Literature Review: Prophylactic Impacts of CBT on depression

Depression is considered one of the most common psychiatric disorders in the world and was anticipated to become the most expensive illness in the world by the year 2010 (Weinberger and Beck, 2001). On the other hand, as noted by Glass (2003), the World Health Organization pointed out that by the year 2020, depression will be the second major leading cause of disability in developed countries, while in developing countries, it will be the main leading course of disability.

From a review of the facts and statistics about depression in the USA, as reported by the Anxiety and Depression Association of America (2016), it can be noted that the claims by Weinberger and Beck (2001) and Glass (2003) are valid since according to Anxiety and Depression Association of America (2016);

1. Anxiety disorders are the most prevalent mental illness in the USA, and they affect over 40 million adults in the country that are 18 years and above and make up 18% of the US population
2. The treatment of anxiety disorders in the US costs more than $42 billion annually, with approximately $22 billion of these costs linked to repeated use of healthcare services.

From such perspectives, it can be noted that depression is a major illness all over the world, and it is therefore ideal that a study that seeks to investigate the prophylactic effects of cognitive behavioral therapy (CBT) on depression is carried out since CBT has over the years been used to treat depression all over the world.

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Definition of depression

From a review of the definitions that have been used to define depression by various scholars, experts, and other parties, it can be noted that depression has been defined differently by various parties even though the different definitions are, to some extent, similar. For example, Mayo Clinic (2016) has noted that depression is also referred to as major depressive disorder or clinical depression, and it is “a mood disorder that causes a persistent feeling of sadness and loss of interest” (p.1). On the other hand, Medicine Net (2016) has expounded that depression is an illness that encompasses the body, mood, and opinions and also impacts how a person eats, sleep, views and feels himself/herself, and thinks about other things.

Causes of depression

As far as causes of depression are concerned, it can be noted that the causes of depression have not been precisely established. Indeed, as noted by the National Institute of Mental Health (2000), no specific cause of depression has ever been found. However, it can be mentioned that in situations where a family history of depression exists, a higher risk for an individual being diagnosed with depression exists; hence the reason inheritance of a biological vulnerability has been discussed as one of the causes of the disorder. Nevertheless, some individuals have been diagnosed with depression even though they do not have any family history of the disorder; hence factors such as environmental stressors and psychological and biochemistry factors have been considered to be causes of the disorder (Young, Weinberger, and Beck, 2001). In addition, Young, Weinberger, and Beck (2001) have discussed that depression is seemingly triggered by life situations or enduring problems since an estimated 66% to 90% of cases of depression have had a major development taking place within six months of the starting of depression with most of the people affected having an element of loss.

As far as the gender, race, and age of those affected by depression are concerned, it can be explained that depression affects people from all gender, ages, and races, even though the rate of women that are affected by depression is normally higher when compared to the rate of men. Indeed, one in five women in the US is expected to experience depression during their lifetime, while on the other hand, one in ten men in America is expected to experience depression (Doris, et al. 1999).  However, irrespective of the difference in prevalence rates among the gender, it can be noted that the main signs of depression are usually the same across all genders, ages, and races. However, the distinction of somatic moans, social withdrawal, and prickliness tend to be common in children, while confusion, loss of memory, and distractibility are quite common in the elderly (McGinn and Sanderson, 2001).

Reasons to compare CBT to other types of treatment

As noted by Pattison and Lynd-Stevenson (2001) and National Health Services (2016), various treatments can be used to treat depression. To be precise, anti-depressants and therapy (cognitive behavioral therapy and counseling) are the most common treatments used to treat depression.

On the other hand, Garland and Scott (2002) discussed that cognitive behavioral therapy has been the most common treatment approach used to treat depression for many years. According to Butler and Beck (1995), cognitive behavioral therapy emanates from the cognitive theory of depression that was advanced by Beck, and it entails a dynamic, organized, issue-dedicated, and time-bound approach to treatment which is founded on the proposition that depression is upheld by negative-biased information handling and dysfunctional principles and opinions. On the other hand, CBT is mainly developed to help ensure that those who are suffering from depression can learn to reason more adaptively and thus experience advances in affect, inspiration, and attitude (Garland and Scott, 2002).

