Cognitive Behaviour Therapy in the Management of Depression

Depression is a global threat and has seen to affect people across all age groups across the globe equally. Depression could be referred to as mental ill health which is signified by consistent melancholy within people. Depression is a much broad spectrum in its clinical definition and is triggered by serotonin and dopamine imbalance within the brain. In the assignment we will be analysing different evidence based literature sources against and for using cognitive behaviour therapy in management of depression.

The figures and estimates suggesting the prevalence of depression within the Australian population is alarming. As per the figures and reports around one million people in Australia currently suffer from depression (Richards et al. 2016). The depression within in the Australian population group increased from 6.8% to 10.3% from the year 2008 onwards (onlinelibrary.wiley 2008). The Cognitive Behavioural Therapy (CBT) is a type of psychological therapy which helps in altering the thought process in individual resulting in a positive and balanced behaviour. As mentioned by van Ballegooijen  et al. (2014), negative feelings are resulted to  due to  distortion of the current  beliefs or thoughts. The CBT is a blend of cognitive and behavioural therapy  where the behavioural therapy targets actions or behaviours (Andrews and Williams 2015).  The goal is to remove dysfunctional schemas that increase the vulnerability to depressive episodes.

The research question could be developed using a PICO format where P refers to Population, I refers to Intervention, C refers to comparison and O refers to Outcome.

Question- “In people affected with depression (P), does cognitive behaviour therapy (I), compared to no treatment (C), improve quality of life (O)?”

A number of evidence based studies could be applied to current clinical setting supporting the application of cognitive behavioural therapy for treating patients with depression (Wilczynski and Mckibbon 2013). The literature sources could be compared with the help of the 6s pyramid. The model could be in a number of stages from top to bottom such as –summaries, systems, syntheses, synopses of syntheses and studies.

Systems could be referred to as integrated clinical decision support services which had been designed to improve clinical decision making. The system allows entry of patient specific information such as age, gender, past history of depression. The patient specific variables in including past administration of specific antidepressants and concurrent episodes of allergies are fitted into the computer systems for designing of specific therapeutic approaches (van den Brink et al. 2016). As mentioned by Andrews and Williams (2015), computerised clinical decision support system has been seen to improve the performance of the health professional.

Computerised Clinical Decision Support Systems for Depression Management

Further analysis of the patient specific variables may suggest the administration of cognitive behavioural approach for managing the recurrence of depression episodes in patients. As argued by van Ballegooijen  et al. (2014), antidepressants have been seen to suppress the function of acid blockers in the stomach and on long term use result in gastric disorders. However, lack of knowledge and infrastructural support makes the implementation of the computerised systems difficult.The summaries consist of the second level of the 6s pyramid and provide recommendations or management of patient. It provides link to other aspects of the disease, which forms the basis for consecutive research and analysis. As mentioned by Andersson  et al. (2014), evidence base clinical guidelines are located at this level of the pyramid. Here, the information resources are not regularly updated as would have been in a website which could lead to gap in research.

In case we do not receive an answer to our question form the summary we can search the synopses of syntheses for   comparing different literature sources. The synopses of symmetric are abstracts of published systematic reviews which could be used for development of evidence based practices. In the current study we have used evidence based secondary journals which corresponds to level three of the 6s pyramid.

In the current study the benefits of cognitive behaviour therapy for management of depression have been highlighted. This has been supported by a number of evidence based journals which have been compared to arrive at a more comprehensive outlook of depression management.

Depression and more comprehensively mental illness is still a taboo word and there are a huge number of social stigmas attached with depression in general and the various methods for depression treatment. As mentioned by Siu et al. (2016), public have negative attitude towards the use of antidepressants and look for a more holistic approach. Research and evidences have emphasised upon the use of therapist training along with the usage of traditional antipsychotic drugs (Jorm et al. 2008).  There has been an emerging demand upon the use of relaxation techniques for the treatment of depression. Some of these have been seen to have long term affects along with reducing the risk of potential drug allergies. Additionally, the antidepressants have been seen to affect the digestive system negatively by blocking the action of the proton pump inhibitors. The articles have been evaluated over here have been derived from the Cochrane database.

Efficacy of Relaxation Techniques in Depression Management

The selection criteria involved in the present study were randomised or quasi randomised trials of relaxation techniques. The participants were divided into control and randomised control groups. The control groups were not provided with any intervention methods; whereas the RCT group were put into relaxation techniques. The participants detected with mild to high depression were provided with progressive muscle relaxation along with autogenic training and relaxation imagery. The relaxation techniques can be administered after brief training and does not require much knowledge and skills (Polzer 2017). The relaxation imagery along with cognitive behaviour therapy has been seen to result in calming effect in the patient.

