This document summarizes the use of cognitive-behavioral therapy (CBT) to treat a patient with depression. It describes selecting appropriate patients for CBT, the progress of the patient over 8 therapy sessions, key aspects of CBT including psychoeducation, cognitive restructuring to modify negative thoughts, and termination. The patient's depression rating decreased from 34 initially to 1 at termination, and symptoms were maintained without medication 6 months later, demonstrating the effectiveness of CBT for this individual.

1. Cognitive-Behavioral Therapy
Psychiatry Department Postgraduate CPC
2nd December 2001

2. Selection for CBT
1. Is the patient depressed
2. Nature of depression? –unlikely successful with
severe, highly suicidal and bipolar(Beck et al 1979)
Rush and Shaw(1983)- unlikely to succeed in
endogenous and melancholic
3. Cognitive depression? – should look for negative
cognitive triad seen by Beck as central to depression
4. Willingness to accept?
5. Collaborative relationship? – working as a team,
ability to reveal her problem

3. Progress
She was behaving well in the ward
No suicidal risk behaviour
She was able to sleep with medication
She was doing well with two sessions of
cognitive therapy
She was discharged after two days of admission
on her request as well her husband consent as
she was willing to continue with medication and
CBT

4. Cognitive Therapy
Short term structure therapy
Active collaboration between patient and
therapist
Oriented towards current problem and their
resolution
Goal – identify and alter cognitive distortions that
maintain the symptoms
It was chosen because patient was cooperative,
had psychological understanding of the
problems, previous treatment was not adequate

5. CT- psychoeducation
CT always begin with psychoeducation
To identify the symptoms and direct explanation
of the basis of the symptoms and outline of
treatments

6. CT- cognitive restructuring
1st session – Automatic thoughts
– Self statements or internal dialogue
– Eg – I am not a good mother (90%)
– Automatic and usually negative
– Normally assume as accurate, never tested
– Subject to cognitive distortion and bias

7. CT – cognitive restructuring
2nd session –demonstrate the link between
thought and emotion from her own experience
Situation- Breakfast with children
Thoughts – I am not a good mother because
they did not like to talk to me (90%)
Emotion – Sad (80%)
Was asked to think of positive event and related
emotion-similar finding

8. First session and second cbt-
12-13/6/2001
BDI- 34
Agenda-psychoeducation
– Reexplain about depression
– Explain about cognitive therapy
– Explain about Dysfunctional Thought Record
– Introduced how to recognize emotions and relationship
Conclusion
– In a day we have many emotions,
– negative emotions associated with negative thoughts
– thoughts and emotions were interrelated
Homework-to complete DTR

9. DTR
Date Situation Thoughts/
Images
Rate-%
Emotion
Rate-%

10. CT – cognitive restructuring
3rd session – Pattern of relationship between
thought and emotion
Situation- Quarrel with husband
Thoughts – I am a failure as a mother (90%)
Emotion – Sad 80%

11. Third session-26/1/2001
BDI-20
Agenda-relationship between thought and
emotion
Content- Learned about vicious cycle

12. CT – cognitive restructuring
Situation
Thinking error
Thought
emotion

13. 4th session 2/7/2001
BDI 15
Thinking errors
– She has noted that she has at least five TE
– I)black and white thinking
– Ii)jumping to conclusion
– Iii)ignoring the positive – focusing to negative
aspects of event or self
– Personalization
– Should statement

14. 5th session 9/7/2001
BDI- 8
How to modify the negativethoughts
Situation
Thinking error
Thought
emotion

15. How to modify the thoughts
1. Distraction- focusing about other things
2. Look for evidences for his negative thoughts
3. Alternative explanation for his negative
thoughts
4. Aware of his thinking errors
5. Aware that the way she think would have an
effect onto her emotion and further on

16. 6th CBT – 24/7/2001
BDI-11
Agenda- discuss about her future
– Learn more about Islam
– Improve her relationship with family

17. 7th CBT- 7/8/2001
Only 5% more depressed
Discuss about daily problems
Explain about the need to terminate the CBT
soon

18. 8th CBT - 21/8/2001
BDI – 1
About 1-2% depressed
Summary of what she has learned- conclusion
Terminate
TCA six weeks - well

19. Conclusion
I can have many emotions in a day.
Thoughts and emotions had a interrelation
Positive thoughts lead to positive emotions etc
Everybody has their own NAT
NAT are negative and automatic, they seem to be right
or believable and most of the time it is biased
I should catch my NAT by
– 1. Use my own feelings as a cue
– It may come as a picture or imagination or streams of thought
– If the events are upsetting then I should ask ‘ What is the
situation means to m…….etc

