Cognitive Therapy for Mood Disorders: Analysis

Cognitive Therapy for Mood Disorders AnalysisCognitive therapy is a highly hard-hitting discourse for mood roughnesss. Discuss.As Karasu noted in 1982, in that respect has historically been a polarization of the field of sermon of all psychological conditions on the one hand, there is a camp which touts psychotherapy as the nearly effective and superior form of treatment, and on the other, there ar those who champion the cause of pharmacotherapy as the most effective treatment.1 In Karasus words, this separation between the two disciplines is likely to be symptomatic of the post-Cartesian mind-body dichotomy at the core of modern medicine. Statements some the enduringness of the one or the other, which is often held to be thus the superior of the two, should be viewed through this lens.Before we can address the question of whether or not cognitive therapy is a highly effective treatment for mood disorders, we wishing to be clear about what we mean by cognitive therapy and m ood disorders. Mood disorders are typically taken to cover a range of depressive disorders which include both(prenominal) unipolar first gear and bipolar disorder, and which index range from full-blown major drop-off through to the display of some depressive symptoms.According to Blackburn et al., citing Becks (1967, 1976) cognitive theory of depression, someone who is depressed pass on view themselves as a loser and will interpret all their experiences in terms of their own inadequacies. They will anticipate that their present difficulties will continue indefinitely and, blaming themselves, they will become increasingly self-critical. As well as this negative view of the self, the world and the future, they will also make logical systematic errors, which will lead them to draw erroneous conclusions about their experiences. Such errors superpower include personalization, over-generalization, magnification and minimization. They will also cast dysfunctional basic premises or i diosyncratic schemas, which help them to sieve, categorize and practice upon information that they receive from their experiences of the world around them..2The aim of cognitive therapy is to change these negative schemas through the use of a variety of cognitive and doingsal techniques. The go on is problem-oriented and time-limited, typically lasting about 12 weeks.1 The most frequently reported forms of cognitive therapy in the literature are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). separate techniques include psychoeducation, psychodynamic focal therapies and mindfulness-based cognitive therapy (MBCT). Throughout this paper, the terms cognitive therapy and psychotherapy are used interchangeably.Among these diametrical cognitive therapy techniques, CBT is the one most often considered in the literature, and it is widely reported to be effective, and how do we decide if something is highly effective or not? To decide how effective a treatment is, we need to consider the unattached take the stand. What follows is not a full and systematic review of the literature, which is beyond the scope of this paper, but rather, a look at some of the available evidence to date on the subject and an outline of the key issues. In it, I propose that the evidence for the effectiveness of cognitive therapy as a treatment for depression is not unequivocal and that a to a greater extent integrated approach would be more beneficial.Writing in 1981, Blackburn et al. cite a study by Rush et al. (1977), which was one of the prior studies comparing cognitive therapy and pharmacotherapy, and which showed that cognitive therapy was superior to the drug imipramine in outpatients with unipolar depression in both train of response and rate of premature treatment termination.2 They attempted to replicate that study, but comparing a range of drugs with cognitive therapy, rather than just imipramine, and they also time-tested a crew of both cognitive t herapy and pharmacotherapy. They plunge cognitive therapy to be only minimally more effective than the drugs in a group of lightly to moderately depressed hospital outpatients, but significantly more so than drugs alone in general practice, both alone and in combination with drugs. In both groups, using a combination of cognitive therapy and pharmacotherapy produced the greatest effect of all.1 However, as the researchers do note, they used no objective method to assess patients compliancy with the