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Cognitive Behavioral Therapy (4 Hours/Units)

© 2009 by Aspira Continuing Education. All rights reserved. No part of this material

may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.

Course Objectives:

This course is designed to help you:

1. Identify Cognitive Behavioral Therapy Fundamental concepts 2. Explore the history and development of CBT 3. Apply CBT assessment strategies 4. Identify and utilize CBT clinical approaches 5. Apply CBT principles and therapeutic techniques 6. Utilize CBT tools and interventions 7. Access CBT resources

Table of Contents:

1. Definition 2. History 3. Cognitive-Behavioral Assessment 4. Approaches 5. Applications 6. Cognitive Behavioral Therapies 7. Tools and Interventions

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8. Risk Factors 9. Resources 10. References

1. Definition

Cognitive behavioral therapy (or cognitive behavior therapy, CBT) is a psychotherapeutic approach that is designed to influence dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure. CBT can be seen as an umbrella term for therapies that share a theoretical basis in behavioristic learning theory and cognitive psychology, and that use methods of change derived from these theories (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

In the cognitive behavioral approach, emphasis is placed on expressing concepts in operational terms and on the empirical validation of treatment, using both group and single case experimental designs in research settings and in everyday clinical practice. CBT treatments have received empirical support for efficient treatment of a variety of clinical and non-clinical problems, including mood disorders, anxiety disorders, personality disorders, eating disorders, substance abuse disorders, and psychotic disorders. It is often brief and time-limited. It is used in individual therapy as well as group settings, and the techniques are also commonly adapted for self-help applications. Some CBT therapies are more oriented towards predominately cognitive interventions while some are more behaviorally oriented. In recent years cognitive behavioral approaches have become prevalent in correctional settings. These programs are designed to teach

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criminal offenders cognitive skills that will reduce criminal behaviors. It has become commonplace, if not pervasive, to find cognitive behavioral program strategies in use in prisons and jails in many countries. In cognitive oriented therapies, the objective is typically to identify and monitor thoughts, assumptions, beliefs and behaviors that are related and accompanied to debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace or transcend them with more realistic and useful ones (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4)

CBT was primarily developed through a merging of behavior therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the "here and now" and symptom removal. Many CBT treatment programs for specific disorders have been developed and evaluated for efficacy and effectiveness; the health-care trend of evidence-based treatment, where specific treatments for specific symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments. In the United Kingdom, the National Institute for Health and Clinical Excellence recommends CBT as the treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

2. History

The infancy of CBT can be traced back to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behavior therapeutical approaches appeared as early as 1924, with Mary Cover Jones' work on the unlearning of fears in children. However, it was during the period 1950 to 1970 that the field really emerged, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull. In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization, the precursor to today's fear reduction techniques. British psychologist Hans Eysenck, inspired by the writings of Karl Popper, criticized psychoanalysis in arguing that "if you get

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rid of the symptoms, you get rid of the neurosis", and presented behavior therapy as a constructive alternative. In the United States, psychologists were applying the radical behaviorism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior and autism (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

Although the early behavioral approaches were successful in many of the neurotic disorders, it had little success in treating depression. Behaviorism was also losing in popularity due to the so-called "cognitive revolution". The therapeutic approaches of Aaron T. Beck and Albert Ellis gained popularity among behavior therapists, despite the earlier behaviorist rejection of "mentalistic" concepts like thoughts and cognitions. Both these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Ellis' system, originated in the early and mid 1950s, was first called rational therapy, and can arguably be called one of the first forms of cognitive behavioral therapy. It was partly founded as a reaction against popular psychotherapeutic theories at the time, mainly psychoanalysis. Aaron T. Beck, inspired by Ellis, developed cognitive therapy, in the 1960s (Ellis, Albert, 1975. A New Guide to Rational Living. Prentice Hall. ISBN 0-13-370650-8).

Concurrently with the contributions of Ellis and Beck, starting in the late 1950s and continuing through the 1970s, Arnold A. Lazarus developed what was arguably the first form of broad-spectrum cognitive behavioral therapy. He later broadened the focus of behavioral treatment to incorporate cognitive aspects. When it became clear that optimizing therapy's effectiveness and effecting durable treatment outcomes often required transcending more narrowly focused cognitive and behavioral methods, Arnold Lazarus expanded the scope of CBT to include physical sensations (as distinct from emotional states), visual images (as distinct from language-based thinking), interpersonal relationships, and biological factors (Arnold Allan Lazarus, The Encyclopedia of Psychology).

Cognitive therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive behavioral therapy. Pivotal in this merging was the successful developments of treatments of panic disorder by David M. Clark in the UK and David H. Barlow in the US.

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Samuel Yochelson and Stanton Samenow pioneered that idea that cognitive behavioral approaches can be used successfully with a criminal population. They are the authors of, Criminal Personality Vol.I. This book has an extensive amount of information regarding the dynamics of criminal thinking and application of cognitive behavioral approaches (Samenow, Yochelson, Criminal Personality Vol.I.)

Albert Ellis

Born September 27, 1913 Pittsburgh

Died July 24, 2007

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New York Residence United States Nationality American

Fields Clinical Psychology, Philosophy & Psychotherapy

Known for Formulating and developing Rational Emotive Behavior Therapy, Cognitive Behavioral Therapy

Notable awards

2003 award from the Association for Rational Emotive Behavior Therapy (UK), Association for Behavioral and Cognitive Therapies 2005 Lifetime Achievement Award, Association for Behavioral and Cognitive Therapies 1996 Outstanding Clinician Award, American Psychological Association 1985 award for Distinguished professional contributions to Applied Research, American Humanist Association 1971 award for "Humanist of the Year", New York State Psychological Association 2006 Lifetime Distinguished Service Award, American Counseling Association 1988 ACA Professional Development Award, National Association of Cognitive-Behavioral Therapists' Outstanding Contributions to CBT Award

Religious stance Nontheistic humanism

Albert Ellis (September 27, 1913 – July 24, 2007) was an American psychologist who in 1955 developed Rational Emotive Behavior Therapy. He held M.A. and Ph.D. degrees in clinical psychology from Columbia University and founded and was the president and president emeritus of the New York City-based Albert Ellis Institute. He is generally considered to be one of the originators of the cognitive revolutionary paradigm shift in psychotherapy and the founder of cognitive-behavioral therapies. Based on a

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1982 professional survey of U.S. and Canadian psychologists, he was considered as the second most influential psychotherapist in history. Carl Rogers ranked first in the survey and Sigmund Freud was ranked third.

Aaron Beck

Aaron Temkin Beck (born July 18, 1921) is an American psychiatrist and a professor emeritus at the department of psychiatry at the University of Pennsylvania. Beck is known as the father of cognitive therapy and inventor of the widely used Beck Scales, including the Beck Depression Inventory (BDI), Beck Hopelessness Scale, Beck Scale for Suicidal Ideation (BSS), Beck Anxiety Inventory (BAI) and Beck Youth Inventories. He is the President of the Beck Institute for Cognitive Therapy and Research and the Honorary President of the Academy of Cognitive Therapy, which certifies qualified Cognitive Therapists. Aaron Beck was born in Providence, Rhode Island, the youngest child of his three siblings. Beck’s parents were Jewish immigrants from Russia. Beck's daughter, Judith Beck, is also well recognized in cognitive therapy. Beck attended Brown University, graduating magna cum laude in 1942. At Brown he was elected a member of the Phi Beta Kappa Society, was an associate editor of the Brown Daily Herald, and received the Francis Wayland Scholarship, William Gaston Prize for Excellence in Oratory, and Philo Sherman Bennett Essay Award. Beck attended Yale Medical School, graduating with an M.D. in 1946.

Beck believes that depression is due to negative idiosyncratic views towards the self, world, and the future. For example, according to Beck, depressed people may say things such as "I can't do my job" or "Nobody cares about me." These negative views are personalized and in turn trigger depression. Beck is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, which led to his creation of Cognitive Therapy, for which he received the 2006 Lasker Foundation Clinical Research Award, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. Beck is also known for his creation of the Beck Hopelessness Scale and the Beck Anxiety Inventory, and

Dr. Beck is an emeritus professor in the Department of Psychiatry at the University of Pennsylvania and the director of the Psychopathology Research Unit (PRU), which is the parent organization of the Center for the Treatment and Prevention of Suicide (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

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has founded the Beck Institute in Philadelphia, Pennsylvania, in which his daughter, Dr. Judith Beck, works. Beck asserts that depression is developed due to unrealistic negative views about the world. Depressed people have a negative cognition in three areas that are placed into the depressive triad. They develop negative views about: themselves, the world, and their future. Beck starts treatment by engaging in conversation with clients about their negative thoughts. Cognitive therapy has also been applied with success to individuals with anxiety disorders, schizophrenia, and many other disorders. In recent years, cognitive therapy has been disseminated outside academic settings, including throughout the United Kingdom, and in a program developed by Dr. Beck and the City of Philadelphia (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998).

3. Cognitive Behavioral Assessment

Certain principals drive the foundations of cognitive behavioral assessment. The central principle of cognitive behavioral assessment is that an individual’s behaviors are driven by immediate situations and the individual’s interpretation of them. The characteristics of the therapist are also believed to be important because the client needs to feel safe to disclose important and often distressing information (Beck, 1991). This will be facilitated if there is a warm and trusting atmosphere and the therapist is empathic (Beck, 1991).

Goals of Cognitive Behavioral Assessment

Cognitive Behavioral Formulation of Problems (Beck, 1991): The first few sessions are used to devise an initial hypothesis and treatment plan. The hypothesis (formulation) is tested in subsequent homework and treatment sessions and modified if necessary. Although most of the assessment occurs during the initial sessions, the assessment process continues throughout treatment (Beck, 1991).

Educating the client about the cognitive behavioral approach (Beck, 1991): The therapist should educate the client that the CBT approach is largely self –help and that the therapist aims to help the client develop skills to overcome current problems as well as similar ones in the future. The therapist should emphasize the important role of homework assignments and

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communicate that therapy occurs in everyday life, with the client applying what has been discussed in sessions(Beck, 1991).

Initiating the therapeutic process (Beck, 1991): The therapist helps to identify and differentiate between problems so the challenges are reduced to manageable goals and the client sees that change is possible (Beck, 1991).

Modes of Assessment

Measurement (Beck, 1991): Measurements during and between treatment sessions allow the client and therapist to modify treatment if needed. It can also have therapeutic effects by providing the client with information about progress. Regular measurements also ensure that the therapist and patient remain focused on treatment goals (Beck, 1991).

