Preface

One of the most influential theories and treatments of depression is cognitive theory and cognitive therapy (CT) of depression (Beck, Rush, Shaw, & Emery, 1979). To date, there have been over 75 clinical trials evaluating the efficacy of CT for depression. Results from these studies indicate that CT is an effective treatment for major depression (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Hollon, Thase, & Markowitz, 2002), and that it may have a prophylactic effect in reducing relapse and recurrence of depression (Hollon et al., 2002).

Despite its overall efficacy, however, not all depressed patients respond to standard CT for depression (Hamilton & Dobson, 2002; Whisman, 1993). Furthermore, most depressed patients present with complex sets of issues and problems that exacerbate, or are exacerbated by, their depressive symptoms. Although clinicians are likely to believe they can improve treatment success by modifying and supplementing standard CT for depression, there are few guidelines for clinicians to use in deciding whether, when, and how to modify standard treatment in working with different kinds of depressed patients.

This book was written to respond to that need. In these chapters, authors integrate clinical, theoretical, and empirical developments in presenting a unified set of clinical guidelines for adapting CT to different manifestations of depression. The focus of the book is on presentations of depression that are commonly encountered in everyday clinical practice, that are likely to be difficult or challenging to treat, and that call for modifying "standard" CT for depression.

The book is divided into four main sections. Part I provides an overview of, and delineates the most current methods for, conducting CT for depression, including detailed discussions of assessment, case conceptualization, and treatment planning.

Part II focuses on the treatment of subtypes or subgroups of depressed patients that are defined in terms of severity and historical features. The treatment of a severely or chronically depressed patient poses a challenge to even the well-seasoned clinician. Therefore, this section includes chapters on adaptations of CT for severe, chronic, drug-resistant, partially remitted, and recurrent depression.

Part III focuses on treating depression that co-occurs with other mental, physical, or interpersonal problems. Nearly three-fourths of people with lifetime and nearly two-thirds of people with 12-month major depression also met criteria for at least one other Axis I disorder during their lifetime or the past year, respectively (Kessler et al., 2003). In addition, approximately 50-85% of depressed inpatients and 20-50% of depressed outpatients have personality disorders (Corruble, Ginestet, & Guelfi, 1996). Depression has also been found to co-vary with medical conditions (Stevens, Merikangas, & Merikangas, 1995) and impaired interpersonal and social relationships (Hirschfeld et al., 2000). Furthermore, compared to depressed individuals without comorbid conditions, those with comorbid conditions have more severe and persistent depression (Kessler et al., 1996) and are more likely to seek mental health services (Kessler et al., 2003), suggesting that the depressed people clinicians are likely to encounter are people with comor-bid conditions. Moreover, most individuals with comorbid conditions seeking treatment for depression desire treatment for their comorbid conditions (Zimmerman & Chelminski, 2003). The high rate of comorbidity suggests that "pure" cases of depression not only are rare but also may be unrepresentative of people with depression, particularly with respect to depressed individuals in treatment. The relative rarity of cases that meet criteria for a single diagnosis of major depression suggests the need for a change in the way depression is conceptualized and treated. The chapters in Part III cover adaptations of CT for depression for some of the most common conditions and disorders that co-occur with depression, including suicide, Axis I disorders (anxiety disorders, substance use disorders), personality disorders, medical conditions, and family and relationship problems.

Part IV focuses on the treatment of depression in special populations. Research has shown that the manifestation, risk factors, and treatment of depression vary among people who differ in race and ethnicity, sexual orientation, and age. For example, sociodemographic characteristics are associ ated with differential exposure to discrimination, which in turn is associated with elevated risk for depression (Kessler, Mickelson, & Williams, 1999). Consequently, Part IV focuses on adaptations of CT for depression in special populations, including racial and ethnic minorities; lesbian, gay, and bisexual women and men; adolescents; and older persons.

Each chapter begins with a brief overview and general conceptualization of the manifestation of depression covered in the chapter, along with a discussion of clinical assessment methods. The emphasis of each chapter, however, is on providing a detailed, practical discussion of treatment strategies, including recommended adaptations of standard CT for depression and recommendations regarding the use of medication. Each chapter also includes a case study to further illustrate the core aspects of the approach. Finally, each chapter ends with a summary of the empirical findings regarding the efficacy of the treatment for the manifestation of depression covered in the chapter.

Taken as a whole, this book provides readers with detailed and practical suggestions for conceptualizing, assessing, and treating different presentations of depression that are commonly encountered in clinical practice. Each of the chapters can be read as a compact treatment manual for a particular manifestation of depression. The adaptations of CT that are covered are both evidence based (i.e., empirically supported) and clinically flexible. Although the chapters differ in their recommendations, they share a common theoretical and philosophical model of psychopathology and change in psychotherapy: namely, a cognitive theory of psychopathology and therapy in which maladaptive information processing is central to understanding the onset, course, and treatment of depression (Clark, Beck, & Alford, 1999). It is this cognitive theory, and not whether an intervention is labeled a "cognitive" intervention (vs. a behavioral, interpersonal, or some other intervention), that "provides a unifying theoretical framework within which the clinical techniques of other established, validated approaches may be properly incorporated" (Alford & Beck, 1997, p. 112).

Clinicians and researchers from across the globe have contributed to the book, reflecting international developments in adapting CT for various presentations of depression. This book, therefore, comprises a wealth of information regarding the evolution of CT for depression over the past 30 years. The guidelines offered on adapting CT for the varying, and often challenging, presentations of depression commonly encountered in clinical practice not only should improve clinical outcome, but should also serve as a foundation for future developments in cognitive theory and therapy for depression.

REFERENCES

Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York: Guilford Press.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific foundations of cognitive theory and therapy of depression. Hoboken, NJ: Wiley.

Corruble, E., Ginestet, D., & Guelfi, J. D. (1996). Comorbidity of personality disorders and unipolar major depression: A review. Journal of Affective Disorders, 37, 157-170.

Gloaguen, V., Cottraux,J., Cucherat, M., & Blackburn, I.-M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59-72.

Hamilton, K. E., & Dobson, K. S. (2002). Cognitive therapy of depression: Pretreat-ment patient predictors of outcome. Clinical Psychology Review, 22, 875-893.

Hirschfeld, R. M. A., Montgomery, S. A., Keller, M. B., Kasper, S., Schatzberg, A. F., Moller, H.-J., et al. (2000). Social functioning in depression: A review. Journal of Clinical Psychiatry, 61, 268-275.

Hollon, S. D., Thase, M. E., & