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This essay will focus on mild to moderate depression and compare two types of action-orientated therapy: problem-solving therapy and cognitive-behavioural therapy. These two types of interventions for depression have shown varying degrees of effectiveness in different studies. They will briefly be described and some of the major evidence evaluated, before the approaches are compared.
Cognitive behavioural therapy (CBT) is considered an important
and effective treatment for mild to moderate depression. It is often
referred to as one treatment, but is more correctly a number of
strategies that come from both cognitive and behavioural treatment
approaches. CBT is often a longer term intervention that require highly
trained practitioners. It is largely based on the idea that it is the
learning of certain non-adaptive beliefs and behaviours that causes and
maintains depressive states. The intervention is, therefore, based on
tackling these problems using a method that aims to break down these
cycles using learning principles. Behavioural strategies are focused on
the idea that a person receives a low level of reinforcement in their
normal environment and so includes training in social skills,
self-control and contingency-management (Hollon, Thase & Markowitz,
2002). Cognitive strategies concentrate on how life events are
perceived by the depressed patient. Patterns of thought that are
considered to be depressive are identified and these beliefs are
tested. Patients are often encouraged to vary their behaviour to test
what kind of outcomes this produces.
A large number of studies have been carried out into the effectiveness
of CBT. Gloaguen, Cottraux, Cucherat & Blackburn (1998), for
example, carried out a meta-analysis that reviewed the results of 78
studies on cognitive therapy (CT) carried out between 1977 and 1996 on
patients with mild to moderate forms of depression. They found that
cognitive therapy was superior to the control or placebo conditions.
Some evidence was found that CT was superior to pharmacological
interventions, and also that it had similar effectiveness to
behavioural therapies. Also, CT was seen to be more effective at
preventing relapses than antidepressants. Other meta-analyses, for
example the re-analysis carried out of Gloaguen et al. (1998) by
Wampold, Minami, Baskin & Tierney (2002), have questioned this.
Wampold et al. (2002) found that when the control treatments were
accounted for, there was an equivalence found between different
psychological therapies, rather than a superiority for CT.
CBT, like pharmacological treatments, has largely been evaluated in
heterogeneous populations. Parker, Roy & Eyers (2003) argue that
there has not been sufficient testing of which specific therapies are
best for which specific patients. Parker et al. (2003) state that all
depressive patients cannot be treated as a single homogenous unit that
can be treated in the same way. For example, there is evidence that,
Parker et al. (2003) argue, for nonmelancholic depression, CBT is more
effective than for other sub-types. Similarly, as Parker et al. (2003)
point out, there is little evidence that CBT is effective because of
the specific benefits of the therapy. This type of argument is often
raised against the different treatment modalities in psychotherapy.
MacLeod (1988) makes the distinction between specific and common
factors in psychotherapeutic interventions. Common factors include the
therapist's empathy, acceptance and warmth. These factors have been
shown by research such as Strupp (1996) to account for as much as 85%
of the variability in the outcomes of psychotherapeutic interventions.
In contrast, one of the advantages of CBT, in theory, is that it gives
the patient the skills that they need to avoid a relapse, something
that a psychopharmacological approach does not. As a result some
studies, such as Barber & DeRubeis (1989) have shown that compared
to antidepressant medication, CBT does indeed prevent a relapse when
the patient is later followed-up.
The second type of action-orientated therapy to be reviewed is
problem-solving therapy (PST). PST evolved from techniques developed by
de Shazer et al, (1988) which in turn was inspired by behavioural
therapy. Problem-solving therapy is, in essence, a purely behavioural
intervention and can be seen as a more focussed subset of some of the
ideas used in CBT. As the name suggests, the therapy concentrates on
the problem that the patient has, in this case depression, and ways in
which to help solve it. This is done using a three stage approach.
First, the link is identified between the patient's problems and their
symptoms, secondly, an attempt is made to define these problems more
clearly. Finally, an attempt is made to solve the problem and provide
the patient with a clear method of doing this. Through this process the
patient can be encouraged to envisage achievable goals, generate some
realistic options for change and attempt to make the changes required.
