Efficaciousness of Cognitive Therapy
Cognitive behavioural therapy (CBT) has previously been suggested by professionals to be a highly effective treatment for depression; however an increasing amount of research has contradicted these proposals. One of the largest and most influential treatment outcomes ever conducted in determining the best treatment for depression is the Treatment of Depression Collaborative Research Program (TDCRP). A sample of 250 unipolar depressed patients at three different sites where randomly assigned to one of four treatment conditions; CBT, IPT, imipramine plus clinical management (ICM) and a pill-placebo control group. Initially, the findings suggested few differences between the four conditions in the full sample. However, when each sample was split in terms of initial severity of depression, CBT was the least effective, with both ICM and IPT producing significantly greater acute responses than the placebo pill, (Jacobson and Hollon, 1996). These results suggested that CBT was not as effective as other forms of treatment for depression.
Due to the size and methodological sophistication of TDCRP, these findings have had a major impact on the field of treatment of depression and many experiments used the results of the TDCRP to guide their results. An example of a suspected experiment influenced by the TDCRP was that of Dimidjian, Hollon, Dobson, Schmaling, et al. (2006) in which the effects of behavioural activation (BA) were compared with CBT and antidepressant medication (ADM) in a randomized placebo controlled design. Results suggested that among severely depressed patients, BA was comparable to ADM, which significantly out-performed CBT. Although these results support the TDCRP, the poor performance on CBT relative to BA and ADM on the continuous measurement was in part a consequence of a subset of extreme non responder based on observed post-treatment assessments.
Although the TDCRP is held in high regard within the field of psychology, concerns about its efficaciousness have been raised concerning the quality of the CBT provided, leading some to question whether these findings should supersede those of other randomized comparisons of ADM and CBT in severe depression (Jacobson & Hollon, 1996). A further criticism of the TDCRP includes the ideas provided by Klein (1990, as cited in Jacobson & Hollon, 1996), who suggests that TDCRP investigators chose too stringent levels of significance which has lead them to understate the superiority of psychotherapy over ADM. Moreover, advocates for pharmacotherapy have seized the fact that ADM results were superior to pill-placebo among the sever cases of depression in comparison to CBT. However, they have over-looked any evidence that suggests that CBT works equally as well as ADM. Finally, Klein suggests that all studies which test CBT and ADM should include a placebo-pill control group to ensure that each treatment is correctly implemented. Without this control group, findings become debatable due to the uncertainty of ADM being correctly implemented in the absence of drug-placebo differences. Therefore, these aspects should be considered before interpreting results of experiments determining the efficaciousness of CBT and depression.
Although earlier research suggested that CBT was not as effective as ADM in the treatment of depression, more recent research suggests that it can perform as well as antidepressants in treating patients with moderate to severe depression (Jacobson & Dobson, 1996). DeRubeis, Hollon, Amsterdam, Shelton, et al., (2005) compared the efficacy of ADM with CBT in a placebo-controlled trial, finding that CBT was as effective as medications for the initial treatment of moderate to severe major depression. However, this degree of effectiveness was dependant on various factors, including a high level of therapist experience or expertise. Similarly, Parker, Roy, & Eyers (2003) supported the theory that the effectiveness of CBT has been linked to therapist’s characteristics, including their capacity to structure the treatment and empathy levels. Therefore, it is difficult to determine whether CBTs inconsistent reliability throughout trials is due to CBT or the effectiveness of the therapist conducting the CBT. The uncertainty surrounding the relative efficacy of CBT and ADM highlights the importance that studies ensure that the interventions are adequately implemented. Therefore, it can not be concluded that CBT is more efficacious than pharmacotherapy and other forms of psychotherapy, however evidence suggests that CBT has the same amount of efficacy than the other treatments.
CBT has also been compared to other psychological treatments which don’t have evidence to support the use with depression, such as non-directive supportive treatments. Non-directive supportive treatments emphasis rapport and are based on respect, congruence, and empathy when promoting healthy psychological development. Cuijpers, van Straten, Andersson and van Oppen (2008) investigated the treatment for mild to moderate adult depression through CBT, non-directive supportive treatment, behavioural activation (BA) treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training. The results found that there was no indication that one of the treatments was more or less efficacious, with the exception of non directive support theory which was somewhat less effective that the other forms of treatment. These results suggest that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression; however it does suggest that psychotherapies and ADM are more efficacious than non-directive treatments when treating depression.
Although this experiment suggested each treatment was not any more efficacious, drop out rate for CBT was unusually high, which could be attributed to the complexities of the therapy, with the clients unable to understand cognitions and how they can be changed. The findings, therefore, do not suggest that each treatment is equally efficacious due to the small differences which may have been missed owing to the limited number of effect sizes.
When analysing the effectiveness of CBT in treating depression, some have come to the conclusion that not all components of CBT need to be used in order for it to be effective. Cognitive aspects of CBT have been shown to not necessarily treat depression psychologically (Wampold, Minami, Baskin, T, Tierney, 2002). Furthermore, it has been suggested that behavioural components may account for the efficacy when using CBT. Dimidjian, Hollon, Dobson, Schmaling, et al. (2006) tested the efficacy of behavioural activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder. The results found that BA components of CT were more effective in treating depression than other components of CT. Although the quality of CBT in the TDCRP has been criticized, it is not clear that these same concerns apply with these results. Thus, it appears that the superiority of BA was not due to poorly implemented CT but rather to the greater efficacy of BA.
When treating depression, the most common form of depression being treated it moderate to sever. The effectiveness of treating severely depressed patients is still under investigation, however thus far CBT has been found to be not as effective as once thought when treating depression, with many people still opting to only use medication (Dimidjian, Hollon, Dobson, Schmaling, et al., 2006). However, occasionally CBT teamed with medication can be an effective treatment, as ADM helps treat immediate symptoms, such as; low energy levels and sleep levels, however the CBT gives the patient the tools to change the way they think about life in a positive way (Hollon., DeRubeis, Shelton, Amsterdam, et al., 2005).
Using both forms of treatment have also been shown to reduce relapse rates. In an experiment conducted by Hollon., DeRubeis, Shelton, Amsterdam, et al., 2005, relapse, defined as a return of symptoms for at least two weeks, was less predominant in patients who were withdrawn from CBT, and were significantly less likely to relapse during continuation than patients withdrawn from medications . Furthermore, patients on CBT were no more likely to relapse than patients who kept taking continuation medication. From these results, it can be concluded that cognitive therapy has an enduring effect hat extends beyond the end of treatment which is as effective as keeping patients on medication. However, it is still unknown as to why CBT has more lasting effects than ADM.
Alternatively, conflicting research has found that there is no difference between relapse rates between CBT and ADM in the long term outcome, suggesting that ultimately, there is no difference in effectiveness between the treatments (Jacobson & Hollon,1996).
Conclusion
When summarising all available information regarding the effectiveness of CBT in treating depression, results indicate that CBT is no more effective for treating depression than ADM. When comparing CBT with other forms of treatment, such as IBT and ADM, CBT was either less effective or equally effective, but was never a superior form of treatment. However, CBT was found to be superior to non-directive supportive therapy. Furthermore, not all components were found to be necessary when treating depression, with the behavioural aspects being the most predominantly important aspects of CBT. Not necessarily all who suffer from depression will benefit from CBT, however it is still seen as a form of treatment which should be implemented. Reasons for this include evidence that supports that CBT has a low level of relapse over a short period of time. However, it has been shown that over an extended period, relapse in CBT is not more effective that AMD. Therefore, it can be concluded that although CBT is not as effective as once thought, it should still be considered with a combination of medication when treating depression.
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