Editorials

Integrating Cognitive Behavioral Therapy into the Management of Depression



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Am Fam Physician. 2012 Apr 1;85(7):686-687.

Cognitive behavioral therapy (CBT) is a well-established, scientifically proven treatment for patients with depression. For family physicians to take full advantage of this treatment, they must be able to understand the nature and application of CBT; access professional resources that support effective collaboration with patients and consultants; and incorporate CBT into organized systems of depression care, such as the patient-centered medical home.

CBT is based on the work of American psychiatrist Aaron Beck, who reasoned that some persons learn to perceive self, personal world, and the future in a biased fashion. Through a variety of cognitive errors, a person may develop dysfunctional beliefs that lead to ineffective behavior (coping), depressed mood, and unpleasant physical symptoms. Automatic thoughts that are derived from dysfunctional beliefs (cognitive schema) are thought to be the central element maintaining depressed mood.13

In contrast to other forms of psychotherapy, CBT is: (1) active (the therapist and patient engage in speaking, in listening, and in refining an understanding of the patient's problems); (2) directive (the therapist has a set of techniques, derived from CBT, to apply to the patient's underlying cognitive schema); (3) time sensitive (session length is fixed at 30 to 45 minutes; number of sessions is fixed at six to 12, with subsequent “booster” sessions available); (4) structured (the therapist works to keep the patient on task to complete in-session work and outside-session homework assignments); and (5) collaborative (the therapist and patient work together in setting mutually acceptable goals).3

CBT effectively treats depression (to remission) in a number of populations. Depression remission is typically defined as at least a 50 percent reduction in pretreatment depression scores. Based on this criterion, the literature supports recommending CBT in patients eight to 19 years of age (number needed to treat [NNT] = 3 or 4), 18 to 64 years of age (NNT = 3 or 4), and 65 years and older (NNT = 8 to 10) with mild to moderate depression.1,2,411 In addition, combining CBT and antidepressants may be better than either approach alone in adults with recurrent or severe depression (NNT = 3).1,2,6 CBT alone in adults with depression is associated with lower relapse rates than antidepressants alone (NNT = 6).1,2,6,12 CBT may also be effective in reducing self-harm in adults and adolescents.1,13

Individual and group CBT (with and without antidepressants) have been helpful in patients with mild to moderate postpartum depression.1416 Adults with mild to moderate depression and a chronic medical condition also benefit from CBT (improvement in both depressive symptoms and the chronic medical condition).17

Family physicians can access several CBT resources (Table 1) that include educational handouts, podcasts, and therapist locator functions. For family physicians who are interested in providing CBT, the Beck Institute for Cognitive Behavior Therapy (http://www.beckinstitute.org) offers on-site and off-site training programs to teach CBT skills. A video of Judith Beck, PhD, discussing CBT can be viewed at http://www.youtube.com/watch?v=45U1F7cDH5k.

Table 1.

Cognitive Behavioral Therapy Resources

Academy of Cognitive Therapy

Web site: http://www.academyofct.org

American Board of Professional Psychology

Web site: http://www.abpp.org

Association for Behavioral and Cognitive Therapies

Web site: http://www.abct.org

Beck Institute for Cognitive Behavior Therapy

Web site: http://www.beckinstitute.org

National Association of Social Workers

Web site: http://www.socialworkers.org

National Register of Health Service Providers in Psychology

Web site: http://www.nationalregister.org

Table 1.   Cognitive Behavioral Therapy Resources

View Table

Table 1.

Cognitive Behavioral Therapy Resources

Academy of Cognitive Therapy

Web site: http://www.academyofct.org

American Board of Professional Psychology

Web site: http://www.abpp.org

Association for Behavioral and Cognitive Therapies

Web site: http://www.abct.org

Beck Institute for Cognitive Behavior Therapy

Web site: http://www.beckinstitute.org

National Association of Social Workers

Web site: http://www.socialworkers.org

National Register of Health Service Providers in Psychology

Web site: http://www.nationalregister.org

A consensus has emerged that depression is most effectively managed within an organized system of care.1823 Accordingly, the U.S. Preventive Services Task Force recommends screening adults and adolescents for depression in practices with systems in place to assure accurate diagnosis, effective treatment, and follow-up.18,19 In this regard, multiple depression management strategies based on principles of chronic disease management have been evaluated.2022