Behavioral interviewing (Beck, 1991): Historical information is only collected if it is directly relevant to the development of the presenting problem. There may or may not be a clear onset for the problem. For many clients, the problem develops gradually with a succession of events contributing to the client’s recognition that there is a problem. As a first step, it is advantageous to ask the client for a detailed description of a recent example of the problem (Beck, 1991).

Self-monitoring (Beck, 1991): The introduction of self-monitoring at the beginning of treatment emphasizes the self-help, collaborative nature of treatment. Only relevant and meaningful information should be requested of the client to prevent overwhelm. The measurement procedure should be relevant to the question asked. It is difficult to achieve reliable measurement of vague concepts such as “self confidence” (Beck, 1991).

Self-report questionnaires (Beck, 1991): It is most advantageous to use questionnaires which have demonstrable psychometric soundness (Beck, 1991).

Direct observation of behavior (Beck, 1991): Direct observation of behavior cannot be underestimated. Observation of naturally occurring behaviors is invaluable (Beck, 1991).

4. Approaches

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CBT includes a variety of approaches and therapeutic systems. Some of the most well known approaches include cognitive therapy, rational emotive behavior therapy and multimodal therapy. Defining the scope of what constitutes a cognitive–behavioral therapy is a difficulty that has persisted throughout its development. Psychologists Keith Dobson and David Dozois, who have faculty positions in Canadian Universities, define cognitive–behavioral therapies as “sharing the theoretical assumption that behavioral change is mediated by cognitive events”.

Therapeutic techniques vary among CBT approaches according to the types of issues. However, CBT techniques commonly include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly used. Cognitive behavioral therapy is often also used in combination with mood stabilizing medications to treat a variety of disorders including mood disorders. Also, its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines within the British NHS. Cognitive behavioral therapy generally is not an overnight process for clients. Even after clients have learned to recognize when and where their mental processes go awry, it can in some case take considerable time of effort to replace a dysfunctional cognitive-affective-behavioral process or habit with a more reasonable and adaptive one. Cognitive behavioral group therapy is a group therapy approach, developed by Richard Heimberg for the treatment of social phobia (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

CMHS Consumer Affairs E-News November 27, Vol. 07-187

Internet-Based PTSD Therapy May Help Overcome Barriers to Care

NIMH-funded researchers recently completed a pilot study showing that an Internet-based, self-managed cognitive behavioral therapy (CBT) can help reduce symptoms of post-traumatic stress disorder (PTSD) and depression, with effects that last after treatment has ended. This study supports further development of PTSD therapies that focus on self-management and

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innovative methods of providing care to large numbers of people who do not have access to mental health care or who may be reluctant to seek care due to stigma. The researchers published their study in the November 2007 issue of the American Journal of Psychiatry.

Brett Litz, Ph.D., of the National Center for PTSD at the VA Boston Healthcare System and Boston University, and colleagues recruited service members from the Department of Defense who had developed PTSD following the September 11, 2001, attack on the Pentagon or from recent combat exposure. Forty-five participants first met with a therapist to determine their baseline PTSD and depression symptoms, and then were randomly assigned to one of two 8-week long, therapist-assisted, Internet-based treatments.

One treatment used strategies from CBT, which previous research has shown to be effective in relieving symptoms of PTSD. This CBT-based therapy aimed to first help participants identify situations that triggered their PTSD symptoms by working with a therapist and then improve their ability to manage those symptoms through on-line homework assignments. The other therapy, called supportive counseling, asked participants to monitor their own current, non-trauma-related problems, and then write about those experiences online. These participants also received periodic phone calls or emails from their therapist, who provided supportive but non-directed counseling. Participants in both groups were asked to log on daily to a Web site specific to their assigned treatment. After rating their PTSD and depression symptoms using a checklist, participants were allowed access to the Web site where they could find information about PTSD, stress, trauma, and other related health topics; communicate with their therapist; or complete treatment-specific activities.

After eight weeks of treatment, participants in both groups had fewer or less severe PTSD and depression symptoms, but those in CBT-based therapy showed greater improvements than those in supportive counseling therapy. Six months after their first meeting with a study therapist, participants who received CBT-based therapy showed continued improvements, while those in the supportive therapy group experienced an increase in PTSD and depression symptoms.

These findings suggest the CBT-based online therapy may be an efficient, effective, and low-cost method of providing PTSD treatment following a

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traumatic event to a large number of people. The researchers noted that fewer people completed the CBT-based therapy than the supportive counseling therapy. However, regardless of therapy group, the discontinuation rate among study participants was similar to the 30 percent discontinuation rate reported in studies of face-to-face treatment. Further study is needed to improve treatment use and completion and to test Internet-based PTSD therapies in a larger study population.

Litz BT, Engel CC, Bryant R, Papa A. A Randomized Controlled Proof-of-Concept Trial of an Internet-Based, Therapist-Assisted Self-Management Treatment for Posttraumatic Stress Disorder. Am J Psychiatry. 2007 Nov;164(11):1676-84.

Overview of Treatment

Introduction to Range of Treatments

Mental disorders are treatable, contrary to what many think.12 An armamentarium of efficacious treatments is available to ameliorate symptoms. In fact, for most mental disorders, there is generally not just one but a range of treatments of proven efficacy. Most treatments fall under two general categories, psychosocial and pharmacological.13 Moreover, the combination of the two—known as multimodal therapy—can sometimes be even more effective than each individually.

The evidence for treatment being more effective than placebo is overwhelming, as documented in the main chapters of this report (Chapters 3 through 5). The degree of effectiveness tends to vary, depending on the disorder and the target population (e.g., older adults with depression). What is optimal for one disorder and/or age group may not be optimal for another. Further, treatments generally need to be tailored to the client and to client preferences.

The inescapable point is that studies demonstrate conclusively that treatment is more effective than placebo. Placebo (an inactive form of treatment) in both pharmacological and psychotherapy studies has a powerful effect in its own right, as this section later explains. Placebo is more effective than no treatment. Therefore, to capitalize on the placebo response, people are encouraged to seek treatment, even if the treatment is not as optimal as that described in this report.

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If treatment is so effective, then why are so few people receiving it? Studies reveal that less than one-third of adults with a diagnosable mental disorder, and even a smaller proportion of children, receive any mental health services in a given year. This section of the chapter strives to explain why by examining the types of barriers that prevent people from seeking help. But the chapter first covers some general points about psychological and pharmacological therapies. It also discusses why therapies that work so well in research settings do not work as well in practice.

Psychotherapy

Psychotherapy is a learning process in which mental health professionals seek to help individuals who have mental disorders and mental health problems. It is a process that is accomplished largely by the exchange of verbal communication, hence it often is referred to as“talk therapy.” Many of the theories undergirding each orientation to psychotherapy were summarized earlier in this chapter.

Participants in psychotherapy can vary in age from the very young to the very old, and problems can vary from mental health problems to disabling and catastrophic mental disorders. Although people often are seen individually, psychotherapy also can be done with couples, families, and groups. In each case, participants present their problems and then work with the psychotherapist to develop a more effective means of understanding and handling their problems. This report focuses on individual psychotherapy and also mentions couples therapy and various forms of family interventions, particularly psycho-educational approaches. Although not discussed in the report, group psychotherapy is effective for selected individuals with some mood disorders, anxiety disorders, schizophrenia, personality disorders, and for mental health problems seen in somatic illness (Yalom, 1995; Kanas, in press).

Estimates of the number of orientations to psychotherapy vary from a very small number to well over 400. The larger estimate generally refers to all the variations of the three major orientations, that is, psychodynamic, behavioral, and humanistic. Each orientation falls under the more general conceptual category of either action or reflection.

Psychodynamic orientations are the oldest. They place a premium on self-understanding, with the implicit (or sometimes explicit) assumption that

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increased self-understanding will produce salutary changes in the participant. Behavioral orientations are geared toward action, with a clear attempt to mobilize the resources of the patient in the direction of change, whether or not there is any understanding of the etiology of the problem. Humanistic orientations aim toward increased self-understanding, often in the direction of personal growth, but use treatment techniques that often are much more active than are likely to be employed by the psychodynamic clinician.

While the following paragraphs focus on psychodynamic, behavioral, and humanistic orientations, they also discuss interpersonal therapy and cognitive-behavioral therapy as outgrowths of psychodynamic and behavioral therapy, respectively. Psychodynamic, interpersonal, and cognitive-behavioral therapy are most commonly the focus of treatment research reported throughout this report.

Psychodynamic Therapy

The first major approach to psychotherapy was developed by Sigmund Freud and is called psychoanalysis (Horowitz, 1988). Since its origin more than a century ago, psychoanalysis has undergone many changes. Today, Freudian (or classical) psychoanalysis is still practiced, but other variations have been developed—ego psychology, object relations theory, interpersonal psychology, and self-psychology, each of which can be grouped under the general term“psychodynamic” (Horowitz, 1988). The psychodynamic therapies, even though they differ somewhat in theory and approach, all have some concepts in common. With each, the role of the past in shaping the present is emphasized, so it is important, in understanding behavior, to understand its origins and how people come to act and feel as they do. A second critical concept common to all psychodynamic approaches is the belief in the unconscious, so that there is much that influences our behavior of which we are not aware. This makes the process of understanding more difficult, as we often act for reasons that we cannot state, and these reasons often are linked to previous experiences. Thus, an important part of psychodynamic psychotherapy is to make the unconscious conscious or to help the patient understand the origin of actions that are troubling so that they can be corrected.

For some psychodynamic approaches, such as the classical Freudian approach, the focus is on the individual and the experiences the person had

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in the early years that give shape to current behavior, even beyond the awareness of the patient. For other, more contemporary approaches, such as interpersonal therapy, the focus is on the relationship between the person and others. First developed as a time-limited treatment for midlife depression, interpersonal therapy focuses on grief, role disputes, role transitions, and interpersonal deficits (Klerman et al., 1984). The goal of interpersonal therapy is to improve current interpersonal skills. The therapist takes an active role in teaching patients to evaluate their interactions with others and to become aware of self-isolation and interpersonal difficulties. The therapist also offers advice and helps the patient to make decisions.

Behavior Therapy

A second major approach to psychotherapy is known as behavior modification or behavior therapy (Kazdin, 1996, 1997). It focuses on current behavior rather than on early patterns of the patient. In its earlier form, behavior therapy dealt exclusively with what people did rather than what they thought or felt. The general principles of learning were applied to the learning of maladaptive as well as adaptive behaviors. Thus, if a person could be conditioned to act in a functional way, there was no reason why the same principles of conditioning could not be employed to help the person unlearn dysfunctional behavior and learn to replace it with more functional behavior. The role of the environment was very important for behavior therapists, because it provided the positive and negative reinforcements that sustained or eliminated various behaviors. Therefore, ways of shaping that environment to make it more responsive to the needs of the individual were important in behavior therapy.