The techniques of relaxation were found to be effective in reducing self rated symptoms of depression than minimal or lack of treatment methods (Jorm et al. 2008). However, they were not found to be comparatively less fruitful than psychological treatment.  On the other hand, the relaxation techniques can be used as first line treatment for depression management in younger people (Hind et al. 2014). In this aspect further research has pointed out that provision of a combinatorial treatment including CBT and simple relaxation techniques can have much better outcome.

Depression is one of the wide spread and most common mental health issues which seeds in childhood and if left untreated may become more prominent in adulthood. Depression ranks 4^th in the global burden of disease and contributes towards a significant portion of the overall healthcare costs. The cognitive behaviour therapy (CBT) and behavioural activation (BA) are the preliminary treatments method for depression. As mentioned by Greenberg (2017), the CBT along with administration of drugs have been seen to produce much long term feeling of well –being within the patient. The current study emphasises upon the treatment of depression though BA based self-help and CBT interventions available over the internet (Huguet et al. 2016). The goal is to enable self help for treating depression in youth as well as old age with the help of mobile apps.

In the current article a review had been conducted with an aim to identify the self help apps in controlling and management of depression in people by offering CBT and BA. 10.26 % of the apps detected through the search methods were found to offer support systems which were in accordance with evidence based principles of CBT and BA (Huguet et al. 2016). However, the low level of efficacy based studies and diversion from the core principles of CBT, the credibility of the CBT/BA apps are questionable. Additionally, they are not guided by sufficient privacy policies which make personal data sharing across the apps unsafe.

Self-Help Mobile Apps for Depression Management

In the study designed over here only the apps providing self help treatment for CBT and BA were considered. The full paid version of the apps was only downloaded in order to provide a comprehensive assessment package whereas the free and incomplete versions were excluded. Chan et al. (2008), had designed an evaluative framework which would help in choosing the best mobile app base upon usefulness, usability, integration and infrastructure. However, a number of loopholes were found such as the lack of sufficient evidence based literatures entailing the effectiveness of mobile based apps for delivery of depression care treatment.

Secondly the help for CBT using mobile apps was provided by one expert only than a counsel of experts. As commented by Gilbody et al. (2015), the lack of a second opinion may hinder a vast section of population from using the specified services. Additionally, the extent to which the app imbibes core ingredients of CBT could not be deciphered from the number of downloads made.

The journal here compares the affectivity of cognitive behavioural therapy and pharmacotherapy for the treatment of adult depression. The articles here aim to compare the long term effects of continuing with CBT alongside pharmacotherapy for treatment of depression in adults. The patients were divided into control and randomised control trial groups. Out of the 506 total patients registered, one group of patients had undergone CBT whereas the other group was provided with pharmacotherapy (Cuijpers et al. 2018).  This group was not provided with CBT therapies and were dependent on pharmacotherapy. The patients were checked for relapse of a depressive condition after they had undergone treatment discontinuation for longer periods of time. It was found that the ones who had received CBT as treatment methods showed little or no tendency to relapse (Cuijpers et al. 2018). It was found that CBT had enduring effect after and helped he patients with management of their depression after the acute treatment procedures were discontinued.

The literature pieces used over here corresponds to level three of the 6s pyramids. The articles have been derived from different secondary databases such as BMJ, PLOS and Cochrane library. The articles have been chosen as a means of comparing with other intervention methods and processes which could be used in the treatment of depression. The articles have been chosen in an order which helps in gradually progressing through the different stages of psychotherapy. The CBT he been compared with a number of depression treatment methods such as – relaxation techniques and online methods of CBT administration.

Comparative Analysis of Cognitive Behaviour Therapy and Pharmacotherapy for Depression Treatment

A review through the literature helped me in choosing the most suitable method for provision of care and support services to people suffering from depression. In my current clinical set up I had been catering to the depression management of adolescents and the aged. Since we have to provide depression care services to diverse age group of people we need to balance between a number of intervention methods and practices.  The relaxation techniques were found to be useful in combination with the CBT methods.  They were provided before and after the administration of the acute psychotherapeutic interventions, which particularly made the youths better self-manage their conditions. However, the administration of the CBT have been found to be effective in producing a long term enduring effects and prevent the relapse of depression after discontinuation of the acute psychotherapies (Weitz et al. 2015). The patients were seen to excise better behavioural controls.