Collaborative care models for the management of depression in primary care improve diagnostic accuracy, treatment quality, adherence, and patient and physician satisfaction; reduce symptoms and hasten resolution; and improve functional status.2022 Adults of all ages with depression have been shown to benefit from these models. Many collaborative care models include CBT as a treatment option. Essential personnel include a primary care physician, mental health specialist, and midlevel case manager.2022 Effective collaborative care strategies include physician education, enhanced case management, integration among all health professionals, telephone or e-mail counseling by midlevel professionals, and a stepped-care approach. Stepped-care refers to determining patient response to depression treatment on a scheduled basis (more often early in treatment, less often during maintenance and follow-up) through routine readministration of a brief self-report questionnaire (e.g., nine-item Patient Health Questionnaire).24,25 For patients who remain depressed, treatment can be intensified as determined by the primary care team (e.g., adding CBT to antidepressants, adding antidepressants to CBT, increasing the dosage of antidepressants, adding or changing antidepressants).2022

Professional resources are available to assist family physicians in treating patients with depression within an organized system of care. Table 2 provides links to practical tools relevant to the development of primary care–based systems for depression care.

Table 2.

Resources for Developing Primary Care–Based Systems for Depression Care

American Academy of Family Physicians

Measuring, Evaluating, and Translating Research Into Care (METRIC) modules

Web site: http://www.aafp.org/cme/cme-topic/all/metric.html

National Committee for Quality Assurance

Patient-centered medical home

Web site: http://www.ncqa.org/tabid/631/default.aspx

The Macarthur Initiative on Depression and Primary Care

Web site: http://www.depression-primarycare.org/

Table 2.   Resources for Developing Primary Care–Based Systems for Depression Care

View Table

Table 2.

Resources for Developing Primary Care–Based Systems for Depression Care

American Academy of Family Physicians

Measuring, Evaluating, and Translating Research Into Care (METRIC) modules

Web site: http://www.aafp.org/cme/cme-topic/all/metric.html

National Committee for Quality Assurance

Patient-centered medical home

Web site: http://www.ncqa.org/tabid/631/default.aspx

The Macarthur Initiative on Depression and Primary Care

Web site: http://www.depression-primarycare.org/

Address correspondence to John R. Freedy, MD, PhD, at freedyjr@musc.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

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9. Purra K. Childhood depression. In: Ebell M, Ferenchick G, Smith M, et al., eds. Essential Evidence. Hoboken, N.J.: John Wiley & Sons; 2009.

10. Essential Evidence Plus. Cognitive behavior therapies in the depression in children and adolescents. http://www.essentialevidenceplus.com/content/ebmg_evd/526 (login required). Accessed February 24, 2012.

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14. Chabrol H, Teissedre F, Saint-Jean M, Teisseyre N, Rogé B, Mullet E. Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. Psychol Med. 2002;32(6):1039–1047.

15. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitivebehavioural counseling in the treatment of postnatal depression. BMJ. 1997;314(7085):932–936.

16. Crockett K, Zlotnick C, Davis M, Payne N, Washington R. A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression. Arch Womens Ment Health. 2008;11(5–6):319–325.

17. Levenson JL, ed. The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill. 2nd ed. Washington, DC: American Psychiatric Pub.; 2011.

18. U.S. Preventive Services Task Force. Screening for depression in adults. December 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm. Accessed January 19, 2012.

19. U.S. Preventive Services Task Force. Screening for major depressive disorder in children and adolescents. March 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm. Accessed January 19, 2012.

20. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA. 2003;289(23):3145–3151.

21. Oxman TE, Dietrich AJ, Schulberg HC. Evidence-based models of integrated management of depression in primary care. Psychiatr Clin North Am. 2005;28(4):1061–1077.

22. Dietrich AJ, Oxman TE, Williams JW Jr, et al. Going to scale: re-engineering systems for primary care treatment of depression. Ann Fam Med. 2004;2(4):301–304.

23. Korsen N. Translating a guideline into practice: the USPSTF recommendations on screening depression in adults. Am Fam Physician. 2010;82(8):891.

24. Kroenke K, Spitzer RL. The PHQ-9: a new depression and diagnostic severity measure. Psychiatr Ann. 2002;32:509–521.

25. Pinto-Meza A, Serrano-Blanco A, Peñarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? J Gen Int Med. 2005;20(8):738–742.


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