Studying therapy for depression
Today, we look at three studies of psychotherapy for depression. First, Snippe, Elmer, Ceulemans, Smit, Lutz & Helmich (2024) published “The Temporal Order of Emotional, Cognitive, and Behavioral Gains in Daily Life during Treatment of Depression” in Journal of Consulting and Clinical Psychology. Here’s the edited abstract:
Despite the importance for understanding mechanisms of change, little is known about the order of change in daily life emotions, cognitions, and behaviors during treatment of depression. This study examined the within-person temporal order of emotional, cognitive, and behavioral improvements using ecological momentary assessment data. Thirty-two individuals with diagnosed depression completed ecological momentary assessment questions on emotions (sad mood, happy mood), behaviors (social interaction, number of activities), and cognitive variables (worrying, negative self-thoughts) 5 times a day during a 4-month period in which they underwent psychotherapy for depression. Nonparametric change-point analyses were used to determine the timing of gains (i.e., improvements in the mean of each variable) for each individual. We then established whether the first (i.e., earliest) gains in emotions preceded, followed, or occurred in the same week as cognitive and behavioral gains for each individual. Contrary to our hypotheses, first gains in behaviors did not precede first emotional gains (3 times, 8%) more often than they followed them (26 times, 70%). Cognitive gains often occurred in the same week as first emotional gains (43 times, 58%) and less often preceded (13 times, 18%) or followed emotional gains (18 times, 24%). The first improvements in behaviors did not tend to precede the first improvements in emotions likely because fewer behavioral gains were found. The finding that cognitive variables tend to improve around the same time as sad mood may explain why many studies failed to find that cognitive change predicts later change in depressive symptoms.
So, emotional gains more often preceded behavioral gains and cognitive gains often co-occur with emotional gains. Although this is a small sample, I like the fact that it rejects traditional behavioral psychology’s assumption that, if you change behavior, cognition and affect will follow. The next study looks at internet-based therapy, focusing on behavior and cognition.
Brose, Heinrich, Bohn, Kampisiou, Zagorscak & Knaevelsrud (2023) published “Sequencing Effects of Behavioral Activation and Cognitive Restructuring in an Internet-Based Intervention for Depressed Adults are Negligible: Results from a randomized controlled trial” in Journal of Consulting and Clinical Psychology. Here are the edited abstract and impact statements:
Applying elements of cognitive behavioral therapy (CBT) in internet-based interventions (IBIs) is effective in treating depression. However, CBT-based IBIs differ in which kind of components are applied and the order of their application. Furthermore, it is as yet unknown whether such sequencing matters. Using an IBI for depression, we examined whether the sequence of two major CBT components, behavioral activation (BA) and cognitive restructuring (CR), affect patterns of symptom changes and dropout rates. Individuals with moderate to mild depressive symptoms (N = 2,304, 59% female) were randomly assigned to two groups: one group that received BA in Modules 2 and 3 and CR in Modules 4 and 5, and another group with the opposite sequence. The component contents were identical. We investigated group differences in dropout rates, symptom changes, and change trajectories across the intervention. The groups had similar dropout rates and showed similar changes pre- to postassessment, and from pre- to 3-, 6-, and 12-month follow-up assessments. Between-group differences were small enough to be considered equivalent. Three classes of change trajectories emerged in both groups, but they did not differ in shape or size and did not show diverging associations with person-level characteristics. Results suggest that the sequence of the CBT components BA and CR in IBIs for depression does, on average, not systematically impact how individuals change during and after participation, which provides flexibility in designing CBT-based interventions.
This is a very large sample with findings that are consistent with Snippe et al. in that cognitive and behavioral changes were interchangeable in predicting outcomes. The final study looks specifically at positivity. Geschwind, Bosgraaf, Bannink & Peeters (2020) published “Positivity Pays Off: Clients’ perspectives on positive compared with traditional cognitive behavioral therapy for depression. Psychotherapy. The edited abstract and impact statements follow:
In this qualitative study, we explored the experiences of clients receiving cognitive behavioral therapy (CBT) for major depressive disorder. All participants received 8 sessions of traditional CBT (based on Beck, Rush, Shaw, & Emergy, 1979) and 8 sessions of positive CBT (order counterbalanced). The aim of the study was to examine clients’ experience of positive CBT and to contrast this with their experience of traditional CBT. Positive CBT structurally and selectively focuses on better moments (exceptions to the problem as opposed to the problem), strengths, and positive emotions and integrates traditional CBT with solution-focused brief therapy and positive psychology. In addition to conducting interviews with 12 individuals, the second author attended all therapy sessions of 4 clients and observed biweekly supervision sessions as further methods of data collection. Qualitative analysis showed that, despite initial skepticism, clients preferred positive CBT and indicated experiencing a steeper learning curve during positive, compared with traditional, CBT for depression. The popularity of positive CBT was attributable to 4 influences: feeling good and empowered, benefitting from upward spiral effects of positive emotions, learning to appreciate baby steps, and (re)discovering optimism as a personal strength.
How do clients with moderate to severe depression experience positive cognitive behavioral therapy (i.e., CBT with a structural focus on better moments, strengths, and positive emotions)? Respondents in this qualitative study perceived the structural focus on better moments, strengths, and positive emotions as enjoyable and motivating for change. Paying explicit attention to positive emotions in psychotherapy may be beneficial, given that respondents appreciated the lightness of tone and viewed exploration of their strengths, shared laughter, and compliments as memorable, motivating, and empowering. Next steps include replication of these findings in a larger sample receiving only positive CBT (rather than positive CBT as part of their treatment) and exploration of long-term effects, potentially expanding to different disorders and settings.
It’s another small sample study but I thought it was consistent with the other two in highlighting emotion in psychotherapy.