FROM THE LITERATURE

Cognitive Behavioral Therapy of Depression:

Theory, Treatment, and Empirical Status

L A T A K. M c G I N N , P h . D . *

C O G N I T I V E THEORIES O F DEPRESSION

Cognitive theories of depression hypothesize that particular negative ways

of thinking increase individuals' likelihood of developing and maintaining
depression when they experience stressful life events. According to these
theories, individuals who possess specific maladaptive cognitive patterns
are vulnerable to depression because they tend to engage in negative
information processing about themselves and their experiences. Beck (1,2)
hypothesized that depression-prone individuals possess negative self-
schemata (beliefs), which he labeled the "cognitive triad." Specifically,
depressed patients have a negative view of themselves (seeing themselves as
worthless, inadequate, unlovable, deficient), their environment (seeing it as
overwhelming, filled with obstacles and failure), and their future (seeing it
as hopeless, no effort will change the course of their lives). This negative
way of thinking guides one's perception, interpretation, and memory of
personally relevant experiences, thereby resulting in a negatively biased
construal of one's personal world, and ultimately, the development of
depressive symptoms. For example, the depression-prone individuals are
more likely to notice and remember situations in which they have failed or
did not live up to some personal standard and discount or ignore successful
situations. As a result, they maintain their negative sense of self, leading to
depression.
A second cognitive model, the hopelessness theory of depression,
proposed by Abramson, Metalsky, & Alloy (3) is based on Seligman's work
on learned helplessness and attribution styles (4, 5). The hopelessness

"Assistant Professor of Psychiatry; Director, Cognitive Behavior Therapy Program, Montefiore

Medical Center, Albert Einstein College of Medicine. Mailing address: Montefiore Medical Center,
Department of Psychiatry, Bronx, N Y 10467-2490.

A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. 54, No. 2, Spring 2000

257
A M E R I C A N J O U R N A L O F PSYCHOTHERAPY

theory of depression posits that when confronted with a negative event,

people who exhibit a depressogenic inferential (thinking) style, defined as
the tendency to attribute negative life events to stable (enduring) and global
(widespread) causes, are vulnerable to developing depression because they
will infer that: a) negative consequences will follow from the current
negative event, and b) that the occurrence of a negative event in their lives
means that they are fundamentally flawed or worthless. For example,
consider a woman whose fiance breaks off their engagement. If she
attributes the cause of the break-up to her personality flaws, a stable-global
cause that will lead to many other bad outcomes for her, or if she infers that
a consequence of the break-up is that she will never marry or have children,
or if she infers that without a lover, she is worthless, she is likely to become
hopeless and develop the symptoms of depression. Thus, according to
hopelessness theory, a specific cognitive vulnerability operates to increase
the risk for depression through its effects on processing or appraisals of
personally relevant life experiences.

COGNITIVE BEHAVIOR THERAPY O F DEPRESSION

Aaron T. Beck and colleagues (1) initially developed cognitive therapy as a

treatment for depression. Cognitive behavioral treatment (CBT) of depres-
sion involves the application of specific, empirically supported strategies
focused on depressogenic information processing (1) and behavior (6, 7).
In order to alleviate depressive affect, treatment is directed at the following
three domains: cognition, behavior, physiology, (see Depression [8]) for a
session-by-session description). In the cognitive domain, patients learn to
apply cognitive restructuring techniques so that negatively distorted thoughts
underlying depression can be corrected, leading to more logical and
adaptive thinking. Within the behavioral domain, techniques such as
activity scheduling, social skills training, and assertiveness training are used
to remediate behavioral deficits that contribute to and maintain depression
(e.g., social withdrawal, loss of social reinforcement). Finally, within the
physiological domain, patients with agitation and anxiety are taught to use
imagery, meditation, and relaxation procedures to calm their bodies.
CBT is oriented towards empowering the patient. Within this specific,
brief psychotherapeutic treatment modality, the emphasis is on providing
patients with skills to offset their depression. One primary goal of CBT is to
facilitate the use of treatment techniques outside therapy sessions to create
a "positive emotional spiral" wherein patients can implement specific
strategies to offset their depressive mood (e.g., cognitive restructuring is
used to offset negative thought patterns and the consequent depressive
258
 Cognitive Behavioral Therapy of Depression

affect, scheduling pleasant activities is used to offset decreased reinforce-

ment secondary to social withdrawal).
EFFICACY O FCOGNITIVE BEHAVIOR THERAPY FOR DEPRESSION

