An overview of cognitive therapy for depression

Treatment usually proceeds through the following stages:

• diagnosis, assessment, and problem identification

• specific cognitive interventions designed to reduce the frequency of negative thoughts

• behavioural assignments intended to tackle behavioural and motivational deficits

• monitoring and questioning negative automatic thoughts (the main body of therapy)

• relapse prevention.

Generally speaking, patients move from one skills area to the next as each is mastered effectively. The starting point varies: severely depressed patients often need to begin with simple behavioural interventions, whereas relatively mild depression may be immediately amenable to work at the level of automatic thoughts. At each level, cognitive and behavioural treatment elements are closely integrated. Thus behavioural interventions such as activity scheduling present opportunities to identify and question negative thoughts, while work on thoughts and assumptions is always closely linked to changes in everyday behaviour.

Traditionally, up to 20 sessions of therapy are offered, twice a week for the first 4 weeks and once weekly thereafter. Follow-up sessions may be used to ensure that patients become increasingly confident and skilled at 'flying solo'. In practice, most patients respond within about 15 sessions. Some do well with four to six sessions, whereas severe chronic depressions may require more than 20 sessions, as well as increased frequency early on. Sessions start with agenda-setting (deciding what to work on and prioritizing items), a homework review, and feedback on the previous session. After the day's main topics have been discussed, more homework is agreed to ensure generalization to the patient's home environment and to consolidate skills acquired. Key points are summarized, and the therapist asks for reactions to the session, including anything that has been uncomfortable or unclear.

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