In that view, it can thus be noted that there is a need to compare CBT with other types of treatment used to treat depression to establish whether CBT is effective or where the other types of treatments are effective.

Importance of looking at long-term effects

As already noted, CBT is the most common treatment used to treat depression in most parts of the world. Thus, the long-term impacts of CBT must be investigated since, from the investigation, it can be established whether CBT has the desired long-term effects on individuals suffering from depression.

Literature review

Overview of CBT

As already highlighted, cognitive behavioral therapy has been the most common treatment approach used to treat depression for many years. Cognitive behavioral therapy emanates from the cognitive theory of depression that was advanced by Beck, and it entails a dynamic, organized, issue-dedicated, and time-bound approach to treatment which is founded on the proposition that depression is upheld by negative-biased information handling and dysfunctional principles and opinions.

Some of the key aspects of CBT are its emphasis on precise, quantifiable, and attainable objectives. The setup of these objectives results in the establishment of a cooperative treatment strategy with the individual who happens to be suffering from depression. On the other hand, other vital aspects of CBT entail setting the agenda, evaluating the signs, and managing certain techniques, including an assessment of the interventions used (McGinn and Sanderson, 2001).

According to Dozois, Cogin, and Brinker (2003), when using cognitive behavioral therapy, a comprehension of sign severity and analysis is vital in the development of a treatment strategy as well as an outcome assessment. Because the adjustment of the negative automatic opinions and dysfunctional attitudes is stressed in CBT, a vital aspect of result evaluation for depression entails the quantification of cognition. Indeed, it has been hypothesized in various studies that cognitive alteration is linked to alterations in depressive symptomatology, while cognitive change seems as if it is a vital variable to evaluate in therapeutic change for depression (Dozois, Cogin, and Brinker, 2003).

Past studies on CBT

Over the years, various studies that have investigated various aspects of CBT have been carried out. In this section of the research, some of these past researches will be reviewed, with the main emphasis being on the studies that focused on the prophylactic effects of CBT on depression.

One of the studies on CBT entails the study carried out by Parker and Fletcher (2007), which critiqued the evidence of treating depression with evidence-based psychotherapies comprising cognitive behavior therapy and interpersonal therapy. Nevertheless, it can be explained that the main shortcoming of this study by Parker and Fletcher (2007) was that the scholars did not carry out any primary research and mainly depended on secondary information contained in various secondary sources. As a result, the reliability and validity of the findings of the study by Parker and Fletcher (2007) could be questioned since the use of secondary sources meant that the researchers might have used information that might have been biased as they did not get the chance to securitize the data that was used in the secondary researches that they used. Nevertheless, from a review of some of the sources that were used by the scholars, it can be pointed out that the researchers who carried out these researches had adopted various measures to ensure that the findings of the studies they carried out were valid and reliable. From the clinical review by Parker and Fletcher (2007), the scholars found that the specialty for cognitive behavior therapy and interpersonal therapy for depression is yet to be found, and in that view, they proposed that to prove or substantiate the effectiveness of CBT over IPT, it will be crucial that the tests are carried out across defined situation instead of universal situations. Indeed, according to the scholars, they were not able to determine whether cognitive behavior therapy is more effective than interpersonal therapy.

On the other hand, Driessen and Holln (2011) conducted a study investigating the effectiveness of cognitive behavioral therapy in the acute stage of depression, specifically in adult populations, while emphasizing moderation and response mediation. From a review of the research methods that were used, it can be noted that the study’s findings can be considered reliable and valid as the researchers put in place various measures to ensure that their study did indeed measure what it was intended to measure. From the meta-analytic findings of the study that was carried out, the researchers found that cognitive behavioral therapy had a medium effect size (d=67) relative to various control situations that vary from the lack of treatment to non-specific controls. Indeed, from the research, the scholars noted that only one in three patients that will be treated through cognitive behavioral therapy will be better off because the patient will have come into therapy. Those findings can also be understood to suggest that CBT is more effective than its absence and slightly more successful than the deployment of hope and contact with the therapist. Thus, according to the scholars, CBT was deemed to work better than its absence for various reasons since when it is used with other medications, it was found to be more effective. Regarding the enduring effects, the scholars found that CBT has enduring effects that tend to last even beyond the end of the treatment as it does not protect the patient against subsequent deterioration once the treatment has ended. On the other hand, the scholars also found that individuals who are married, have no jobs, or have different antecedent life events are likely to do better in CBT than in antidepressant medications. In conclusion, Driessen and Holln (2011) noted that there are signs that CBT could work through procedures identified by theory to result from changes in perception that would then arbitrate successive changes in depression and freedom from decline following the end of treatment even though more researches need to carried out to prove that.  