Since cognitive therapy was first formulated by Beck (9), numerous studies
have demonstrated the efficacy of cognitive therapy for depression. The
first landmark study conducted by Rush and colleagues in the late seventies
(10) demonstrated that cognitive therapy was more effective than tricyclic
antidepressant therapy in patients suffering from clinical depression. In
contrast with previous outcome research which demonstrated that psycho-
therapies were no more effective than pill-placebos and less effective than
antidepressant medications, the Rush et al. study was the first to show that a
psychosocial treatment was superior to pharmacotherapy in the treatment
of depression (11). Further, a follow-up study conducted twelve months
post-treatment showed that relapse rates were lower among patients who
received CT (39%) versus those who received antidepressant medication
(65%), although this difference did not reach statistical significance (12).
In the two decades since the initial trial, many controlled trials have
been undertaken to replicate these findings. Although many experts now
believe that the Rush study was sufficiently flawed to negate study findings
(11) , many qualitative and quantitative reviews now conclude that cognitive
therapy: 1) effectively treats depression, 2) is at least comparable, if not,
superior to medication treatment, and 3) may have lower rates of relapse in
comparison to medication treatments (11, 13-17). As a result, cognitive
therapy has gained widespread acceptance as a first-line treatment for
depression, and cognitive behavioral therapy is one of only two psychothera-
pies included in the guidelines for the treatment of depression published by
the Agency for Health Care and Policy Research (AHCPR).
FUTURE DIRECTIONS

Although the breadth of support for CBT is impressive, additional multicen¬

ter studies that compare medications and different forms of psychotherapy
are still needed to confirm the efficacy of short-term CBT as a treatment for
depression, especially in light of the results of the recent National Institute
of Mental Health Treatment of Depression Collaborative Research Pro-
gram study (NIMH TDCRP) which concluded that cognitive behavior
therapy was not effective in the treatment of severe depression (18).
Although many investigators now suggest that the TDCRP study was
flawed in several important respects (19-21), additional studies still need to
be conducted to see if these findings can be replicated. However, for any
study findings to be valid, it is essential that active treatments are adminis-
259
A M E R I C A N J O U R N A L O F PSYCHOTHERAPY

tered by clinicians adequately trained in the various approaches and that

issues of researcher allegiance and site differences are appropriately ad-
dressed. Further, adding controls such as a pill placebo and a placebo plus
CBT control condition are imperative to enhance treatment interpretabil-
ity.
In order to enhance treatment effects, studies must also examine the
relative efficacy of CBT in depressive subtypes that may have characteris-
tics that are associated with poorer outcome. For example, it has been
demonstrated that patients with atypical depression (AD), a new subtype of
the mood disorders in the DSM-IV are less responsive to tricyclic antide-
pressants (22, 23). Hence, cognitive behavioral treatment for depressed
patients with atypical depression may need to be modified to meet their
unique symptom needs (24). Along the same lines, there is preliminary
evidence that patients with personality disorders may be less responsive to
short-term CBT, and that optimal treatment can only be accomplished for
these patients if the treatment is modified to address the personality
disorder as well (25 for a review). Identifying specific populations who do
not respond as well to short-term CBT will lead to the elucidation of factors
that must be modified to provide more appropriate treatment.
Finally, future research studies need to evaluate the effectiveness of CBT
for depression outside of clinical research centers. The demonstration of
treatment efficacy in controlled research environments is only the first step
in treatment research. Once a positive therapeutic effect has been conclu-
sively demonstrated, generalizability becomes of paramount importance.
With regard to CBT for depression, it seems fair to conclude from the
reviews conducted that CBT is an effective treatment in clinical research
settings. But data are not available on the efficacy of CBT for depression
when delivered in non-research clinical settings to a diverse group of
patients (This is not unique to CBT, and applies to other empirically
supported treatments as well, e.g., pharmacological approaches). Without
data, one must be cautious in generalizing the results from research settings
to typical clinical settings because there are several factors that might
reduce the efficacy of this treatment (26). For example, one area of
particular concern is that clinicians in research settings are likely to possess
greater expertise in the administration of a particular treatment developed
in that setting compared to the average clinician. Thus, since clinician
competence may be an important factor for success, one would expect a
less favorable outcome in uncontrolled settings where the quality of
treatment may not be as good. While caution may be warranted until data
are generated specifically on CBT for depression, it is reassuring to note
260
 Cognitive Behavioral Therapy of Depression

that data are beginning to appear that support the effectiveness of evidence
based treatments outside of controlled research environments (27), and a
recent meta-analysis of psychotherapy studies found that the effect sizes of
psychotherapy in "clinically representative settings" is slightly lower (ap-
proximately 10%) but comparable to that obtained in clinical research
settings (28).