More recently, there has been a significant addition to the interests and activities of behavior therapists. Although behavior continued to be important in relation to reinforcements, cognitions—what the person thought about, perceived, or interpreted what was transpiring—were also seen as important. This combined emphasis led to a therapeutic variant known as cognitive-behavioral therapy, an approach that incorporates cognition with behavior in understanding and altering the problems that patients present (Kazdin, 1996).

Cognitive-behavioral therapy draws on behaviorism as well as cognitive psychology, a field devoted to the scientific study of mental processes, such as perceiving, remembering, reasoning, decision making, and problem

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solving. The use of cognition in cognitive-behavioral therapy varies from attending to the role of the environment in providing a model for behavior, to the close study of irrational beliefs, to the importance of individual thought processes in constructing a vision of the surrounding world. In each case, it is critical to study what the individual in therapy thinks and does and less important to understand the past events that led to that pattern of thinking and doing. Cognitive-behavioral therapy strives to alter faulty cognitions and replace them with thoughts and self-statements that promote adaptive behavior (Beck et al., 1979). For instance, cognitive-behavioral therapy tries to replace self-defeatist expectations (“I can’t do anything right”) with positive expectations (“I can do this right”). Cognitive-behavioral therapy has gained such ascendancy as a means of integrating cognitive and behavioral views of human functioning that the field is more frequently referred to as cognitive-behavioral therapy rather than behavior therapy (Kazdin, 1996).

Humanistic Therapy

The third wave of psychotherapy is referred to variously as humanistic (Rogers, 1961), existential (Yalom, 1980), experiential, or Gestalt therapy. It owes its origins as a treatment to the client-centered therapy that was originated by Carl Rogers, and the theory can be traced to philosophical roots beginning with the 19th century philosopher, Soren Kierkegaard. The central focus of humanistic therapy is the immediate experience of the client. The emphasis is on the present and the potential for future development rather than on the past, and on immediate feelings rather than on thoughts or behaviors. It is rooted in the everyday subjective experience of the person seeking assistance and is much less concerned with mental illness than it is with human growth.

One critical aspect of humanistic treatment is the relationship that is forged between the therapist, who in some ways serves as a guide in an exploration of self-discovery, and the client, who is seeking greater knowledge of the self and an expansion of inherent human potential. The focus on the self and the search for self-awareness is akin to psychodynamic psychotherapy, while the emphasis on the present is more similar to behavior therapy.

Although it is possible to describe distinctive orientations to psychotherapy, as has been done above, most psychotherapists describe themselves as eclectic in their practice, rather than as adherents to any single approach to

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treatment. As a result, there is a growing development referred to as“psychotherapy integration” (Wolfe & Goldfried, 1988). It strives to capture what is best about each of the individual approaches. Psychotherapy integration includes various attempts to look beyond the confines of any single orientation but rather to see what can be learned from other perspectives. It is characterized by an openness to various ways of integrating diverse theories and techniques. Psychotherapy also should be modified to be culturally sensitive to the needs of racial and ethnic minorities (Acosta et al., 1982; Sue et al., 1994; Lopez, in press).

The scientific evidence on efficacy presented in this report, however, is focused primarily on specific, standardized forms of psychotherapy.

Pharmacological Therapies

The past decade has seen an outpouring of new drugs introduced for the treatment of mental disorders (Nemeroff, 1998). New medications for the treatment of depression and schizophrenia are among the achievements stoked by research advances in both neuroscience and molecular biology. Through the process known as rational drug design, researchers have become increasingly sophisticated at designing drugs by manipulating their chemical structures. Their goal is to create more effective therapeutic agents, with fewer side effects, exquisitely targeted to correct the biochemical alterations that accompany mental disorders.

The process was not always so rational. Many of the older pharmacotherapies (drug treatments) that had been introduced by 1960 had been discovered largely by accident. Researchers studying drugs for completely different purposes serendipitously found them to be useful for treating mental disorders (Barondes, 1993). Thanks to their willingness to follow up on unexpected leads, drugs such as chlorpromazine (for psychosis), lithium (for bipolar disorder), and imipramine (for depression) became available. The advent of chlorpromazine in 1952 and other neuroleptic drugs was so revolutionary that it was one of the major historical forces behind the deinstitutionalization movement that is discussed later in this chapter.

The past generation of pharmacotherapies, once shown to be safe and effective, was introduced to the market generally before their mechanism of action was understood. Years of research after their introduction revealed

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how many of them work therapeutically. Knowledge about their actions has had two cardinal consequences: it helped probe the etiology of mental disorders, and it ushered in the next generation of pharmacotherapies that are more selective in their mechanism of action.

Mechanisms of Action

The mechanism of action refers to how a pharmacotherapy interacts with its target in the body to produce therapeutic effects. Pharmacotherapies that act in similar ways are grouped together into broad categories (e.g., stimulants, antidepressants). Within each category are several chemical classes. The individual pharmacotherapies within a chemical class share similar chemical structures. Table 2-9 presents several common categories and classes, along with their indication, that is, their clinical use. Many pharmacotherapies for mental disorders have as their initial action the alteration—either increase or decrease—in the amount of a neurotransmitter. Neurotransmitter levels can be altered by pharmacotherapies in myriad ways: pharmacotherapies can mimic the action of the neurotransmitter in cell-to-cell signaling; they can block the action of the neurotransmitter; or they can alter its synthesis, breakdown (degradation), release, or reuptake, among other possibilities (Cooper et al., 1996).

Neurotransmitters generally are concentrated in separate brain regions and circuits. Within the cells that form a circuit, each neurotransmitter has its own biochemical pathway for synthesis, degradation, and reuptake, as well as its own specialized molecules known as receptors. At the time of neurotransmission, when a traveling signal reaches the tip (terminal) of the presynaptic cell, the neurotransmitter is released from the cell into the synaptic cleft. It migrates across the synaptic cleft in less than a millisecond and then binds to receptors situated on the membrane of the postsynaptic cell. The neurotransmitter’s binding to the receptor alters the shape of the receptor in such a way that the neurotransmitter can either excite the postsynaptic cell, and thereby transmit the signal to this next cell, or inhibit the receptor, and thereby block signal transmission. The neurotransmitter’s action is terminated either by enzymes that degrade it right there, in the synaptic cleft, or by transporter proteins that return unused neurotransmitter back to the presynaptic neuron for reuse, a“recycling” process known as reuptake. The widely prescribed class of antidepressants referred to as the selective serotonin reuptake inhibitors primarily block the action of the

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transporter protein for serotonin, thus leaving more serotonin to remain at the synapse (Schloss & Williams, 1998). Depression is thought to be reflected in decreased serotonin transmission, so one rationale for this class of antidepressants is to boost the level of serotonin (see Chapter 4).

Table 2-9. Selected types of pharmacotherapies

Category and Class Example(s) of Clinical Use

Antipsychotics (neuroleptics) Typical antipsychotics* Atypical antipsychotics**

Schizophrenia, psychosis

Antidepressants Selective serotonin reuptake inhibitors Tricyclic and heterocyclic antidepressants*** Monoamine oxidase inhibitors

Depression, anxiety

Stimulants Attention-deficit/hyperactivity disorder

Antimanic Lithium Anticonvulsants Thyroid supplementation

Mania

Antianxiety (anxiolytics) Benzodiazepines Antidepressants B-Adrenergic-blocking drugs

Anxiety

Cholinesterase inhibitors Alzheimer’s disease

* Also known as first-generation antipsychotics, they include these chemical classes: phenothiazines (e.g., chlorpromazine), butyrophenones (e.g., haloperidol), and thioxanthenes (Dixon et al., 1995). ** Also known as second-generation antipsychotics, they include these chemical classes: dibenzoxazepine (e.g., clozapine), thienobenzodiazepine

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(e.g., olanzapine), and benzisoxazole (e.g., risperidone). *** Include imipramine and amitriptyline.

Source: Perry et al., 1997

Although the effects of reuptake inhibitors on neurotransmitter concentrations in the synapse occur with the first dose, therapeutic benefit typically lags behind by days or weeks. This observation has spurred considerable recent research on chronic and “downstream” actions of psychotropics, particularly antidepressants. For example, in animal models the repeated administration of nearly all antidepressants is associated with a reduction in the number of postsynaptic 12/7/99 receptors, so-called down-regulation that parallels the time course of clinical effect in patients (Schatzberg & Nemeroff, 1998). Some of the secondary effects of reuptake inhibitors may be mediated by the activation of intraneuronal“second messenger” proteins which result from the stimulation of postsynaptic receptors (Schatzberg & Nemeroff, 1998).

Receptors for each transmitter come in numerous varieties. Not only are there several types of receptor for each neurotransmitter, but there may be many subtypes. For serotonin, for example, there are seven types of receptors, designated 5-HT1 –5-HT7

A pharmacotherapy typically interacts with a receptor in either one of two ways—as an agonist or as an antagonist.

, and seven receptor subtypes, totaling 14 separate receptors (Schatzberg & Nemeroff, 1998). The pace at which receptors are identified has become so dizzying that these figures are likely to be obsolete by the time this paragraph is read.

14 When a pharmacotherapy acts as an agonist, it mimics the action of the natural neurotransmitter. When a pharmacotherapy acts as an antagonist, it inhibits, or blocks, the neuro-transmitter’s action, often by binding to the receptor and preventing the natural transmitter from binding there. An antagonist disrupts the action of the neurotransmitter.

The diversity of receptors presents vast opportunities for drug development. Through rational drug design, pharmacotherapies have become increasingly selective in their actions. Generally speaking, the more selective the pharmacotherapy’s action, the more targeted it is to one receptor rather than another, the narrower its spectrum of action, and the fewer the side effects. Conversely, the broader the pharmacotherapy’s action, the less targeted to a

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receptor type or subtype, the broader the effects, and the broader the side effects (Minneman, 1994). However, the interaction among neurotransmitter systems in the brain renders some of the apparent distinctions among medications more apparent than real. Thus, despite differential initial actions on neurotransmitters, both serotonin and norepinephrine reuptake blockers have similar biochemical effects after chronic dosing (Potter et al., 1985).

Complementary and Alternative Treatment

Recent interest in the health benefits of a plethora of natural products has engendered claims related to putative effects on mental health. These have ranged from reports of enhanced memory in people taking the herb, ginseng, to the use of the St. John’s wort flowers as an antidepressant (see Chapter 4).

