Behavioral Therapy May Be Better Than Cognitive Therapy for Severe Depression

Mark Dombeck, Ph.D. Updated: Sep 11th 2006

The documented success of cognitive approaches to therapy for Depression have tended to eclipse older 'behavioral-only' varieties of therapy that were once prescribed. However, recent research suggests that, at least when it comes to treating severe forms of depression, cognitive therapy may actually not be a better treatment strategy than purely behavioral approaches.

Specifically cognitive approaches to treating depression focus on helping teach people how to identify thoughts that cause depression, how to do reality testing on those thoughts and how to correct errors and exaggerations that are found so as to think more clearly. The idea is that when you teach people to think in a more clear and objectively accurate manner, their mood will tend to clear up. There is tremendous evidence from years of study that this proposition is true in large part.

Older, more pure behavioral approaches to treating depression focus less on what people are thinking, and more on what they are doing. An approach known as Behavioral Activation is based on the idea that people are less depressed when they are out in the community doing things and not withdrawn in their bedrooms with the covers pulled over their heads. This approach emphasizes the utility of helping depressed patients to schedule their lives, and maintain their involvements in social activities and work. There is also good evidence that this approach is helpful for treating depression.

Until recently, it has been assumed by many therapists that the cognitive approach was superior to the more pure behavioral approach. In light of recent evidence, however, it appears that this may have been an artifact of the newness of the cognitive approach. A study titled, "Randomized Trial of Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Acute Treatment of Adults With Major Depression", published in the most recent Journal of Consulting and Clinical Psychology (August 2006 Vol. 74, No. 4, 658-670) examined the efficacy of pure cognitive therapy, pure behavioral therapy in the form of Behavioral Activation, and pure medication therapy on depression outcomes. Their findings suggest that for more severe cases of depression, that the pure behavioral and antidepressant medication treatments worked equally well, and both therapies worked better than the pure cognitive therapy approach.

This is a potentially revolutionary finding, in that if such findings are repeatable (and they appear to be so), there may now be cause for therapists to switch towards more pure behavioral treatments when confronted with serious depression.

Many studies have borne out the efficacy (and in many cases the superiority) of cognitive therapy for treating depression. Why would the approach fail in comparison to these other means of treatment? It seems likely to me that the answer will have to do with the severity of depression that is being treated.

Cognitive therapy has always been a more mentally demanding approach than pure behavioral approaches to therapy. Verbally skillful people have the backgrounds and the interior articulateness needed to identify automatic thoughts and correct cognitive errors. People without good verbal skills sometimes find the therapy difficult and confusing. Now, merge that thought with the idea that severely depressed people are not at their cognitive and intellectual best, and you may see a pattern. To the extent that this finding of the current research is true, my guess is that it is simply harder for severely depressed people to engage and benefit from cognitive therapy, and easier for them to benefit from the behavioral therapy. There is less specifically mental effort that need be expended when you work behaviorally vs. cognitively.

This is a very interesting line of research, which I will attempt to keep tabs on as it progresses.

Mark Dombeck, Ph.D. is Director of Mental Help Net (a public service of CenterSite.Net - a provider of website and internet services and educational content to employee assistance and behavioral health organizations), and a licensed Psychologist in the state of Ohio (License #5698).

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