REFERENCES

1. Beck, A . X , Rush, A. J . , Shaw, B., & Emery, G . (1979). Cognitive therapy of depression. New York:
Guilford.
2. Beck, A . T. (1983). Cognitive therapy of depression: New perspectives. I n RJ. Clayton & J . E.
Barett (Eds.), Treatment of depression: O l d controversies and new approaches. New York:
Raven Press, pp. 265-284.
3. Abramson, L . Y , Metalsky, G . I . , & Alloy, L . B. (1989). Hopeless depression: A theory based
subtype of depression. Psychological Review, 96, 358-372.
4. Seligman, M . E. P. (1975). Helplessness: On depression, development, and death. San Francisco, CA:
W. H . Freeman.
5. Seligman, M . E. P., Abramson, L . Y , Semmel, A., & von Baeyer, C. (1979). Depressive attributional
style. Journal of Abnormal Psychology, 88, 242-247'.
6. Lewinsohn, P. M . (1975). The behavioral study and treatment of depression. I n M . Hersen, & R. M .
Eisler (Eds.), Progress in behavior modification. New York: Academic Press, pp. 19-64.
7. Lewinsohn, P. M . , Munoz, R , Youngren, M . , & Zeiss, A . M . (1986). Control your depression. New
York: Fireside.
8. Klosko, J . S., & Sanderson, W. C. (1999). Depression: Clinical application of empirically supported
psychotherapy. Northvale, NJ: Jason Aronson.
9. Beck, A . T. (19963). Thinking and depression: 1. Idiosyncratic content and cognitive distortions.
Archives of General Psychiatry, 9, 324-333.
10. Rush, A . , Beck, A . T , Kovacs, M . , et al. (1979). Comparative efficacy of cognitive therapy and
imipramine in the treatment of depressed patients. Cognitive Therapy and Research, 1, 17-37.
11. Hollon, S. D . , Shelton, R. C , & Loosen, P. T. (1991). Cognitive therapy and pharmacotherapy for
depression. Journal of Consulting and Clinical Psychology, 59, 88-99.
12. Kovacs, M . , Rush, A . J . , Beck, A . T , et al. (1981). Depressed outpatients treated with cognitive
therapy or pharmacotherapy. Archives of General Psychiatry, 38, 33-39.
13. Dobson, K. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of
Consulting and Clinical Psychology, 57, 414^19.
14. Hollon, S. D . (1981). Comparisons and combinations with alternative approaches. I n L . P. Rehm
(Ed.). Behavior therapy for depression. New York: Academic Press, pp. 33-71.
15. Hollon, S. D . , & Beck, A. T. (1986). Cognitive and cognitive-behavioral therapies. I n S. L . Garfield,
& A . E. Bergin, (Eds.), The handbook of psychotherapy and behavior change: An empirical
analysis, 2nd ed. New York: Wiley, pp. 443^82.
16. Hollon, S. D . , & Najavits, L . (1988). Review of empirical studies on cognitive therapies. I n A . J .
Frances, & R. E . Hales (Eds.), American Psychiatric Press Review of Psychiatry, Vol. 7.
Washington, DC: American Psychiatric Press, pp. 643-666.
17. Miller, R. C , & Berman, J . S. (1983). The efficacy of cognitive behavior therapies: A quantitative
review of research evidence. Psychological Bulletin, 94, 39-53.
18. Elkin, I . , Shea, T., Watkins, J . , et al. (1989). National Institute of Mental Health of Depression
Collaborative Treatment Program. Archives of General Psychiatry, 46, 971-982.
19. Jacobson, N . S., & Hollon, S. D . (1993). Cognitive-behavior therapy versus pharmacotherapy: N o w
that the jury's returned its verdict, it's time to present the rest of the evidence. Journal of
Consulting and Clinical Psychology, 64, 74-80.
20. Jacobson, N . S., & Hollon, S. D . (1993). Prospects for future comparisons between drugs and
psychotherapy: Lessons from the CBT-versus pharmacotherapy exchange. Journal of Consulting
and Clinical Psychology, 64, 104-108.

261
A M E R I C A N J O U R N A L O F PSYCHOTHERAPY

21. Klein, D . F (1996). Preventing hung juries about therapy studies. Journal of Consulting and Clinical
Psychology, 64, 81-87.
22. Asnis, G . M . , McGinn, L . K., & Sanderson, W. C. (1995). Atypical depression: Clinical aspects and
noradrenergic function. American Journal of Psychiatry, 152, 31-36.
23. McGinn, L . K., Asnis, G . M . , & Rubinson, E. (1996). Clinical and biological validation of atypical
depression. Psychiatary Research, 60, 191-198.
24. McGinn, L . K., Ortiz, C , Sanderson, W. C , et al. (1998). Prevalence and implications of axis I I
disorders in patients with atypical depression. Paper presented at the annual convention of the
Association for the Advancement of Behavior Therapy (AABT, Washington, D C . (Available
from author).
25. McGinn, L . K., Young, J . E., & Sanderson, W. C. (1995). When and how to do longer-term therapy
. . . without feeling guilty. Cognitive and Behavioral Practice, 2, 187-212.
26. Wolfe, B. E. (1994). Adapting psychotherapy outcome research to clinical reality. Journal of
Psychotherapy Integration, 4, 160-166.
27. Sanderson, W. C , Raue, P. J . , & Wetzler, S. (1998). The generalizibility of cognitive behavior
therapy for panic disorder. Journal of Cognitive Psychotherapy, 12, 323-331.

262