There are major challenges to evaluating the role of complementary and alternative treatments in maintaining mental health or treating mental disorders. In many cases, preparations are not standardized and consist of a variable mixture of substances, any of which may be the active ingredient(s). Purity, bioavailability, amount and timing of doses, and other factors that are standardized for traditional pharmaceutical agents prior to testing cannot be taken for granted with natural products. Current regulations in the United States classify most complementary and alternative treatments as“food supplements,” which are not subject to premarketing approval of the Food and Drug Administration.

At present, no conclusions about the role, if any, of complementary and alternative treatments in mental health or illness can be accepted with certainty, as very few claims or studies meet acceptable scientific standards. With funding from government and private industry, controlled clinical trials are under way, including the use of St. John’s wort (Hypericum perforatum) as a treatment for depression, and omega-3 fatty acids (fish oils) as a mood stabilizer in bipolar depression. In addition, it is important for clinicians and investigators to account for any herbs or natural products being taken by their patients or research subjects that might interact with traditional treatments.

Issues in Treatment

The foregoing section has furnished an overview of the types and nature of mental health treatment. The resounding message, which is echoed throughout this report, is that a range of efficacious treatments is available.

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The following material deals with four issues surrounding treatment—the placebo response, benefits and risks, the gap between how well treatments work in clinical trials versus in the real world, and the constellation of barriers that hinder people from seeking mental health treatment.

Placebo Response

Recognized since antiquity, the placebo effect refers to the powerful role of patients’ attitudes and perceptions that help them improve and recover from health problems. Hippocrates established the therapeutic principle of physicians laying their hands in a reassuring manner to draw on the inner resources of the patient to fight disease. Technically speaking, the placebo effect refers to treatment responses in the placebo group, responses that cannot be explained on the basis of active treatment (Friedman et al., 1996a). A placebo is an inactive treatment, either in the form of an inert pill for studying a new drug treatment or an inactive procedure for studying a psychological therapy. The effects of active treatment are often compared with a control group that receives a pharmacological or psychological placebo.

It is not unusual for a placebo effect to be found in up to 50 percent of patients in any study of a medical treatment (Schatzberg & Nemeroff, 1998). For example, about 30 percent of patients typically respond to a placebo in a clinical trial of a new antidepressant (see Chapter 4). The rate is even higher for an antianxiety agent (an anxiolytic) (Schweizer & Rickels, 1997). The placebo effect is of such import that a placebo group or other control group15 is mandated by the Food and Drug Administration in clinical trials of a new pharmacotherapy to establish its efficacy prior to marketing (Friedman et al., 1996a). If the pharmacotherapy is not statistically superior to the control, efficacy cannot be established. It is somewhat more difficult to fashion an analog of an inert pill in the testing of new and experimental psychological therapies. Psychological studies can employ a “psychological” placebo in the form of a treatment known to be ineffectual. Or they can employ a comparison group, which receives an alternative psychological therapy. Some treatment studies employ both a “psychological” placebo, as well as a comparison group.16

The basis of the placebo response is not fully known, but there are thought to be many possible reasons. These reasons, which relate to attributes of the disorder or the disease, the patient, and the treatment setting, include

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spontaneous remission, personality variables (e.g., social acquiescence), patient expectations, attitudes of and compassion by clinicians, and receiving treatment in a specialized setting (Schweizer & Rickels, 1997). In studies of postoperative pain, the placebo response is mediated by patients’ production of endogenous pain-killing substances known as endorphins (Levine et al., 1978).

Benefits and Risks

Throughout this report, currently accepted treatments for mental disorders will be described. Except where otherwise indicated, the efficacy of these interventions has been documented in multiple controlled, clinical trials published in the peer-reviewed literature. In some cases, these have been supplemented by expert consensus reports or practice guidelines.

Most studies of efficacy of specific treatments for mental disorders have been highly structured clinical trials, performed on individuals with a single disorder, in good physical health. While necessary and important, these trials do not always generalize easily to the wider population, which includes many individuals whose mental disorder is accompanied by another mental or somatic disorder and/or alcohol or substance abuse, and who may be taking other medications. Moreover, children, adolescents, and the elderly are excluded from many clinical trials,17 as are those in certain settings, such as nursing homes. Newer, more generalizable studies are being undertaken to address these shortcomings of the scientific literature (Lebowitz & Rudorfer, 1998).

Pending the results of these newer studies, it is important for clinical decisionmakers to review the current best evidence for the efficacy of treatments. People with mental disorders and their health providers should consider all possible options and carefully weigh the pros and cons of each, as well as the possibility of no treatment at all, before deciding upon a course of action. Such an informed consent process entails the calculation of a benefit-to-risk ratio" for each available treatment option. Most medications or somatic treatments have side effects, for example, but a likelihood of significant clinical benefit often overrides side effects in support of a treatment recommendation.

Gap Between Efficacy and Effectiveness

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Mental health professionals have long observed that treatments work better in the clinical research trial setting as opposed to typical clinical practice settings. The diminished level of treatment effectiveness in real-world settings is so perceptible that it even has a name, the“efficacy-effectiveness gap.” Efficacy is the term for what works in the clinical trial setting, and effectiveness is the term for what works in typical clinical practice settings. The efficacy-effectiveness gap applies to both pharmacological therapies and to psychotherapies (Munoz et al., 1994; Seligman, 1995). The gap is not unique to mental health, for it is found with somatic disorders too.

The magnitude of the gap can be surprisingly high. With schizophrenia medications, one review article found that, in clinical trials, the use of traditional antipsychotic medications for schizophrenia was associated with an average annual relapse rate of about 23 percent, whereas the same medications used in clinical practice carried a relapse rate of about 50 percent (Dixon et al., 1995). The magnitude of the gap found in this study may not apply to other medications and other disorders, much less to psychological therapies. Studies of real-world effectiveness are scarce. Yet some degree of gap is widely recognized. The question is, why?

Efficacy studies test whether treatment works under ideal circumstances. They typically exclude patients with other mental or somatic disorders. In the past, they typically have examined relatively homogeneous populations, usually white males. Furthermore, efficacy studies are carried out by highly trained specialists following strict protocols that require frequent patient monitoring. Finally, participation in efficacy studies is often free of charge to patients.

It is not surprising that the reasons commonly cited to explain the discrepancy between efficacy and effectiveness focus on the practicalities and constraints imposed by the real world. In real-world settings, patients often are more heterogeneous and ethnically diverse, are beset by comorbidity (more than one mental or somatic disorder),18 are often less compliant, and are seen more often in general medical rather than specialty settings; providers are less inclined to adequately monitor and standardize treatment; and cost pressures exist on both patients and providers, depending on the nature of the financing of care (Dixon et al., 1995; Wells & Sturm, 1996). This constellation of real-world constraints appears to explain the gap.

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Barriers to Seeking Help

Most people with mental disorders do not seek treatment, according to figures presented in the next section of this chapter and in Chapter 6. This general statement applies to adults and older adults and to parents and guardians who make treatment decisions for children with mental disorders. There is a multiplicity of reasons why people fail to seek treatment for mental disorders but few detailed studies. The barriers to treatment fall under several umbrella categories: demographic factors, patient attitudes toward a service system that often neglects the special needs of racial and ethnic minorities, financial, and organizational.

Several demographic factors predispose people against seeking treatment. African Americans, Hispanics (Sussman et al., 1987; Gallo et al., 1995), and poor women (Miranda & Green, 1999) are less inclined than non-Hispanic whites—particularly females—to seek treatment. Common patient attitudes that deter people from seeking treatment are not having the time, fear of being hospitalized, thinking that they could handle it alone, thinking that no one could help, and stigma (being too embarrassed to discuss the problem) (Sussman et al., 1987). Above all, the cost of treatment is the most prevalent deterrent to seeking care, according to a large study of community residents (Sussman et al., 1987). Cost is a major determinant of seeking treatment even among people with health insurance because of inferior coverage of mental health as compared with health care in general. Finally, the organizational barriers include fragmentation of services and lack of availability of services (Horwitz, 1987). Members of racial and ethnic minority groups often perceive that services offered by the existing system do not or will not meet their needs, for example, by taking into account their cultural or linguistic practices. These particular barriers are discussed in greater depth with respect to minority groups (later in this chapter) and with respect to different ages (Chapters 3 to 5).

Demographic, attitudinal, financial, and organizational barriers operate at various points and to various degrees. Seeking treatment is conceived of as a complex process that begins with an individual or parent recognizing that thinking, mood, or behaviors are unusual and severe enough to require treatment; interpreting symptoms as a“medical” or mental health problem; deciding whether or not to seek help and from whom; receiving care; and, lastly, evaluating whether continuation of treatment is warranted (Sussman et al., 1987)

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12 About 40 percent of those surveyed thought that they “didn’t think anyone could help” as a reason for not seeking mental health treatment (Sussman et al., 1987). 13 Other treatments are electroconvulsive therapy (Chapters 4 and 5) and some types of surgery. 14 There are certainly exceptions to this general rule. Some pharmacotherapies work as partial agonists and partial antagonists simultaneously. 15 When it is unethical to deprive patients of treatment, such as the case with AIDS, conventional treatment is given as the control. 16 The criteria developed by a division of the American Psychological Association for establishing treatment efficacy call for the experimental treatment to be statistically superior to “pill or psychological placebo or to another treatment” (Chambless et al., 1998). 17 In March 1998, the NIH issued a policy guideline stating that NIH-funded investigators will be expected to include children in clinical trials, which normally would involve adults only, when there is sound scientific rationale and in the absence of a strong justification to the contrary. 18 Having a second disorder increases the possibility of drug interactions, which may translate into reduced dosing. Comorbidity is discussed throughout this report.

CBT is applied to many clinical and non-clinical conditions and has been successfully used as a treatment for many clinical disorders, personality disorders, and behavioral problems. Although CBT is effective for many disorders, it is important to note that cognitive behavioral therapy is unlikely to be effective in patients with substance dependence and/or abuse problems as cognitive behavioral therapy itself cannot change drug or alcohol induced mental health symptoms (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

5. Applications

Anxiety disorders

Beck (1976) argues that in anxiety states, individuals overestimate the inherent danger in a given situation. These estimates automatically activate the “anxiety programe” which is a set of responses which we have inherited and are designed to protect us from harm. Within cognitive models of anxiety disorders, two different levels of distorted thinking are identified. Negative automatic thoughts are thoughts or images which are present in specific situations when an individual experiences anxiety. Dysfunctional assumptions and rules are general beliefs which individuals have about the world and themselves which makes them prone to interpret certain situations in an excessively negative and dysfunctional manner. Cognitive models of generalized anxiety (Beck, Emery, and Greenberg, 1985) propose that individuals experience pervasive anxiety resulting from their beliefs about themselves and the world which cause them to interpret a wide range of situations as threatening. Although the dysfunctional beliefs and

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assumptions involved with generalized anxiety are highly varied, most dysfunctional beliefs revolve around acceptance, competence, responsibility, control, and the symptoms of anxiety themselves (Beck, A.T., Emery, G., and Greenberg, R.L., Anxiety Disorders And Phobias: A Cognitive Perspective. Basic Books, 2005. - ISBN 0-465-00587-X).