Another study that focused on cognitive behavioral therapy entails the study that was carried out by Javastavi et al. (2011), which sought to investigate the impact of cognitive behavioral therapy and changes in depressive symptoms among Thai adults infected with HIV. The cohort study was carried out between September 2010 and February 2011 at King Chulalongkorn Memorial Hospital, located in Bangkok, Thailand. CBT has been a routine service treatment administered to patients who had HIV and depression. From an analysis of the research methods that were applied by Javastavi et al. (2011), it can be explained that the study was carried out in an ideal manner, and for that reason, the research findings were reliable and reliable also valid. Among others, the fact that the researchers collected informed consent from the patients and also used an ideal sampling approach implies that this research’s findings can be considered credible. The study found that the average ages of the research subjects were 44.8 years for subjects who were undergoing CBT and 43.4 years for subjects who were not undergoing CBT. Regarding the gender of the research, subjects were conserved; it can be noted that in both CBT and non-CBT groups, there was an equal representation of males and females in both groups, making us 50% of the group. As far as life stress event score was concerned, it was found that in the case of the CBT group, it was considerably higher than the non-CBT group (p < 0.01). On the other hand, at baseline, the average TDI score of the CBT group was 26.7, while that of the non-CBT group was 25.3, respectively. Once amendment for age, sex, social help, life stress event and existing opportunistic infection was considered; the average changes of TDI scores in the CBT group were considerably higher than the non-CBT group both directly [12.13 (95% CI, 10.00 – 14.26)] (p < 0.001) and at 3-month post-treatment [15.94 (95% CI, 13.69 – 18.18)] (p < 0.001). From the findings of the study, Javastavi et al. (2011) concluded that CBT was beneficial for the management of depression among adult patients who happened to be infected with HIV in Thailand. In addition, Javastavi et al. (2011) also noted that the beneficial impact of CBT was not only valid for a short time since it was found to be sustained three months after the treatment has ended.

The other study that investigated cognitive behavioral therapy is the study by Parker, Roy, and Eyers (2003). In their study, Parker, Roy, and Eyers (2003) sought to establish whether there exist any problems with the numerous efficacy studies that have focused on cognitive behavior therapy. Thus, for these scholars to achieve their objective, they reviewed various original and quantitative studies that have analyzed the application of cognitive behavior therapy for depression.  Even though this study used only information that was collected from secondary sources, it can be noted that the research helped contribute to the existing literature as it compared cognitive behavioral therapy with other treatment approaches that are used in the treatment of depression. From the secondary research that was carried out by Parker et al. (2003), it was found that claims for cognitive behavior therapy success are exaggerated as there were questions about whether the efficacy of cognitive behavioral therapy underpins its theory while cognitive behavior therapy was also found to be a universal strategy instead of been a targeted strategy. In conclusion, Parker et al. (2003) noted that even though cognitive behavior therapy mighty do more by its generic therapeutic elements, testing cognitive behavior therapy’s effectiveness in assorted study groups instead of in specific subgroups results to failure to distinguish it from control therapies thus raising questions on the validity of cognitive behavior therapy efficacy studies.

Wilson, Scott, Abou-Saleh, Burns, and Copeland (1995) also conducted a study that focused on the long-term impacts of cognitive-behavioral therapy and lithium therapy on depression in the elderly. In this research, the scholars assessed the impacts of cognitive-behavioral therapy as an adjuvant to severe physical treatment and lithium sustenance therapy in minimizing depression seriousness over a follow-up year in elderly depressed patients. This study by Wilson et al. (1995) was carried out in three stages where in the acute treatment and continuation phase, nearly half of the research subjects were treated with CBT. On the other hand, in the maintenance stage, the subjects were involved in a double-blind, placebo-controlled study of low-dose lithium therapy. From the analysis of the study’s findings, the scholars found that receiving adjuvant CBT suggestively minimized the research subject’s score on the Hamilton Rating Scale for Depression during the follow-up year, even though no major variation was found between lithium and placebo maintenance therapy.  As a result, the researchers concluded that CBT can be applied as adjuvant therapy to treat seriously depressed elderly patients and minimize depression seriousness during follow-up. In addition to that, Wilson et al. (1995) noted that the prophylactic failure of long-term therapy could be expounded by poor compliance. Considering the research methodology applied in this specific research, it can be explained that the research findings can be considered reliable and indeed valid.

