Good Mood: The New Psychology
of Overcoming Depression

APPENDIX D

Unlike traditional psychoanalysis1, cognitive therapy has been subjected to controlled tests. Tests that compare drugs with psychotherapy, as well as tests of various forms of psychotherapy, must overcome a particularly difficult set of obstacles, such as allowing for the quality and style of the particular psychotherapist.2 But the body of work has been sufficiently competent that we are safely able to conclude that cognitive therapy works well @@@ - at least as well as drugs, on average, better than drugs for some kinds of people, and as an adjunct that may improve the performance of drugs when they are used.

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@@@ Miller, Norman, and Keitner (1989) summarize as follows:

dd>

A number of psychotherapies that can be described as cognitive-behavioral have been found to be effective treatments for depressed outpatients, producing at least as much improvement as was produced by pharmacotherapy. Combining cognitive-behavioral treatment with pharmacotherapy has been found to result in higher response rates in some studies but equivalent rates in others (p. 1274).

And in their own long-run follow-up study they found that "significantly higher proportions of the patients who received additional [to the standard treatment including drugs] cognitive- behavioral treatment (cognitive therapy or social skills) had responded by the end of the formal treatment period and did not relapse for the remainder of the 1-year follow-up period" (p. 1274).@@@

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The first study seems to have been that of Ellis in 1957, which showed that his variety of cognitive therapy -- Rational- Emotive Therapy -- is indeed effective. Since then there have been a wide variety of studies from many different angles. Beck (1976, Chapter 12) summarized the studies of his own variety of cognitive therapy until that time; they are further reviewed in Beck et. al. (1979, Chapter 18). The studies show that for un-hospitalized depressed persons -- both volunteers and clinic patients -- of several sorts, the groups that received cognitive therapy did better than did groups that received no therapy or only support. For hospitalized patients, cognitive therapy generally did as well or better than anti-depressant drugs, and the addition of drugs to cognitive therapy did not improve results, though Beck et. al. suggest that in some cases adding drugs to cognitive therapy probably is warranted. A long-term follow-up study by Miller, Norman, and Keitner (1989) showed that patients treated with cognitive-behavioral therapy in addition to drugs have fewer recurring episodes than do patients treated with drugs alone.

Inter-personal Therapy is another form of cognitive treatment that has been evaluated in controlled tests, and has been shown to be effective. Klerman et. al. (1984, pp. 18, 19; see also Klerman, 1988) @@@and Karasu (1990a; 199b)@@@ summarize the studies of their method.

A large scale and well-controlled double-blind (for drugs) test was done by the National Institute of Mental Health at three separate university sites, beginning in 1980, comparing Beck's Cognitive Therapy, Interpersonal Therapy, imiprimine (a tricyclic anti-depressant drug), and a placebo-plus-support-group. As of 1986, slightly more than half of the drug and psychotherapy groups had "returned to normal" after 16 weeks, whereas only 29% of the placebo-support subjects had done so.3 At the conclusion of treatment, the active psychotherapies were as successful as the drug imipramine in reducing the symptoms of depression and improving the patient's ability to function. Drug treatment produced improvement more rapidly, but the active psychotherapies caught up later. Both more-severely and less-severely depressed patients benefited from the active psychotherapies (Elkin et. al., 1986, abstract).

In addition to the outcome studies of cognitive therapy, there have been studies of the mechanism of depression that support the underlying theory. For example, Seligman et. al. (1988) found that what has come to be called "explanatory style" -- the reasons people give for bad events that occur, and the extent to which they blame either themselves or outside forces -- changes during cognitive therapy for depression in a fashion which confirms the theory; improvement in mood is accompanied by reduction of self-blame.

It should be reasonably easy and inexpensive to determine the extent to which the thought processes of depressives are indeed framed as negative self-comparisons. There exist numerous protocols of depressed patients as well as questionnaire studies of samples of depressed and non-depressed persons that have been used for research on cognitive therapy (e. g. the studies reviewed in Peterson and Seligman, 1984, and in Beck, 1976, pp. 124-128; see also Peterson, Bettes, and Seligman, 1985. The content of these protocols and questionnaires could be re-analyzed for the purposes at hand using standard techniques of content analysis. And questionnaire studies gathering new data with instruments adapted from the existing survey instruments should be able to take advantage of the pre-existing body of research.

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Along with this book is offered the computer program Overcoming Depression developed by Kenneth Colby - the "father" of computer-delivered therapy - based on the Self-Comparisons Therapy described in the book, and presented in natural-language English rather than computerese; this is the first natural- language computer program to do cognitive therapy. The findings of a study by Selmi et. al. (1990) of cognitive therapy administered by computer are most relevant here. The patients suffering from mild to moderate depression who were treated with the computer program did as well as the patients who received similar cognitive therapy in person, and significantly better than control subjects. @@@

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1See Colby and Stoller (1988) for discussion of the untested and perhaps untestable status of psychoanalysis.

2See Elkin et. al., 1988a and 1988b for a cogent discussion of these research problems.

3Holden, 1986, 723-727

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