The cognitive model of panic (Clark, 1986a, 1988) explains that people experience panic attacks because they have a tendency to interpret a range of bodily sensations as catastrophic. The sensations misinterpreted are mostly those involved in normal anxiety response such as heart palpitations, breathlessness, and dizziness. This misinterpretation involves perceiving sensations as an immediately impending physical or mental disaster. The figure below illustrates this concept.

A basic concept in CBT treatment of anxiety disorders is in vivo

Trigger Stimulus Apprehension Body sensations Interpretation of sensations as catastrophic

exposure which is a gradual exposure to the actual, feared stimulus. This treatment is based on the theory that the fear response has been classically conditioned and that avoidance positively reinforces and maintains that fear. This "two-factor" model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this conditioning can be unlearned; this is referred to as extinction and habituation. A specific phobia, such as fear of spiders, can often be treated with in vivo exposure and therapist modeling in one session. Obsessive compulsive disorder is typically treated with exposure with response prevention. Social phobia has often been treated with exposure coupled with cognitive restructuring, such as in Heimberg's group therapy protocol. Evidence suggests that cognitive interventions improve the result of social phobia treatment.

CBT has been shown to be effective in the treatment of generalized anxiety disorder, and possibly more effective than pharmacological treatments in the long term. In fact, one study of patients undergoing benzodiazepine withdrawal who had a diagnosis of generalized anxiety disorder showed that those who received CBT had a very high success rate of discontinuing benzodiazepines compared to those who did not receive CBT. This success rate was maintained at 12 month follow up. Furthermore in patients who had discontinued benzodiazepines it was found that they no longer met the diagnosis of general anxiety disorder and that patients no longer meeting the

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diagnosis of general anxiety disorder was higher in the group who received CBT. Thus CBT can be an effective tool to add to a gradual benzodiazepine dosage reduction program leading to improved and sustained mental health benefits (Beck, A.T., Emery, G., and Greenberg, R.L., Anxiety Disorders And Phobias: A Cognitive Perspective. Basic Books, 2005. - ISBN 0-465-00587-X).

One etiological theory of depression is Aaron Beck's cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema (belief system) of the world in childhood and adolescence as an effect of stressful life events. When the person with such schemata encounters a situation that in some way resembles the conditions in which the original schema was learned, the negative schemata of the person are activated. Beck also described a negative cognitive triad, made up of the negative schemata and cognitive biases of the person; Beck theorized that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as "I never do a good job," and "things will never get better." A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. This is the negative triad. Also, Beck proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalization, magnification and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

Mood disorders

For treatment of depression, a large-scale study in 2000 showed substantially higher results of response and remission (73% for combined therapy vs. 48% for either CBT or a particular discontinued antidepressant alone) when a form of cognitive behavior therapy and that particular discontinued anti-depressant drug were combined than when either modality was used alone.

For more general results confirming that CBT alone can provide lower but nonetheless valuable levels of relief from depression, and result in increased ability for the patient to remain in employment, see The Depression Report, which states: 100 people attend up to sixteen weekly sessions one-on-one

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lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work.

The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder.

Cognitive behavioral therapy has been found to be effective in reducing benzodiazepine usage in the treatment of insomnia. A large-scale trial utilizing CBT for chronic users of sedative hypnotics including nitrazepam and zopiclone found the addition of CBT to improve outcome and reduce drug consumption in the treatment of chronic insomnia. Persisting improvements in sleep quality, sleep latency, and increased total sleep, as well as improvements in sleep efficiency and significant improvements in vitality and physical and mental health at 3-, 6- and 12-month follow-ups were found in those receiving cognitive behavioral therapy with hypnotics compared with those patients receiving hypnotics alone. A marked reduction in total sedative hypnotic drug use was found in those receiving CBT, with 33% reporting no hypnotic drug use. Authors of the study suggested that CBT is potentially a flexible, practical, and cost-effective treatment for the treatment of insomnia and that CBT administered coincident to hypnotic treatment leads to a reduction of benzodiazepine drug intake in a significant number of patients. Chronic use of hypnotic medications is not recommended due to their adverse effects on health and the risk of

Insomnia

dependence. A gradual taper is usual clinical course in getting people off of benzodiazepines but even with gradual reduction a large proportion of people fail to stop taking benzodiazepines. The elderly are particularly sensitive to the adverse effects of hypnotic medications. A clinical trial in elderly people dependent on benzodiazepine hypnotics showed that the addition of CBT to a gradual benzodiazepine reduction program increased the success rate of discontinuing benzodiazepine hypnotic drugs from 38% to 77% and at 12 month follow-up from 24% to 70%. The paper concluded

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that CBT is an effective tool for reducing hypnotic use in the elderly and reducing the adverse health effects that are associated with hypnotics such as drug dependence, cognitive impairments and increased road traffic accidents (Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4).

Another study in older people with insomnia comparing the hypnotic drug zopiclone against CBT found that CBT actually improved EEG slow wave sleep as well as increased time spent asleep and found that the benefits were maintained at 6 month follow-up. Zopiclone however worsened sleep by suppressing slow wave sleep. A lack of slow wave sleep is linked to impaired functioning and sleepiness. Zopiclone reduced slow wave sleep and was similar to placebo in that it produced no lasting benefits after treatment had finished and at 6 month follow-up whilst CBT did have significant lasting benefits. The authors stated that CBT was superior to zopiclone both in the short term and in the long term. A comparison of CBT and the hypnotic drug zolpidem (Ambien) found similar results with CBT showing superiority and sustained benefits after long term follow up. Interestingly the addition of CBT and zolpidem offered no benefit over CBT alone.

CBT has been used to treat children and adolescents with effective results. It is often used to treat major depressive disorder, anxiety disorders, and symptoms related to trauma and posttraumatic stress disorder. Significant work has been done in this area by Mark Reinecke et al at Northwestern University in the Clinical Psychology program in Chicago. Paula Barrett and her colleagues have also validated CBT as effective in a group setting for the treatment of youth and child anxiety using the Friends Program she authored. This CBT program has been recognized as best practice for the treatment of anxiety in children by the World Health Organization. CBT has been used with children and adolescents to treat a variety of conditions with good success. CBT is also used as a treatment modality for children who have experienced

CBT with children and adolescents

complex posttraumatic stress disorder and chronic maltreatment.

Research

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Cognitive behavioral therapy most closely allies with the scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalization of the problem, an emphasis on measurement (and measurable changes in cognition and behavior) and measurable goal-attainment.

Treatment of Depression in Older Adults

A broad array of effective treatments, both pharmacological and psychosocial, exists for depression. Despite the pervasiveness of depression and the existence of effective treatments, a substantial fraction of patients receive either no treatment or inadequate treatment, as described earlier. Some of the barriers relate to underdiagnosis, while others relate to treatment where there are patient, provider, and clinical barriers (for more details see Unutzer et al., 1996).

Pharmacological Treatment There is consistent evidence that older patients, even the very old, respond to antidepressant medication (Reynolds & Kupfer, 1999). About 60 to 80 percent of older patients respond to treatment, while the placebo response rate is about 30 to 40 percent (Schneider, 1996). These rates are comparable to those in other adults (see Chapter 4). Treatment response is typically defined by a significant reduction—usually 50 percent or greater—in symptom severity. Yet because patients 75 years old and older typically have higher prevalence of medical comorbidity, both they and their physicians are often reluctant to add another medication to an already complex regimen in a frail individual. However, newer antidepressants are less frequently associated with factors contraindicating their use. Moreover, because the very old are also at high risk for adverse medical outcomes of depression and for suicide, treatment may be favored. Despite the availability of effective treatments, a minority of patients properly diagnosed with depression receive adequate dosage and duration of pharmacotherapy, as noted earlier.

In general, pharmacological treatment of depression in older people is similar to that in other adults, but the selection of medications is more complex because of side effects and interactions with other medications for concomitant somatic disorders. Treatment of minor depression is generally the same as treatment for major depression, but there is not a large body of

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evidence to support this practice. Studies are under way to identify effective pharmacological treatments for minor depression (Lebowitz et al., 1997).

The following paragraphs describe the major classes of medications for treatment of depression in older adults. They focus on side effects and other concerns that distinguish the treatment of depression in older adults from that in younger ones.

Tricyclic Antidepressants Tricyclic antidepressants (TCAs) have been widely used to treat depressed patients of all ages. Alexopoulos and Salzman (1998) reviewed studies of TCAs in older depressed patients and concluded that these compounds are similar in efficacy across the age spectrum, but the side effect profiles differ considerably. Widespread use of the TCAs in older adults is limited by adverse reactions. While anticholinergic effects such as dry mouth, urinary retention, and constipation can be annoying in younger adults, they can lead to severe problems in older adults. For example, constipation can lead to impaction, and dry mouth can prevent the wearing of dentures. The anticholinergic effects of the TCAs may also cause tachycardia or arrhythmias and can further compromise preexisting cardiac disease (Roose et al., 1987; Glassman et al., 1993). Central anticholinergic effects may result in acute confusional states or memory problems in the depressed older adult (Branconnier et al., 1982). Orthostatic hypotension, which may lead to falls and hip fractures, is also a concern when the TCAs are administered. Nevertheless, TCAs are still frequently used in older adults.

Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressants Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, and sertraline, whose use is increasing across age groups, may be especially useful in the treatment of late-life depression, because these agents are reported to have fewer anticholinergic and cardiovascular side effects than the TCAs. The more commonly observed side effects with SSRIs include sexual dysfunction and gastrointestinal effects such as nausea, vomiting, and loose stools. Treatment with the SSRIs may also produce insomnia, anxiety, and restlessness. The few studies that have examined the efficacy of these compounds in older adults have shown efficacy similar to the TCAs and fewer side effects (see Small & Salzman, 1998, for a review). While the relative efficacy of SSRIs and TCAs is still debated, SSRIs are easier to prescribe because of simpler dosing patterns and more manageable side effects.