A number of barriers may be faced for the implementation of evidence based practices for the management of depression using cognitive behavioural therapy. There are approachability concerns within the youth regarding availing psychiatric help services. It has been reported that only in one in five youths will receive a psychiatric diagnosis and less than 20 % would actually avail of the services (Riper et al. 2014). Multidimensional perceptions of the use of evidence based practices in mental healthcare providers may lead to hindrances in effective dissemination of the services. As mentioned by Weitz  et al. (2015), cultural beliefs possessed by an individual and the community in general further dictates the health behaviour and approaches adopted by them. Additionally lack of training manuals can also affect the quality of the mental health support services.

The implementation of the evidence based methods and services in clinical care for depression would receive greater levels of scrutiny due to the involvement of relatively small patient population (Polzer 2017).  Moreover, the results were found to be not relevant to the problem situation.  In addition, inadequate staffing and lack of funds have been seen to hinder the implementation of the evidence based practices. For the implementation of effective evidence based methods, understanding the thought process of the stakeholders is very important. However, inability to correlate with the patients or their individual ideologies may prove to be a barrier in the implementation of patient centred approaches (Gilbody  et al. 2015).

Though CBT have been found to be beneficial in the treatment of anxiety in youths sufficient levels of loopholes have been found. The physician has been seen to use a number of alternate strategies along with CBT for management of youth anxiety. However, the methods have been not been implemented as frequently as required due to lack of resources. Ineffective documentation is another issue which may serve as a barrier to effective dissemination of mental health processes. Sometime the root cause for inappropriate care and support services lies in a failure to identify the actual mental health problem within the patient. As commented by Huguet  et al. (2016), the problem may be deep rooted in nature and sometimes is backed up by genetic or hereditary causes.  There is a very thin line between some of the mental health problems such as bipolar disorder and depression. As mentioned by Amick  et al. (2015), inability to identify the actual cause may result in wrong treatment being delivered to the patients.

The older patients have been less likely in reporting depression compared to the youth.  This is because they often associate depression with weak moral character. The consistent low mood has been seen to be associated with physical illness by the aged which prevents them from consulting physicians (Hollinghurst et al. 2014). Sometimes the physicians have been seen to confuse the presence of depression as normal mood swings exhibited in old age. The nurses possessing less knowledge regarding the depression screening tools have been seen to develop reluctance within them in the handling and management of severe depression in patients. As commented by Bakker and Rickard (2017), lack of cooperation and collaboration between primary health care team may result in erroneous reporting of patient condition.

A number of steps and measures have been employed within the mental healthcare set up in order to deal effectively with the barriers faced in the implementation of evidence based practices. Some of these are implementation of effective documentation within the geriatric wards. This is because the old age population often suffer from low memory syndromes afflicted by conditions such as dementia or multiple sclerosis (Kuyken et al. 2015). Therefore, documentation of the health records of the patients would prevent administration of wrong medicines to the patients. In addition, we have initiated nursing training programmes within our healthcare set up in order to educate the nurses upon the screening mechanisms. Moreover, adequate support from the government in the form of required amount of funds would also help in dissemination of adequate mental health services (Hedman et al. 2014). Additionally, implementation of a patient centred approach would also help us in understanding the specific concerns of the patients and their respective families which would help in improving the quality of the care services.

References 

Amick, H.R., Gartlehner, G., Gaynes, B.N., Forneris, C., Asher, G.N., Morgan, L.C., Coker-Schwimmer, E., Boland, E., Lux, L.J., Gaylord, S. and Bann, C., 2015. Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis. Bmj, 351, p.h6019.

Andersson, G., Cuijpers, P., Carlbring, P., Riper, H. and Hedman, E., 2014. Guided Internet?based vs. face?to?face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta?analysis. World Psychiatry, 13(3), pp.288-295.

Andrews, G. and Williams, A.D., 2015. Up-scaling clinician assisted internet cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care. Clinical Psychology Review, 41, pp.40-48.

Bakker, D. and Rickard, N., 2017. Engagement in mobile phone app for self-monitoring of emotional wellbeing predicts changes in mental health: MoodPrism. Journal of affective disorders, 227, pp.432-442.

Cuijpers P, Hollon SD, van Straten A, et al (2018). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A metaanalysis. BMJ Open, pp.105-215. doi:10.1136/ bmjopen-2012-002542

Cuijpers, P., Weitz, E., Lamers, F., Penninx, B.W., Twisk, J., DeRubeis, R.J., Dimidjian, S., Dunlop, B.W., Jarrett, R.B., Segal, Z.V. and Hollon, S.D., 2017. Melancholic and atypical depression as predictor and moderator of outcome in cognitive behavior therapy and pharmacotherapy for adult depression. Depression and anxiety, 34(3), pp.246-256.

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, G., Tharmanathan, P., Araya, R., Barkham, M., Bower, P., Cooper, C., Gask, L. and Kessler, D., 2015. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ, 351, p.h5627.