pharmacotherapy regimen.2In their study of cognitive behaviour therapy (CBT) and assertion training (AT) groups for patients with depression and comorbid personality disorders, addict et al. gear up CBT alone to produce a significant proceeds in all the outcomes measured, including at follow-up.3 However, the group that received a combination of CBT and AT showed only minimal improvement on the amicable competence and misgiving measures4, and only two of the four measures that wer e significant immediately after the treatment were still significant at follow-up.5 In short, the presence of a comorbid personality disorder appeared to impede the response to CBT and AT and the outcomes at follow-up.6 Since depressed patients have high rates of comorbid personality disorders7, these results have significant implications for the use of cognitive therapy in combination with other forms of non-pharmacotherapy for the treatment of depression.The use of a much briefer CBT protocol in this study (15 hours over five weeks), which as Ball et al. note is about one-half that in most studies in the CBT outcomes literature, should be noted. If briefer protocols like this can produce appreciable long-term improvements in the prognosis of depression, then this is likely to be more cost-effective than the longer protocols typically employed.8 However, since the study was uncontrolled, there may well be other explanations for the results. Clearly more studies, particularly rand omised controlled trials (RCTs), of cognitive therapy in this under-researched group are needed.In their recent review of psychotherapy and pharmacotherapy treatments for mood and anxiety disorders, Otto et al. noted that in terms of acute outcomes, both CBT and pharmacological treatments have repeatedly been shown to be efficacious and in most cases to offer an approximately equal effect, though there are some suggestions that CBT is more tolerable and oddly more cost-effective.1 CBT has, however, consistently shown a strong relapse-prevention effect, in direct contrast to pharmacotherapy, which often requires ongoing treatment to prevent relapse.2It has been suggested that pharmacotherapy and cognitive therapy have derivative effects, the fountain on symptom formation and affective distress, and the latter on interpersonal relations and social adjustment, each activated and sustained on a different time schedule, the pharmacological treatments sooner and over a shorter duration and the psycho remedial treatments later and over a longer duration.3 on that point is some evidence that CBT and pharmacotherapy may produce similar limbic and cortical changes in the brain, but also that they target different primary sites.4 There is, moreover, some evidence of complementary modes of natural action among patients who fail on one form of treatment but gain benefit from the other.5 Such complementarity favours a more integrated approach to the treatment of depression that combines the beneficial effects of both pharmacotherapy and cognitive therapy, but is there any evidence that such an approach does indeed work?In their 1986 review of the evidence for the effectiveness of combined psychotherapy and pharmacotherapy for the treatment of depression, Conte et al. found a combination of the two approaches to be more effective than either of the treatments alone, though the apparently elongate effect was not a strong one. Conte et al. highlight a number of potential explanations for the observed effect, including the high drop-out rates in the studies they considered, making generalization difficult, the differential response to pharmacotherapy or psychotherapy dependent on whether the diagnosis was endogenous or situational, questions about whether it is either ethical or even practically possible to have a placebo in psychotherapy trials, and the low power of their own boilers suit approach to their review.1 Conte et al. also suggest that whilst their results might support the additive model, they might also be explained if some patients benefit more from one treatment and some more from the other.2 The non-standard nature of diagnoses, therapies, training and experience of therapists also makes comparisons and generalizations difficult, if not impossible.3,4In 1997, Thase et al. suggested that their mega-analysis comparing psychotherapy with psychotherapy-pharmacotherapy combinations provided evidence of the superiority of a combination of psychotherapy and pharmacotherapy over