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One concern when prescribing the SSRIs in older adults is the potential for drug-drug interactions. This is of clinical importance since older adults commonly receive a large number of medications. The SSRIs vary in their inhibition of the cytochrome p450 family of isoenzymes. Knowledge of these patterns of inhibition in the SSRIs and other medications commonly used in older adults (such as other psychoactive compounds, calcium channel blockers, or warfarin) can help to avoid or minimize interactions. Other newer non-SSRI antidepressants (venlafaxine, bupropion, trazodone, and nefazodone) are often suggested for treating later life depression because their side effects are better tolerated by older adults.

Some compounds that are useful in other individuals may be less useful for treatment of older patients. For example, despite evidence of the efficacy of monamine oxidase inhibitors (see Alexopoulos & Salzman, 1998, for a review), clinical use is often restricted to patients who are refractory to other antidepressant drugs. This is due to potentially life-threatening pharmacodynamic interactions with sympathomimetic drugs or tyramine-containing foods and beverages. The sympathomimetic amines (e.g., phenylpropanolamine and pseudoephedrine) may be present in over-the-counter decongestant products that older patients are prone to self-administer. An additional concern is the risk of orthostatic hypotension, which occurs even at therapeutic doses (Alexopoulos & Salzman, 1998). In addition, bupropion has been shown in older patients to be as effective as TCAs (Branconnier et al., 1983; Kane et al., 1983). Although generally well tolerated, its use requires added caution because of an increased risk of seizures and thus should be avoided in patients with seizure disorder or focal central nervous system disease. Its advantages include a relatively low incidence of cardiovascular complications and a lack of confusion.

Multimodal Therapy Combining pharmacotherapy with psychosocial interventions also appears to be effective in older depressed patients. A high response rate of about 80 percent was found for acute and continuation treatment with combined nortriptyline and interpersonal psychotherapy. The response rate was similar between so-called “young old” patients (primarily in their 60s and early 70s) and patients in their 30s and 40s (Reynolds et al., 1996). Yet older patients showed a somewhat longer time to remission than did other patients (about 2 weeks longer) and twice the rate of relapse during continuation treatment (about 15 percent versus 7 percent). However, because the trial was not controlled, it is not known whether multimodal treatment was more effective

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than either pharmacological or psychosocial treatment alone. Treatment resistance—defined by the lack of recovery in spite of combined treatment with nortriptyline and interpersonal psychotherapy—was seen in about 18 percent of older patients with recurrent major depression (nonpsychotic unipolar depression) (Little et al., 1998). Nortriptyline and interpersonal psychotherapy (IPT) have been shown to be effective maintenance treatments for late-life depression. After 3 years of comparing various treatments, the percentage of older adults who did not experience recurrence were 57 percent of older adults receiving nortriptyline, 36 percent receiving IPT, and 80 percent of those receiving nortriptyline plus IPT. Those receiving a placebo and routine clinical visits had a 90 percent recurrence rate (Reynolds et al., 1999).

Course of Treatment Although 60 to 80 percent of older patients with moderate to severe unipolar2 depression can be expected to respond well to antidepressant treatment (especially combined treatment with medication and psychotherapy), the clinical response to antidepressant treatment in later life follows a variable course, with a median time to remission of 12 weeks (J. L. Cummings & D. J. Kupfer, personal communication, 1999). Thus, treatment response takes 1 month or more longer than that for other adults, for whom treatment response takes an average of 6 to 8 weeks (see Chapter 4). In addition to highly variable trajectories to recovery, reliable prediction of response status (recovery/nonrecovery) is generally not possible in older adults before 4 to 5 weeks of treatment. The delayed onset of antidepressant activity in older adults leads to unique problems. Suffering and disability are prolonged, which often reduces compliance and may increase risk for suicide. The development of strategies to accelerate treatment response and to improve the early identification of nonresponders would be an important advance (Reynolds & Kupfer, 1999).

Data from naturalistic studies have identified several predictors of relapse and recurrence in late-life depression, including a history of frequent episodes, first episode after age 60, concurrent somatic illness, especially a history of myocardial infarction or vascular disease, high pretreatment severity of depression and anxiety, and cognitive impairment, especially frontal lobe dysfunction. These factors appear to interact with low treatment intensity—that is, at dosage and duration below recommended levels—in determining more severe courses of illness. Despite the evidence that high treatment intensity is effective in preventing relapse and recurrence

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(Reynolds et al., 1995), naturalistic studies have shown that intensity of treatment prescribed by psychiatrists begins to decline within 16 weeks of entry and approximately 10 weeks prior to recovery (Alexopoulos et al., 1996). Residual symptoms of excessive anxiety and worrying predict early recurrence after tapering continuation treatment in older depressed patients (Meyers, 1996).

Although progress has been made in identifying effective pharmacological and combined treatments for late-life depression, there is a need for more outcome studies with newer antidepressants. In addition, studies examining effectiveness in real-world settings—rather than in clinical trials conducted in academic clinical sites—are particularly crucial in the older population because of medical comorbidity and provision of care in primary, rather than specialty, care.

Electroconvulsive Therapy Electroconvulsive therapy (ECT) is regarded as an effective intervention for some forms of treatment-resistant depression across the life cycle (NIH & NIMH Consensus Conference, 1985; Depression Guideline Panel, 1993). It may offer a particularly attractive benefit:risk ratio in older persons with depression (NIH Consensus Development Panel on Depression in Late Life, 1992; Sackeim, 1994). Chapter 4 reviews research on ECT and considers risk-benefit issues and controversy surrounding them. As described there, ECT entails the electrical induction of seizures in the brain, administered during a series of 6 to 12 treatment sessions on an inpatient or outpatient basis. Practice guidelines recommend that ECT should be reserved for severe cases of depression, particularly with active suicidal risk or psychosis; patients unresponsive to medications; and those who cannot tolerate medications (NIH & NIMH Consensus Conference, 1985; Depression Guideline Panel, 1993). For those patients, the response rate to ECT is on the order of 50 to 70 percent, and there is no evidence that ECT is any less effective in older individuals than younger ones (Sackeim, 1994; Weiner & Krystal, 1994). ECT is advantageous for older people with depression because of the special problems they encounter with medications, including sensitivity to anticholinergic toxicity, cardiac conduction slowing, and hypotension (see above). Although the newer antidepressants offer a more favorable side-effect profile than do the older tricyclics, their efficacy in melancholic depression, for which ECT is particularly helpful (Rudorfer et al., 1997), is not yet firmly established. Moreover, as noted earlier, older adults respond more slowly than younger ones to antidepressant

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medications, rendering the faster onset of action of ECT another advantage in the older patient (Markowitz et al., 1987). Immobility and reduced food and fluid intake in the older person with depression may pose a greater imminent physical health risk than would typically be the case in a younger patient, again strengthening the case for considering ECT early in the treatment hierarchy (Sackeim, 1994).

Although the clinical effectiveness of ECT is documented and acknowledged, the treatment often is associated with troubling side effects, principally a brief period of confusion following administration and a temporary period of memory disruption (Rudorfer et al., 1997). As described in Chapter 4, there may also be longer term memory losses for the time period surrounding the use of ECT. Although the exception rather than the rule, persistent memory loss following ECT is reported. Its actual incidence is unknown. There are no absolute medical contraindications to ECT. However, a recent history of myocardial infarct, irregular cardiac rhythm, or other heart conditions suggests the need for caution due to the risks of general anesthesia and the brief rise in heart rate, blood pressure, and load on the heart that accompany ECT administration. On the other hand, the safety of ECT is enhanced by the time-limited nature of treatment sessions, which enables this intervention to be administered under controlled conditions, for example, with a cardiologist or other specialist in attendance. Following completion of a course of ECT, maintenance treatment, typically with antidepressant or mood-stabilizing medication or less frequent maintenance ECT, in most cases is required to prevent relapse (Rudorfer et al., 1997).

Psychosocial Treatment of Depression Most research to date on psychosocial treatment of mental disorders has concentrated on depression. These studies suggest that several forms of psychotherapy are effective for the treatment of late-life depression, including cognitive-behavioral therapy, interpersonal psychotherapy, problem-solving therapy, brief psychodynamic psychotherapy, and reminiscence therapy, an intervention developed specifically for older adults on the premise that reflection upon positive and negative past life experiences enables the individual to overcome feelings of depression and despair (Butler, 1974; Butler et al., 1991). Group and individual formats have been used successfully.

A meta-analysis of 17 studies of cognitive, behavioral, brief psychodynamic, interpersonal, reminiscence, and eclectic therapies for late-life depression

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found treatment to be more effective than no treatment or placebo (Scogin & McElreath, 1994). The following paragraphs spotlight some of the key studies incorporated into this meta-analysis and provide evidence from newer studies.

Cognitive-behavioral therapy is designed to modify thought patterns, improve skills, and alter the emotional states that contribute to the onset, or perpetuation, of mental disorders. In a 2-year followup study of cognitive-behavioral therapy, 70 percent of all patients studied no longer met criteria for major depression and maintained treatment gains (Gallagher-Thompson et al., 1990). In another trial, group cognitive therapy was found to be effective. Older patients with major depression partially randomized to receive group cognitive therapy with alprazolam (a benzodiazepine) or group cognitive therapy with placebo had more improvement in depressed mood and sleep efficiency than patients who received alprazolam alone or placebo alone (Beutler et al., 1987). Cognitive-behavioral therapy also has been demonstrated to be effective in other late-life disorders, including anxiety disorders (Stanley et al., 1996; Beck & Stanley, 1997). Cognitive-behavioral therapy’s effectiveness for mood symptoms in Alzheimer’s disease is discussed in the section on psychosocial treatments of Alzheimer’s disease.

Problem-solving therapy postulates that deficiencies in social problem-solving skills enhance the risk for depression and other psychiatric symptoms. Through improving problem-solving skills, older patients are given the tools to enable them to cope with stressors and thereby experience fewer symptoms of psychopathology (Hawton & Kirk, 1989). Problem-solving therapy has been found effective in the treatment of depression of older patients. For example, problem-solving therapy was found to significantly reduce symptoms of major depression, leading to the greatest improvement in a randomized controlled study comparing problem-solving therapy, reminiscence therapy, and placement on a waiting list for treatment (Arean et al., 1993). In a randomized study of depressed younger primary care patients, six sessions of problem-solving therapy were as effective as amitriptyline, with about 50 to 60 percent of patients in each group recovering (Mynors-Wallis et al., 1995).