Greenberg, L.S., 2017. Emotion-focused therapy of depression. Person-Centered & Experiential Psychotherapies, pp.1-12.

Hedman, E., Ljótsson, B., Kaldo, V., Hesser, H., El Alaoui, S., Kraepelien, M., Andersson, E., Rück, C., Svanborg, C., Andersson, G. and Lindefors, N., 2014. Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care. Journal of affective disorders, 155, pp.49-58.

Hind, D., Cotter, J., Thake, A., Bradburn, M., Cooper, C., Isaac, C. and House, A., 2014. Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis. BMC psychiatry, 14(1), p.5.

Hollinghurst, S., Carroll, F.E., Abel, A., Campbell, J., Garland, A., Jerrom, B., Kessler, D., Kuyken, W., Morrison, J., Ridgway, N. and Thomas, L., 2014. Cost-effectiveness of cognitive-behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial. The British Journal of Psychiatry, 204(1), pp.69-76.

Huguet A, Rao S, McGrath PJ, Wozney L, Wheaton M, Conrod J, et al. (2016) A Systematic Review of Cognitive Behavioral Therapy and Behavioral Activation Apps for Depression. PLoS ONE, 11(5), pp.248-315, doi:10.1371/journal. pone.0154248

Jorm AF, Morgan AJ, Hetrick SE (2008). Relaxation for depression. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD007142, pp. 105-225. DOI: 10.1002/14651858.CD007142.pub2.

Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., Lewis, G., Watkins, E., Brejcha, C., Cardy, J. and Causley, A., 2015. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet, 386(9988), pp.63-73.

plos.org (2016), plos.org , Available at : https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0154248&type=printable [Accessed on 22 Jan 2016]

Polzer, E., 2017. Mosh Pits and Mental Health: Metal Communities and Emerging Adults’ Well-Being (Doctoral dissertation, Colorado State University), pp. 135-265.

Richards, D.A., Ekers, D., McMillan, D., Taylor, R.S., Byford, S., Warren, F.C., Barrett, B., Farrand, P.A., Gilbody, S., Kuyken, W. and O’Mahen, H., 2016. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. The Lancet, 388(10047), pp.871-880.

Riper, H., Andersson, G., Hunter, S.B., Wit, J., Berking, M. and Cuijpers, P., 2014. Treatment of comorbid alcohol use disorders and depression with cognitive?behavioural therapy and motivational interviewing: A meta?analysis. Addiction, 109(3), pp.394-406.

Roepke, A.M., Jaffee, S.R., Riffle, O.M., McGonigal, J., Broome, R. and Maxwell, B., 2015. Randomized controlled trial of SuperBetter, a smartphone-based/Internet-based self-help tool to reduce depressive symptoms. Games for health journal, 4(3), pp.235-246.

Siu, A.L., Bibbins-Domingo, K., Grossman, D.C., Baumann, L.C., Davidson, K.W., Ebell, M., García, F.A., Gillman, M., Herzstein, J., Kemper, A.R. and Krist, A.H., 2016. Screening for depression in adults: US Preventive Services Task Force recommendation statement. Jama, 315(4), pp.380-387.

van Ballegooijen, W., Cuijpers, P., van Straten, A., Karyotaki, E., Andersson, G., Smit, J.H. and Riper, H., 2014. Adherence to Internet-based and face-to-face cognitive behavioural therapy for depression: a meta-analysis. PLoS One, 9(7), p.e100674.

van den Brink, G., Stapersma, L., El Marroun, H., Henrichs, J., Szigethy, E.M., Utens, E.M. and Escher, J.C., 2016. Effectiveness of disease-specific cognitive–behavioural therapy on depression, anxiety, quality of life and the clinical course of disease in adolescents with inflammatory bowel disease: study protocol of a multicentre randomised controlled trial BMJ open gastroenterology, 3(1), p.e000071.

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J., David, D., DeRubeis, R.J., Dimidjian, S., Dunlop, B.W., Cristea, I.A. and Faramarzi, M., 2015. Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: an individual patient data meta-analysis. JAMA psychiatry, 72(11), pp.1102-1109.

Wilczynski N. and Mckibbon A., (2013) Finding the evidence, chapter 3. [online] Elsevier healthsciences.Retrievedfromfile:///C:/Users/absas/Downloads/1968472_1925337866_EvidenceBasedPracticeAcrossth.pdfAvailable from [Accessed on 27/01/2018].

Wood, J.J., McLeod, B.D., Klebanoff, S. and Brookman-Frazee, L., 2015. Toward the implementation of evidence-based interventions for youth with autism spectrum disorders in schools and community agencies. Behavior therapy, 46(1), pp.83-95.