 Another research that focused on the prophylactic effects of cognitive behavioral therapy entails the study that was carried out by Durham, Chambers, Power, Sharp, Macdonald, Major, and Gumley (2005) whose aim was to determine the long-term impact of subjects in clinical trials of cognitive behavior therapy for anxiety disorders and psychosis, assessing the efficiency and cost-effectiveness linked with receiving CBT while compared to other substitute treatments. To achieve that aim, the study included 489 participants from mixed and urban settings in five localities within Central Scotland. As far as the anxiety disorder trials were concerned, it can be noted that they were specifically in basic care and comprised three with generalized anxiety disorder, four with panic disorder, and one with post-traumatic stress disorder (PTSD). On the other hand, the psychosis studies (one on relapse avoidance and one with chronic conditions) were undertaken in secondary care. From the research, the scholars found that in the case of the anxiety syndrome studies, more than 50% of the subjects had at least a single diagnosis at long-term follow-up, with major levels of co-morbidity as well as health status scores that were comparable to the bottommost 10% of the normal population. 365 of the participants responded that they had not received interim treatment for anxiety during the follow-up period, while 19% were found to have received nearly constant treatment. Treatment with CBT was linked with an improved long-term result, unlike in cases where there was no CBT, even though the positive impacts of CBT that were found in the initial trials were worn down over an extended period. Additionally, no proof was found regarding the relationship between more rigorous therapy and more lasting impacts of CBT. Indeed, from the research, the long-term consequence was determined to be most intensely anticipated by the difficulty and brutality of presenting problems at the time of referral, by the accomplishment of treatment regardless of modality, and by the nature of interim treatment at the follow-up period. As far as the quality of the therapeutic alliance that was quantified in two of the trials was concerned, it was found to be not connected to long-term results even though it was connected to short-term impact. Given the cost-effectiveness, it can be pointed out that the analysis of the cost-effectiveness of CBT and non-CBT treatment did not find CBT to have any advantages over non-CBT. Indeed, the cost of offering CBT in the initial trials was only a marginal proportion of the entire cost of healthcare for the population. Regarding the psychosis studies that comprised trials 9 and 10 were concerned, the study found that CBT had no long-term impacts. From those findings, Durham et al. (2005) noted that there is a need for psychotherapy services to acknowledge that anxiety disorders are likely to follow a long-lasting course while ideal results of CBT within a short period are in no way assurances of desired results in the long run.

 A recent study on the topic can be discussed as the research by Johnsen and Friborg (2015), which investigates the impacts of cognitive behavioral therapy as an anti-depressive treatment, is declining. The study comprised a meta-analysis of seventy studies that were considered to be qualified and had been carried out from the year 1977 to the year 2014.  From this study, Johnsen and Friborg (2015) found that even though CBT used to be quite effective in the past, the efficacy of the approach has declined over the years, and it is for that reason that other alternative treatment approaches have been preferred. In addition to that, Johnsen and Friborg (2015), went further to expound on some of the reasons why CBT has become less effective. Some of the reasons, as explained by Johnsen and Friborg (2015) that have contributed to the decline of the efficiency of CBT entails; lack of intense training on the who are administering CBT, lack of ample experience from those administering CBT, and standardization of CBT approach even though each case needs to be treated on its own.

Summary of the literature review

 From the literature review, it can be noted that, as per the review, cognitive behavioral therapy was advanced in the 1960s as a depression treatment method. Depression has been a common condition over the years as at least one out of eight people is expected to be diagnosed with depression. If not treated, depression can have devastating impacts. For that reason, scientists and other experts have over the years advanced various approaches that can be used to treat depression.

 Indeed, there exist numerous treatment methods that include medications, cognitive behavioral therapy, and other types of psychotherapy that can be used to treat depression. From a review of the literature, it has been found that there is sufficient evidence to show that in situations where an individual is suffering from either slight or modest depression, CBT can be used to treat depression. Nevertheless, it can also be noted that other researchers have also found that CBT cannot be effective on its own and that it needs to be incorporated with another treatment method to ensure that the individual who is suffering from depression can be able to recover fully.

 On the other hand, the CBT method for treating depression can be categorized into two elements: cognitive and behavioral. As far as the cognitive aspect is concerned, the therapist and the individual who happens to be treated have to establish how to single out negative thinking that results to negative emotions and then questions the validity of these perspectives so that they can come up with substitute balanced perspectives. In the case of the behavioral aspect of treatment, the therapist assists the patient in assessing how the various activities affect the mood of the patient and how some of them can recover from the signs of depression. Thus, the therapist has to assist the patient in developing an action plan that mainly entails creating a variety of activities and prioritizing the activities from the easier ones to the hard ones so that as the patient progresses from the easier activities to the harder activities, the patient’s feeling of mastery gets better as depression decreases.

 From the review of various studies that have focused on the topic of treatment of depression, it can be noted that there seems to be a lack of agreement on whether CBT is an effective depression treatment approach since on the one hand, there are some researchers that have found CBT to be effective while on the other hand, there are some studies that show that CBT can only be effective if it is used together with other approaches that might include medication.

Specific aspects of CBT allow the prophylactic effects

Even though the literature review has highlighted various studies that have focused on cognitive behavior therapy, the study by Driessen and Hollon (2010) can be discussed as one of the studies that have highlighted some of the aspects of CBT that permit the prophylactic effects. Indeed, according to the study, the cognitive and behavioral aspects are the two main aspects of CBT that allow prophylactic effects. As far as the cognitive aspect is concerned, the therapist and the individual who happens to be treated have to establish how to single out negative thinking that results in negative emotions and then questions the validity of these perspectives so that they can come up with substitute balanced perspectives. In this case, if the behavioral aspect of treatment, the therapist assists the patient in assessing how the various activities affect the mood of the patient and how some of them can recover from the signs of depression. Thus, the therapist has to assist the patient in developing an action plan that mainly entails creating a variety of activities and prioritizing the activities from the easier ones to the hard ones so that as the patient progresses from the easier activities to the harder activities, the patient’s feeling of mastery gets better as depression decreases.

Limitations of current research on this topic

 This research is not without its limitations. To begin with, the research has only relied on secondary sources implying that the extent to which the findings of this research can be considered to be valid and reliable is limited since there is a high chance that some of the studies that have been used in this specific research might have been compromised. In addition, it can also be noted that the research has used studies that were conducted a couple of years ago, implying that there is a chance that the findings of the research could be outdated as some developments in the treatment of depression have taken place since some of the studies were carried out.

  Moreover, it can also be highlighted that CBT and depression is a wide topic that demands a lot of time which the research did not have in this case. Thus, there is a chance that some aspects of the research topic needed to be discussed but were overlooked due to time limits.

Recommendations for the future direction of research

Research is always ongoing and can never end since new developments are always taking place. In the context of this research, it can be noted that various recommendations can be made about the future directions that other researchers might adopt as a follow-up to this specific research.

 To begin with, it can be noted that this research mainly depended on secondary sources, specifically studies that have been carried out in the past, implying that there is a chance that the findings of this research could be outdated. Thus, it is recommended that future research focus on undertaking primary research to determine whether this research’s findings are valid.

Moreover, in this research, the cognitive and behavioral aspects have been discussed as the two main aspects of CBT that allow prophylactic effects. Therefore, it is recommended that future research could compare the cognitive and behavioral aspects’ impacts on an individual suffering from depression and undergoing CBT to establish which of the two aspects has the main impact on the individual.

Finally, the other study that could be carried out could aim to investigate the efficacy rate between CBT and medication approaches since, as has been pointed out from the literature review, there seems to be a disagreement on the topic since on the one hand, there were scholars who argue that CBT has for many years been effective in treating depression while on the other hand, there are other scholars who argue that medication is the most effective method.

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