Interpersonal psychotherapy was initially designed as a time-limited treatment for midlife depression. It focuses on grief, role disputes, role transitions, and interpersonal deficits (Klerman et al., 1984). This form of

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treatment may be especially meaningful for older patients given the multiple losses, role changes, social isolation, and helplessness associated with late-life depression. Controlled trials suggest that interpersonal psychotherapy alone, or in combination with pharmacotherapy, is effective in all phases of treatment for late-life major depression. Interpersonal psychotherapy was as effective as the antidepressant nortriptyline in depressed older outpatients, and both were superior to placebo (Sloane et al., 1985; Reynolds et al., 1992; Schneider, 1995). In an open trial, a treatment protocol combining interpersonal psychotherapy with nortriptyline and psychoeducational support groups led to minimal attrition and high remission rates (approximately 80 percent) in older patients with recurrent major depression (Reynolds et al., 1992, 1994). Finally, interpersonal psychotherapy also is effective in the treatment of depression following bereavement (Pasternak et al., 1997).

Brief psychodynamic therapy, typically of 3 to 4 months’ duration, also is successful in older depressed patients. Brief psychodynamic therapy is distinguished from traditional psychodynamic therapy primarily by duration of treatment. The goals of brief psychodynamic therapy vary according to patients’ medical health and function. In disabled older people, the purpose of psychodynamic psychotherapy is to facilitate mourning of lost capacities, promote acceptance of physical limitations, address fears of dependency, and promote resolution of interpersonal difficulties with family members (Lazarus & Sadavoy, 1996). In older patients who are not disabled, psychodynamic psychotherapy deals with the resolution of interpersonal conflicts, adaptation to loss and stress, and the reconciliation of personal accomplishments and disappointments (Pollock, 1987). Brief psychodynamic therapy has been found to be as effective as cognitive-behavioral therapy in reducing symptoms of late-life major depression. An early study found brief psychodynamic therapy to yield higher relapse and recurrence rates than did cognitive and behavioral therapy (Gallagher & Thompson, 1982). However, with a greater number of patients, brief psychodynamic therapy was determined to be as effective as cognitive and behavioral therapy (and superior to being on a waiting list) in preventing recurrences of major depression up to 2 years after treatment (Gallagher-Thompson et al., 1990).

1 Hypomania is marked by abnormally elevated mood, but the symptoms are not severe enough for mania (see Chapter 4).

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2

6. Cognitive Behavioral Therapies

Unipolar depression refers to the depression in patients with major depressive disorders but not to the depression in patients with bipolar disorders.

Cognitive behavioral therapy is an umbrella term that encompasses many therapeutical approaches, techniques and systems.

• Acceptance and Commitment Therapy is a "third wave" behavior therapy, developed by Stephen Hayes based on relational frame theory.

• Anxiety Management Training was developed by Suinn and Richardson (1971) for helping clients control their anxiety by the use of relaxation and other skills.

• Applied Behavioral Analysis, described by Baer, Wolf and Risley in 1968, is the science of applying experimentally derived principles of behavior to improve socially significant behavior.

• Behavioral activation is a behavioral approach to treating depression, developed by Neil Jacobson and others.

• Behavior Modification is a term originally used by Edward Thorndike in 1911.

• Behavior therapy • Cognitive Therapy was developed by Aaron Beck

• Computerized Cognitive Behavioral Therapy

and has become of the most studied psychosocial treatments.

• Cognitive analytic therapy • Cognitive-behavior Modification • Cognitive behavioral analysis system of psychotherapy • Contingency Management • Dialectical Behavior Therapy • Direct therapeutic exposure • Exposure and response prevention • Functional Analytic Psychotherapy • Mindfulness-based Cognitive Therapy • Multimodal Therapy • Problem-Solving Therapy • Rational Emotive Behavior Therapy, formerly called Rational

Therapy and Rational Emotive Therapy, was founded by Albert Ellis

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and is "regarded by many as one of the premiere examples of the cognitive-behavioral approach"

• Reality Therapy • Relapse Prevention • Self Control Training. • Self Instructional Training was developed by Donald Meichenbaum,

influenced by the developmental psychology of Alexander Luria and Lev Vygotsky, designed to treat the mediational deficiencies of impulsive children

• Stress Inoculation Training • Systematic desensitization is an anxiety reduction technique,

developed by Joseph Wolpe. • Systematic Rational Restructuring was an attempt by Marvin

Goldfried to reanalyze systematic desensitization in terms of cognitive mediation and coping skills.

• Prolonged Exposure Therapy

7. CBT Tools and Interventions

Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity of depression. Its development marked a shift among healthcare professionals, who had until then viewed depression from a psychodynamic perspective, instead of it being rooted in the patient's own thoughts. In its current version the questionnaire is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007).

There are three versions of the BDI—the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by healthcare professionals and researchers in a variety of settings. Its main limitations are the potential inaccuracies inherent in any self-report questionnaire and its inclusion of physical symptoms which may have causes other than

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depression (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007).

Historically, depression was described in psychodynamic terms as "inverted hostility against the self".

Beck developed the theory of a triad of negative cognitions about the world, the future, and the self, which are instrumental in the development of depression. An example of the triad in action taken from Brown (1995) is the case of a student obtaining poor exam results:

In contrast, the BDI was developed to measure descriptions of symptoms and using these to structure a scale which could reflect the intensity or severity of a given symptom. Throughout his work, Beck drew attention to the importance of "negative cognitions": sustained, inaccurate, and often intrusive negative thoughts about the self. In his view, it was the case that these cognitions caused depression, rather than being generated by depression (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007).

• The student has negative thoughts about the world, so he may come to believe he does not enjoy the class.

• The student has negative thoughts about his future, because he thinks he may not pass the class.

• The student has negative thoughts about his self, as he may feel he does not deserve to be in college.

The development of the BDI provides the clinical opportunity to measure negative cognition items such as "I have lost all of my interest in other people" to reflect the world, "I feel discouraged about the future" to reflect the future, and "I blame myself for everything bad that happens" to reflect the self. The view of depression as sustained by intrusive negative cognitions has had particular application in cognitive behavioral therapy (CBT), which aims to challenge and neutralize them through techniques such as cognitive restructuring (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007).

The original BDI, first published in 1961, consisted of twenty-one questions about how the subject has been feeling in the last week. Each question has a

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set of at least four possible answer choices, ranging in intensity. For example:

• (0) I do not feel sad. • (1) I feel sad. • (2) I am sad all the time and I can't snap out of it. • (3) I am so sad or unhappy that I can't stand it.

When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is compared to a key to determine the depression's severity. The standard cut-offs are as follows: 0–9 indicates that a person is not depressed, 10–18 indicates mild-moderate depression, 19–29 indicates moderate-severe depression and 30–63 indicates severe depression. Higher total scores indicate more severe depressive symptoms.

Some items on the BDI have more than one statement marked with the same score. For instance, there are two responses under the Mood heading that score a 2: (2a) I am blue or sad all the time and I can't snap out of it and (2b) I am so sad or unhappy that it is very painful.

The BDI-IA was a revision of the original instrument, developed by Beck during the 1970s and copyrighted in 1978. To improve ease of use, the "a and b statements" described above were removed, and respondents were instructed to endorse how they had been feeling during the preceding two weeks. The internal consistency for the BDI-IA was good, with a

BDI-IA

Cronbach's alpha coefficient of around 0.85, meaning that the items on the inventory are highly correlated with each other.

However, this version retained some flaws; the BDI-IA only addressed six out of the nine DSM-III criteria for depression. This and other criticisms were addressed in the BDI-II.

The BDI-II was a 1996 revision of the BDI, developed in response to the

BDI-II

American Psychiatric Association's publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, which changed many of the diagnostic criteria for Major Depressive Disorder (Beck AT,

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Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

Items involving changes in body image, hypochondria, and difficulty working were replaced. Also, sleep loss and appetite loss items were revised to assess both increases and decreases in sleep and appetite. All but three of the items were reworded; only the items dealing with feelings of being punished, thoughts about suicide, and interest in sex remained the same. Finally, participants were asked to rate how they have been feeling for the past two weeks, as opposed to the past week as in the original BDI (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

Like the BDI, the BDI-II also contains 21 questions, each answer being scored on a scale value of 0 to 3. The cutoffs used differ from the original: 0–13: minimal depression; 14–19: mild depression; 20–28: moderate depression; and 29–63: severe depression. Higher total scores indicate more severe depressive symptoms (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

One measure of an instrument's usefulness is to see how closely it agrees with another similar instrument that has been validated against clinical interview by a trained clinician. In this respect, the BDI-II is positively correlated with the Hamilton Depression Rating Scale with a Pearson r of 0.71, showing good agreement. The test was also shown to have a high one-week test–retest reliability (Pearson r =0.93), suggesting that it was not overly sensitive to daily variations in mood.

Depression can be thought of as having two components: the affective component (e.g. mood) and the physical or "somatic" component (e.g. loss of appetite). The BDI-II reflects this and can be separated into two subscales. The purpose of the subscales is to help determine the primary cause of a patient's depression (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

The test also has high internal consistency (α=.91) (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

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The affective subscale contains eight items: pessimism, past failures, guilty feelings, punishment feelings, self-dislike, self-criticalness, suicidal thoughts or wishes, and worthlessness. The somatic subscale consists of the other thirteen items: sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, change in sleep patterns, irritability, change in appetite, concentration difficulties, tiredness and/or fatigue, and loss of interest in sex. The two subscales were moderately correlated at 0.57, suggesting that the physical and psychological aspects of depression are closely related rather than totally distinct (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

Effects

The development of the BDI was an important event in psychiatry and psychology; it represented a shift in healthcare professionals' view of depression from a Freudian, psychodynamic perspective, to one guided by the patient's own thoughts or "cognitions". It also established the principle that instead of attempting to develop a psychometric tool based on a possibly invalid theory, self-report questionnaires when analyzed using techniques such as factor analysis can suggest theoretical constructs (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

The BDI was originally developed to provide a quantative assessment of the intensity of depression. Because it is designed to reflect the depth of depression, it can monitor changes over time and provide an objective measure for judging improvement and the effectiveness or otherwise of treatment methods. The instrument remains widely used in research; in 1998, it had been used in over 2000 empirical studies. It has been translated into multiple European languages as well as Arabic, Chinese, Japanese, Persian, and Xhosa (Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation).

The BDI suffers from the same problems as other

Limitations

self-report inventories, in that scores can be easily exaggerated or minimized by the person completing them. Like all questionnaires, the way the instrument is administered can

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have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations might elicit a different response compared to administration via a postal survey.