psychotherapy alone for the more severely-depressed outpatients, both in terms of overall recovery rates and a shorter time to recovery.5 However, none of the patients older than 60 received psychotherapy and none with non-recurrent depression were in the combination group.6 The less seriously depressed patients treated with interpersonal therapy (IPT) or CBT alone achieved results comparable to those in the combination group.7 As it is, this evidence for the effectiveness of a combined approach is ambiguous.There are further problems with this study, though. Comorbid patients were excluded8 and as has been noted earlier, comorbidity is typically associated with poorer outcomes and a disproportionately large number of the patients had recurrent depression, so if the combination of psychotherapy and pharmacotherapy is more effective in this sub-group, this will lend a skew to the picture suggesting effectiveness in all severely-depressed pati ents.9Finally, inasmuch as this is a mega-analysis, the non-standard nature of diagnoses, therapies, training and experience of therapists highlighted earlier makes generalizations very difficult, a problem noted by the authors of this study also.1In their 2004 review, Pampallona et al. concluded that a combination of pharmacotherapy and psychotherapy produced a greater improvement in depression scores than pharmacotherapy alone.2 Pampallona et al. note that the addition of psychotherapy does appear to reduce the degree of non-response and increase adherence, but they question whether this is because psychotherapy has a genuine therapeutic effect or whether it is merely enhancing compliance with the pharmacological regimen, and suggest further studies with an improved range of outcome measures, including patient satisfaction, well-being and social functioning.3In their 2005 review, however, Otto et al. found that acute outcome studies with depressed outpatients provided only limited support for the theory that a combination of pharmacotherapy and psychotherapy is more efficacious than either approach alone. They did align higher rates of treatment response, but the differences were small and not statistically significant.4 Adding psychotherapy to the acute phase of a pharmacological treatment regimen was found to offer a comparable efficacy to a long-term pharmacological regimen in helping to prevent more than one relapse.5 Otto et al. did find that adding CBT to a pharmacological course of treatment improved medication adherence, reduced the impact of psychosocial stressors such as negative life events and anxiety comorbidity, prevented or limited the grimness of prodromal episodes, and directly improved outcomes in bipolar disorder.6The evidence, then, for the effectiveness of cognitive therapy as a treatment for depression is not unequivocal. It does appear to improve outcomes, but it is unclear whether to a greater or approximately equivalent extent to p harmacological approaches to treatment. Whilst the evidence for adopting a combined approach is also not clear-cut, since the commodious majority of people with depression experience multiple episodes over their lifetime, and are especially prone to relapses shortly after their first episode1, and in light of both the possibly complementary mode of action of cognitive therapy and pharmacotherapy and the possibly harmful effects of long-term anti-depressant use, a more effective long-term strategy might involve the integration of both approaches. This might involve a drugs-based regimen in the earlier stages of depression, to treat symptoms and affective distress, and cognitive therapy throughout, to treat the interpersonal and social dimensions of depression, enhance compliance to the drugs-based regimen and treat and prevent relapses.Vos et al. modeled the impact of adopting a longer-term maintenance strategy on the burden of major depression, and suggested that this could avert h alf the depression occurring in the five years after an episode.2 A combined strategy would appear therefore to show some promise in reducing the quite significant disease burden placed by depression on society and improving the lives of those who suffer from it. Further robust controlled trials are clearly needed to assess the effectiveness of cognitive therapy, both alone and in combination with pharmacotherapy, as a part of an integrated long-term strategy.ReferencesBall, J., Kearney, B., Wilhelm, K., Dewhurst-Savellis, J. Barton, B. (2000) Cognitive