Depression is a common and complex disorder. The 1-month prevalence rate for major depression is 2.6% and disorders occur more frequently in women than men. The main symptoms are feelings of sadness and/or the loss of enjoyment in activities that were previously pleasurable. These features are unlike the everyday mood changes that people experience in response to normal stresses. They may persist for weeks and often months. They may cause disruptions to the person’s ability to care for themselves and cope at work, school/university or in their relationships. Other symptoms include feelings of guilt or worthlessness, suicidal ideas, concentration difficulties, anxiety, sleep problems and appetite changes. All are seen as the result of an interaction between biological vulnerabilities, environmental factors (e.g. stressful events) and thinking biases. The relative contributions of these differ from person to person and even from episode to episode.
In terms of biological vulnerabilities, sometimes the person will have inherited a susceptibility to mood disorders. Other members of their family may suffer from depression although modelling, learning and shared experiences may also contribute to this shared vulnerability. Environmental factors can be difficult life situations or stresses that are new or that the person has struggled with for a while. Of the longer term type, difficult life situations include those that seem insoluble or are restricting the person’s ability to contact other resources or cope in different ways. In terms of thinking biases, rigid and extreme beliefs about goodness, perfect standards, competence and the need to avoid risk or harm are often important.
Treatments for depression include psychological therapies and medication. Both are effective at helping people recover from their episode of depression. There is also evidence that psychological therapies such as cognitive behavioural therapy (CBT) help people stay well for longer after treatment has ended. Maintenance medication also reduces risk of relapse. When depression is more severe or has become persistent, psychological therapies and medication can be used together as a combined treatment. The reanalysis of older data from four studies and a recent investigation of patients with moderate-to-severe depression has shown that cognitive therapy can be used singly in more severe depressive disorders.
Cognitive Behavioural Therapy
At its simplest, the cognitive model of depression states that how individuals interpret events has a substantial influence on their mood and behaviour. If these interpretations are sufficiently distorted, emotional problems and poor functioning are likely consequences. The National Institute for Health and Clinical Excellence (NICE) guidelines for depression have recommended between 6 and 8 sessions for mild-to-moderate depression and between 16 and 20 sessions for moderate-to-severe depression. The description of CBT that follows corresponds more closely to the longer course of therapy.
CBT for depression usually progresses in a series of stages. The first stage, after the initial assessment, involves an introduction to the cognitive model by demonstrating links between mood and extreme or unrealistic thinking. An attempt is also made at this stage to set goals for therapy and some observable means of determining whether or not these have been achieved. For example, if rumination is a problem, a goal for therapy might be that the person feels less compelled to ruminate and is spending less time dwelling on their problems.
The next stage is behavioural activation. Typically, this involves agreeing tasks and activities that have the aim of restoring a sense of achievement and pleasure. Tasks are usually broken down into their component steps to be attempted gradually in order to reduce overwhelm. Behavioural activation is important as it can provide an early challenge to negative thoughts that may be affecting other areas (e.g. ‘I can’t do it anymore’).
Thereafter, a mixture of mainly cognitive but also behavioural techniques are used to challenge biased thinking. Such biases are reflected in inaccurate impressions of recent events or rules for living that the person applies inflexibly. These often relate to what the person thinks they must do in order to be happy or consider themselves acceptable. Most CBT treatments will address these biases and attempt to restructure them along more realistic lines. Finally there are a few sessions towards the end of treatment aimed at relapse prevention and preparing for the ending of therapy.
Some researchers have attempted to discover what elements of CBT are responsible for its therapeutic effects. It would appear that getting people more activated and engaged with rewarding and pleasant experiences is helpful. It would also seem important for therapy to address extreme thinking styles and help patients realise that their thoughts are not facts but rather subjective impressions of events.
How to get help
If you are depressed the first step is to visit your GP. They will be able to refer you to a cognitive behavioural therapist or a clinical psychologist. They may also offer you medication. With milder depressions, psychological therapies are usually offered first. With depression of more moderate severity, medication is usually offered first. With more severe or enduring depressive disorders both psychological therapy and medication can be offered together.
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