20. Conclusion
Whenever I have a negative thought, it would to
negative emotions, which would lead further to another
thoughts, therefore become a vicious circle
In order to break the circle I should modify my thinking
To break the circle, I should
– 1. Look for evidences
– Look for alternative interpretations which might be more
realistic
– I should know the effect of the way I think
– Look for what type of thinking errors that I am using I.e
• Ignoring the positive, Personalization
• Black and white thinking, Jumping to conclusion
• Should statement

21. Conclusion
I should use less thinking
errors because of the thinking
errors I will have negative
thoughts

22. 27/1/2002
She had stopped taking Serzone past two
months since 1st November 2001
She felt that she was able to cope with her
problems using cognitive skills that she has
learned
She still has problems in the family but she was
able to detect her mood changes and used that
as a step to monitor her negative thoughts and
modify it accordingly
Defaulted

23. Progress
1st session, 12/6/2001 :BDI – 34
3rd session, 26/1/2001; BDI- 20
4th session, 2/7/2001: BDI-15
5th session, 9/7/2001: BDI-8
6th session, 24/7/2001: BDI 11
7th session, 7/8/2001: 5% depressed
8th session, 21/8/2001: BDI –1, Terminate
27/1/2002 –maintained till now

24. Cognitive therapy
Popular short term psychotherapy
Provide coherent testable theories of vulnerability,
psychopathology and therapeutic change
CT – identification and monitoring of negative thoughts
- evaluation of those thoughts,evidence for
and against
- encouragement of alternative positive thoughts
and re-attributions
- learning how to modify the negative thoughts

25. Brain and psychotherapy
Kandel 1998 notes that the structure of the brain is
dynamic and it possesses plasticity
Experiments with marine snails, showed number
synapses doubles or triples as a result of learning.
He postulates that psychotherapy may cause similar
changes in brain synapses
In other words psychotherapeutic interventions affect
the brain in addition to their psychological impact
Therefore the effect is longer and maintained

26. Good prognostic factors in therapy
(Bloch 1979)
1. Personality integration and functioning
2. Motivation for change
3. Realistic expectations based on psychological
mindedness
4. At least average intelligence
5.neuroses and mild personality disorders
6.Strong affect is present (anxiety and depression)
7. Life circumstances are free from irresolvable crises

27. Discussion – depression and
psychotherapy APA 2001
CBT and IPT have the best-documented effectiveness
in literature for specific treatment in MDD
Psychodynamic –freq assoc with broader long term
goals, therapist expertise, patient preference
Acute phase
– Alone if mild to moderate depression
– Presence of significant psychosocial stressors, intrpsychic
conflict, interpersonal difficulties or axis II comorbidity
– Patient peference
– Pregnancy, lactation or wish to become pregnant
Continuation

28. Discussion
Continuation phase-following remission(16-20w)
– Less study on use of psychotherapy
– Growing evidence to support its use
Maintenance
– 50-85% of single episode will have at least one more
– Risk of recurrences, severity of episodes, side effects during
continuation and pt preference
– CBT/IPT – decrease in freq of visit eg1/12
– Psychodynamic – continue at same freq to explore axis II
– Combination with drug-optional-not well studied
– Length – not known

29. Cbt -literature
Goal- reduce depressive sx by challenging and
reversing irrational beliefs and distorted attitudes
towards self, environment and future
Extensively studied over 80controlled trials
Effect sizes – compared to no teatment – fairly robust –
generally near or above 1sd in outcome measures
Effect sizes – compared to other treatments –
inconsistent results from meta-analysis
– Probably because differences in criteria in inclusion and
exclusion,- study populations,interventions or controls, or
outcomes measures
– Eg some meta analysis concluded that effect sizes for cbt are
larger than pharmacotherapy while others suggest equal only

30. Discussion
Effect sizes compare to other forms of psychotherapy –
at least as large, in some cases larger than other forms
Base on individual clinical trials
– May differ base on severity of depression
– Elkin et al 1989 – less effective than imipramine plus clinical
mangement in severe depression –HRDS >=20, or GAF
<=50
– Also found there is trend for cbt to be less effective than IPT
– Less severe pt – no differences between cbt, ipt, imipramine
plus clinical management
– Other trials failed to show differential responses( Hollon et al
1992, Evans et al 1992)

31. Discussion
Other characteristics that may associated with
differential responses
– Suggested to be associated with poor response;
unemployment, male, comorbidity, dysfunctional
attitudes, several lab tests values – abnormal sleep
EEG, increased HPA activity and increased T4
– Suggested to be more effective for CBT; depressed
individuals with personality disorders