behaviour therapy and assertion training groups for patients with depression and comorbid personality disorders, Behavioural and Cognitive Psychotherapy 28, 1, 71-85Blackburn, I. M., Bishop, S., Glen, A. I. M., Whalley, L. J. Christie, J. E. (1981) The Efficacy of Cognitive Therapy in slack A Treatment Trial utilize Cognitive Therapy and Pharmacotherapy, each Alone and in Combination, Brit J Psychiatry 139, 181-189Conte, H., Pl utchik, R., Wild, K. V. Karasu, T. (1986) have Psychotherapy and Pharmacotherapy for Depression A taxonomic Analysis of the severalize, revolting Gen Psychiatry 43, 471-479Karasu, T. (1982) Psychotherapy and Pharmacotherapy Toward an Integrative Model, Am J Psychiatry 139, 9, 1102-1113Klein, D. F. (2000) Flawed Meta-Analyses Comparing Psychotherapy with Pharmacotherapy, Am J Psychiatr 157, 1204-1211Otto, M. W., Smits, J. A. J. Reese, H. E. (2005) Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults Review and analysis, Clinical Psychology Science and Practice 12, 1, 72-86Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B. Munizza, C. (2004) Combined Pharmacotherapy and Psychological Treatment for Depression A Systematic Review, Arch Gen Psychiatry 61, 7, 714-719Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. F., Pilkonis, P., Hurley, K., Grochocinski, V. Kupfer, D. J. (1997) Treatment of major Depression With Psychotherapy or Psych otherapy-Pharmacotherapy Combinations, Arch Gen Psychiatry 54, 1009-1015Vos, T., Haby, M., Barendregt, J. J., Kruijshaar, M., Corry, J. Andrews, G. (2004) The Burden of major Depression Avoidable by Longer-term Treatment Strategies, Arch Gen Psychiatry 61, 11, 1097-11031Footnotes1 Karasu, T. (1982) Psychotherapy and Pharmacotherapy Toward an Integrative Model, Am J Psychiatry 139, 9, 11022 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, Brit J Psychiatry 139, 1811 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, Brit J Psychiatry 139, 1812 Blackburn et al., 1821 Blackburn, I. M., Bishop, S., Glen, A. I. M., Whalley, L. J. Christi e, J. E. (1981) The Efficacy of Cognitive Therapy in Depression A Treatment Trial Using Cognitive Therapy and Pharmacotherapy, each Alone and in Combination, Brit J Psychiatry 139, 1882 Blackburn et al., 1883 Ball, J., Kearney, B., Wilhelm, K., Dewhurst-Savellis, J. Barton, B. (2000) Cognitive behaviour therapy and assertion training groups for patients with depression and comorbid personality disorders, Behavioural and Cognitive Psychotherapy 28, 1, 774 Ball et al., 805 Ball et al., 816 Ball et al., 827 Ball et al., 738 Ball et al., 81,821 Otto, M. W., Smits, J. A. J. Reese, H. E. (2005) Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults Review and analysis, Clinical Psychology Science and Practice 12, 1, 732 Otto et al., 733 Karasu, T. (1982) Psychotherapy and Pharmacotherapy Toward an Integrative Model, Am J Psychiatry 139, 9, 11114 Otto et al., 745 Otto et al., 74-751 Conte, H., Plutchik, R., Wild, K. V. Karasu, T. (1986) Combined Psychotherap y and Pharmacotherapy for Depression A Systematic Analysis of the Evidence, Arch Gen Psychiatry 43, 477-4782 Conte et al., 4783 Conte et al., 4784 Klein, D. F. (2000) Flawed Meta-Analyses Comparing Psychotherapy with Pharmacotherapy, Am J Psychiatr 157, 12045 Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. F., Pilkonis, P., Hurley, K., Grochocinski, V. Kupfer, D. J. (1997) Treatment of Major Depression With Psychotherapy or Psychotherapy-Pharmacotherapy Combinations, Arch Gen Psychiatry 54, 1012-10136 Thase et al., 1012-10137 Thase et al., 10138 Thase et al., 10149 Thase et al., 10141 Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. F., Pilkonis, P., Hurley, K., Grochocinski, V. Kupfer, D. J. (1997) Treatment of Major Depression With Psychotherapy or Psychotherapy-Pharmacotherapy Combinations, Arch Gen Psychiatry 54, 10142 Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B. Munizza, C. (2004) Combined Pharmacotherapy and Psychological Treatment for Depression A Systematic Review, Arch Gen Psychiatry 61, 7, 7183 Pampallona et al., 7184 Otto, M. W., Smits, J. A. J. Reese, H. E. (2005) Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults Review and analysis, Clinical Psychology Science and Practice 12, 1, 735 Otto et al., 756 Otto et al., 761 Vos, T., Haby, M., Barendregt, J. J., Kruijshaar, M., Corry, J. Andrews, G. (2004) The Burden of Major Depression Avoidable by Longer-term Treatment Strategies, Arch Gen Psychiatry 61, 11, 11022 Vos et al., 1101-1102