t h e r a p y are i n d i c a t e d .

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