New Developments in Cognitive- Behavioural Therapy for Depression

Evidence-Based Psychotherapies
New Developments in Cognitive-
Behavioural Therapy for Depression
Gilbert Pinard MD, FRCPC
Professor, Department of Psychiatry, McGill University, Montreal, Quebec
Key Words: depression, chronic, recurrent, cognitive-
combination treatment got better faster, compared with
behavioural therapy, CBT, cognitive-behavioral analysis
the group receiving psychotherapy alone, but because the
system of therapy, mindfulness training
effect of the combination appeared only after the first four
weeks, the authors felt justified in writing that the two
Twoaspectsofthepsychotherapyofdepressionappear treatmenteffectswereindependent.The25percentincre-
most promising in terms of specific contributions of
ment secondary to the combination represents a major
cognitive-behavioural interventions: first, the use of the
therapeutic gain.
therapy in combination with medication, particularly in
patients with chronic or resistant conditions; and second,
This form of psychotherapy targets depression, but symp-
its role in the prevention of relapse or recurrence.
toms of anxiety in these depression patients responded
Intuitively, it makes sense that the combination of
better to the combination of both treatments than to either
psychotherapy and pharmacotherapy would be superior to
monotherapy. However, the fact that patients suffering
either treatment alone. However, only a few studies of
from comorbid anxiety disorders treated with CBASP
good methodological quality have demonstrated this.
alone did not show as much improvement in their anxiety
One such study, published in the New England Journal of
symptoms as in their depression speaks to the specificity
Medicine, was by Keller and collaborators from 12 major
of this approach (3). (See the paper in this issue by Talbot
university health centres (1). This huge randomized con-
and McMurray regarding CBT for anxiety disorders; 4.)
trolled trial involved over 650 patients with chronic
depression and had three treatment arms: medication
Standard CBT focuses on the link between one’s perspec-
alone, psychotherapy alone and the combination of the
tive on a situation, the emotions engendered and the
two. Chronic depression was defined as major depressive
resulting behaviours. Patient views of reality, their self-
disorder (MDD) of at least two years’ duration, a current
concept, their world view and their view of the future may
major depression superimposed on an existing dysthymia,
be systematically distorted. Therapy aims to help patients
or a recurrent MDD with incomplete remission. Unfortu-
modify maladaptive patterns of thought or behaviour
nately, the antidepressant used was nefazodone, which
through work during the sessions and at home in
has recently been taken off the market because of hepatic
agreed-upon assignments.
toxicity. Nonetheless, the results are still empirically use-
In the CBASP approach, McCullough (2) integrates exist-
ful owing to its demonstrated efficacy. The psychotherapy
ing theoretical underpinnings from several sources: 1)
arm was the cognitive-behavioral analysis system of
postulated arrested maturational cognitive development
psychotherapy (CBASP), an approach adapted from
from a Piagetian perspective, 2) the role of attachment
cognitive-behavioural therapy (CBT) by McCullough,
and its different dimensions in the course of therapy, and
with particular attention paid to interpersonal dimensions
3) the patient’s habitual patterns of social interaction in
(2). I describe it in more detail later.
the context of the therapeutic alliance. He also greatly
Results of the acute-treatment phase (the first 12 weeks of
elaborates the cognitive and behavioural analyses of
a long-term project) were dramatic. At the last visit in the
patient interactions with the environment in terms of
intent-to-treat cohorts (the more conservative method of
learning theory. I will describe two types of interventions
evaluating results), 48 per cent of depression patients
to help clarify these techniques.
receiving either of the two monotherapies were signifi-
cantly improved. In comparison, 73 per cent of the combi-
In situational analysis, patients are asked to describe a par-
nation treatment group had improved. (Of the three
ticular distressing event, how they appraised it, their reac-
groups, 22 per cent, 24 per cent and 42 per cent, respec-
tions, the outcome of the discrete event and, finally, the
tively, were considered to be in remission.) The group
desired outcome. Patients are then guided to realize how
receiving medication alone and the group receiving
the meaning they assigned to the situation and their reac-
tions influenced the results. They are then asked to consider
whether alternative meanings and a different behavioural
(CPA Bulletin 2004;36[1]:23–24)
response might have led to a more desirable result.
CPA Bulletin de l’APC—February 2004 février
23

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CBASP therapists also carefully use the therapeutic rela-
occurrences) over a period of 60 weeks indicate a protec-
tionship to help patients recognize the difference between
tive effect of these interventions. In subjects who had a
patterns of thinking, emotions and behaviours that are
minimum of three depressive episodes, the rate of recur-
acquired most often through childhood experiences and
rence decreased by approximately one-half, compared
current, in-session and out-of-session interactions. To do
with patients undergoing treatment as usual. The authors
this, they employ exercises that ask patients to identify
underline that this treatment is specifically designed for
five or six significant others and to speculate as to how
patients who have recovered and not for people in the
these people have influenced their present lives.
acute phase of the depression.
Therapists then help patients to discriminate between past
and present in domains such as intimacy, expression of
In conclusion, contemporary authors have borrowed from
needs or negative affects, and failure. For example, a
the literature on developmental cognitive theory, attach-
patient might recount that his father scolded him about his
ment theory and meditation practices to conceive of new
achievements in school, suggesting that he was never
interventions. These new developments, expanding on the
good enough. In such a case, the therapist could ask the
standard methods of CBT, appear to increase treatment
patient whether he noticed how he expected negative
efficacy, particularly when combined with an antidepres-
comments regarding home assignments in therapy but
sant, and to help prevent recurrence or relapse in chronic
was instead congratulated for his tremendous efforts.
depression. This holds promise for much-needed
The second development I address is the mindfulness
improved therapy outcomes.
training CBT approach described by Segal, Teasdale and
Acknowledgements
collaborators (5). Relapse is a major problem in depres-
sion because of its frequency (it occurs in 50 per cent of
I thank Dr. Gail Myhr for her comments on the first draft
patients after a first episode and in 70 per cent after a sec-
of this paper.
ond episode) and also because of the now-accepted rela-
tion between recurrence and residual symptoms. In the
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