In participants with concomitant physical illness the BDI's reliance on physical symptoms such as fatigue may artificially inflate scores due to symptoms of the illness, rather than of depression. In an effort to deal with this concern Beck and his colleagues developed the "Beck Depression Inventory for Primary Care" (BDI-PC), a short screening scale consisting of seven items from the BDI-II considered to be independent of physical function. Unlike the standard BDI, the BDI-PC produces only a binary outcome of "not depressed" or "depressed" for patients above a cutoff score of 4.

Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory (BAI), created by Dr. Aaron T. Beck, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of an individual's anxiety. The BAI consists of twenty-one questions about how the subject has been feeling in the last week, expressed as common symptoms of anxiety (such as numbness, hot and cold sweats, or feelings of dread). Each question has the same set of four possible answer choices, which are arranged in columns and are answered by marking the appropriate one with a cross (

These are:

Leyfer OT, Ruberg JL, Woodruff-Borden J, 2006. "Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders". J Anxiety Disord).

• NOT AT ALL • MILDLY: It did not bother me much. • MODERATELY: It was very unpleasant, but I could stand it. • SEVERELY: I could barely stand it.

The BAI has a maximum score of 63.

• 0-7: minimal level of anxiety • 8-15: mild anxiety • 16-25: moderate anxiety

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• 26-63: severe anxiety

Note: women with anxiety disorders tend to score 4 points higher then men with anxiety disorders

Evidence suggests the scale is best at assessing panic symptomatology. It has been used in a variety of different patient groups, including adolescents and elderly patients. A 1999 review found that it was the third most used research measure of anxiety, behind the State-Trait Anxiety Inventory and the Fear Survey Schedule

Beck Hopelessness Scale (BHS)

.

The Beck Hopelessness Scale (BHS) is a 20-item self-report inventory developed by Dr. Aaron T. Beck that was designed to measure three major aspects of hopelessness; feelings about the future, loss of motivation, and expectations. The test is designed for adults, age 17-80. The BHS moderately correlates with the Beck Depression Inventory, although research shows that the BDI is better suited for predicting suicidal ideation behavior. The internal reliability coefficients are reasonably high (Pearson r= .82 to .93 in seven norm groups), but the BHS test-retest reliability coefficients are modest (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007).

Dowd and Owen

8. Risk Factors

both positively reviewed the effectiveness of the instrument, with Dowd concluding that the BHS was "a well-constructed and validated instrument, with adequate reliability."

Cautions Regarding Cognitive-Behavioral Interventions Provided Within a Month of Trauma How effective is Cognitive-Behavioral Therapy for early intervention? Researchers have conducted over 30 studies examining the effectiveness of Cognitive- Behavioral Therapy (CBT) in treating PTSD and several studies examining a brief, five-session treatment for Acute Stress Disorder (ASD). In general, CBT has proven very effective and produced significant reductions in PTSD symptoms. CBT treatments are often carefully scripted

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in treatment manuals. There are more published well-controlled studies of CBT than of any other PTSD treatment. Furthermore, the magnitude of treatment effects appears greater with CBT than with any other treatment. Bryant et al. , in treating motor vehicle and industrial accident victims who met criteria for ASD, compared five sessions of nondirective supportive counseling (providing support and education and teaching problem-solving skills), with brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). At the conclusion of treatment, 8% of the participants in the CBT group and 83% of the participants in the supportive counseling (SC) group met criteria for PTSD. Six months posttrauma, 17% in the CBT group and 67% in the SC group met criteria for PTSD. There were also significant reductions in depressive symptoms in the CBT group compared to the SC group. Clearly, this is one of the most important developments in years regarding early intervention. What are the obstacles to using Cognitive-Behavioral Therapy in early intervention? Excerpted with permission from Bryant, R.A., & Harvey, A.G. 2 . Acute Stress Disorder: A handbook of theory, assessment, and treatment. Washington, D.C.: American Psychological Association Press. There are a proportion of people for whom any early intervention may be inappropriate. The following issues are commonly encountered in individuals with Acute Stress Disorder, and must be carefully addressed in considering treatment options for these individuals: Excessive Avoidance Excessive avoidance may be an important warning sign that the client needs containment and support vs. exposure. If so, it is recommended to take a supportive approach until they are better able to use therapy. However, if therapist determines that exposure treatment can be tolerated, compare the benefits and disadvantages of proceeding with therapy, give more attention to cognitive therapy to assist in perceiving response to exposure, implement a graded exposure regime that commences with less distressing material, and make sure that all features of the narrative description of the trauma are eventually integrated in exposure treatment. Dissociation Dissociation may indicate a defense or protective mechanism against overwhelming distress. If dissociative symptoms are present, it may be best

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to take a supportive approach until the individual is better able to use therapy. However, if the therapist determines that even with dissociative symptoms, exposure treatment can be tolerated, modified exposure techniques may be effective, such as directing clients to imagine a scene that they can feel emotional about and then switch to the traumatic memory. Anger Anger may serve to inhibit anxiety, especially when avoidance is unsuccessful. Exposure not the optimal treatment if primary presentation is anger. It is best to implement CBT program specifically addressing anger. Grief The bereavement process is normal and takes time. It may not be appropriate to provide exposure during early phases of grieving. It may be best to provide support until better able to use trauma therapy. Extreme Anxiety Any individual who suffers extreme anxiety or panic attacks in the acute phase should be monitored carefully. Provide instruction in anxiety management prior to exposure treatment (SIT). Give more attention to cognitive therapy to assist client in appraising exposure in more adaptive way. Temporarily suspend exposure if panic or extreme anxiety which is intolerable by the client occur. Catastrophic Beliefs Proceeding with exposure without addressing clients' interpretations of the recalled memories may simply reinforce their maladaptive beliefs. Clients who manifest entrenched beliefs arising from their experience should receive substantive cognitive therapy Prior Trauma If prior trauma(s) are too distressing to engage in CBT, allow the posttraumatic upheaval to settle before directly addressing the traumatic memories, and take a supportive approach until the client is better able to use therapy. If, however, the therapist determines that exposure treatment can be tolerated, prioritize the memories that will be addressed, mutually agree on compartmentalizing the intrusive memories into an order that the client feels comfortable addressing. It is usually best to address memories of the recent trauma first -- they are more accessible and were the reason for presentation to treatment. Comorbidity Comorbid disorders may be exacerbated by the distress elicited by exposure therapy. Borderline personality disorder and psychotic disorders may be particularly affected. If deterioration of preexisting disorders is present, it is best to offer support to contain preexisting disorder first.

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Substance Abuse Substance abuse is a common posttraumatic response -- is a form of avoidance behavior that assists in distraction from distressing intrusive symptoms. If the individual exhibits marked substance abuse, require sobriety for several months before commencing exposure treatment, and provide support until better able to use trauma therapy. Depression and Suicide Risk Exposure treatment may enhance attention towards negative aspects of experience. Therefore, it is important to ensure clients who are severely depressed are provided the appropriate assistance to stabilize the depression prior to exposure. If the client is a suicide risk, they require support, containment, and possibly antidepressant medication and hospitalization. Poor Motivation If clear ambivalence exists, attempt to educate the client about the advantages of proceeding with therapy. It is better to not proceed with therapy in the acute phase if the client is not willing. Ongoing Stressors Ongoing stressors can impede with resources to engage in therapy, and the demands of therapy can impede coping with other stressors. Delay active treatment until threats to safety or severe ongoing stressors subside. Cultural Issues The rationale for exposure needs to be integrated in to the client's value system in a way that is congruent with his or her view of recovery. If discrepancy persists, recognize that a client's culturally driven outlook must be recognized and validated. Appropriate versus Inappropriate Avoidance There are many instances in the initial period when avoidance behavior is appropriate because of the recency of the trauma. It is important for clinicians to recognize the functional, and sometimes safety-enhancing roles of some avoidance behaviors in the acute phase. Multiple Survivors of the Same Trauma Sometimes clients' adjustment is directly influenced by the responses of others also involved in the traumatic event.

9. Resources

• Association for Behavioral and Cognitive Therapies (ABCT) • Academy of Cognitive Therapy • The Albert Ellis Institute • National Association of Cognitive-Behavioral Therapists

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• The Jove Institute • Beck Institute for Cognitive Therapy and Research • William Glasser Institute • The Lazarus Institute • The British Association of Behavioral and Cognitive Psychotherapies

10. References

Alford, B.A., Beck, A.T., The Integrative Power of Cognitive Therapy. The Guilford Press, 1998. - ISBN 1-57230-396-4

Beck, A.T., Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. HarperCollins Publishers, 1999. - ISBN 0060193778

Beck, A.T., Freeman, A., and Davis, D.D., Cognitive Therapy of Personality Disorders. The Guilford Press, 2003. - ISBN 1-57230-856-7

Beck A.T. (1988). "Beck Hopelessness Scale." The Psychological Corporation

Beck, A.T., Emery, G., and Greenberg, R.L., Anxiety Disorders And Phobias: A Cognitive Perspective. Basic Books, 2005. - ISBN 0-465-00587-X

Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975. ISBN 0-8236-0990-1

Beck, A.T., Depression: Causes and Treatment. University of Pennsylvania Press, 1972. - ISBN 978-0812276527

Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., Cognitive Therapy of Depression. The Guilford Press, 1979. - ISBN 0898620007

Beck AT, Steer RA and Brown GK (1996) "Manual for the Beck Depression Inventory-II". San Antonio, TX: Psychological Corporation

Beck AT, Ward C, Mendelson M (1961). "Beck Depression Inventory (BDI)". Arch Gen Psychiatry 4: 561-571

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Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall. ISBN 0-13-370650-8.

Lazarus, A. A. "New methods in psychotherapy: a case study". South African Medical Journal, 1958, 32, 660-664

Gould, RA; Michael W. Otto, Mark H. Pollack, Liang Yap (1997). "Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis".

Scott, J., Williams, J.M., Beck, A.T., Cognitive Therapy in Clinical Practice: An Illustrative Casebook. Routledge, 1989. - ISBN 0-415-00518-3

Leyfer OT, Ruberg JL, Woodruff-Borden J (2006). "Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders". J Anxiety Disord

Winterowd, C., Beck, A.T., Gruener, D., Cognitive Therapy With Chronic Pain Patients. Springer Publishing Company, 2003. - ISBN 0-8261-4595-7

Wright, J.H., Thase, M.E., Beck, A.T., Ludgate, J.W., Cognitive Therapy with Inpatients: Developing A Cognitive Milieu. The Guilford Press, 2003. - ISBN 0-89862-890-3