This type of therapy is relatively new and has only been evaluated in a
handful of studies. In common with other types of therapy, it can be
difficult to evaluate because of the question of choosing which
measures to use as significant and meaningful outcomes. Nevertheless,
Dowrick, Dunn, Ayuso-Mateos, Dalgard, Page, Lehtinen. Casey, Wilkinson,
Vazquez-Barquero & Wilkinson (2000) examined 452 participants,
using a randomised, controlled, multi-centre study and compared
problem-solving therapy to group psychoeducation and a control group in
the treatment of mild to moderate depression. The results showed that
six months after the problem-solving therapy was administered, there
was a 17% reduction in depression compared to the control group. In
comparison, there was a 14% reduction in the psychoeducational group.
An important finding of the study was the comparison of the drop-out
rates. As 63% of those in the problem-solving group completed their
treatment, compared to 44% in the psychoeducational group, it can be
assumed that the problem-solving treatment was more acceptable. The
reason for the comparison of both these types of intervention was that
they are relatively cheap to administer and require less education for
the therapists than other approaches, such as psychodynamic or
cognitive therapy.
MynorsWallis, Gath, Day & Baker (2000) carried out a comparison of
problem-solving therapy with antidepressants and also tested their
combined effects. 116 patients received either a combination of the two
treatments or one or the other of them. The results showed that all
groups demonstrated a reasonable recovery from depression. Two thirds
of the participants remained at acceptable levels on depression
inventories at a one year follow-up. There was no advantage seen for
the interventions used together and no significant difference between
them. Limits of this particular study are in the lower number of
participants than the previous study, and in the more localised
selection of participants. This study does, however, suggest that
problem-solving therapy can provide a useful alternative to the use of
antidepressants that does not have the side-effects associated with
pharmacological interventions.
The major difference, practically, between CBT and PST is that CBT
requires extensive training and, normally, a longer period of therapy,
while problem solving therapy only requires some limited training and
is shorter to administer. There are, as can be seen, many similarities
between the two approaches, and, in fact, PST is often seen as a
sub-type of CBT. In the clinical guidelines by the National Institute
for Clinical Excellence (NICE, 2004) it is recommended that
problem-solving therapies are better suited to mild forms of
depression, while, for moderate or severe forms of depression, CBT is
the treatment of choice.
As Gloaguen et al. (1998) make clear, different approaches will be
better for different patients. Overall, though, both these therapies
show benefits over placebo conditions, CBT especially has been shown to
rival medication. Finally, PST probably requires further evaluation,
but certainly shows some promise as a practical intervention that can
be applied with relatively low costs and reasonable results in some
patients.
References
Barber, J. P., DeRubeis, R. J. (1989). On second thought: Where the
action is in cognitive therapy for depression. Cognitive Therapy and
Research, 13 (5), 441-457.
de Shazer, S. (1988) Clues: Investigating Solutions in Brief Therapy. New
York: Norton.
Dowrick, C., Dunn, G., Ayuso-Mateos, J. L., Dalgard, O. S., Page, H.,
Lehtinen. V., Casey, P., Wilkinson, C., Vazquez-Barquero, J. L.,
Wilkinson, G. (2000) Problem solving treatment and group
psychoeducation for depression: multicentre randomised controlled
trial. British Medical Journal, 321, 1450–1454.
Hollon, S. D., Thase, M. E., Markowitz, J. C. (2002). Treatment and
prevention of depression. Psychological Science in the Public Interest,
3, 39-77
Gloaguen, V., Cottraux, J., Cucherat, M., Blackburn, I. M. (1998) A
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patients. Journal of Affective Disorders, 49(1), 59-72.
MacLeod, A. (1998) Therapeutic interventions, In M. W. Eysenck, (Ed.),
Psychology, an integrated approach. London: Prentice Hall.
MynorsWallis, L., Gath, D., Day, A., Baker, F. (2000) Randomised
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care. British Medical Journal, 320, 2630.
NICE (2004) Depression: Management of depression in primary and secondary care. NICE Guideline.
Parker, G., Roy, K., Eyers, K. (2003) Cognitive behavior therapy for
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Strupp, H. H. (1996). The tripartite model and the Consumer Reports study. American
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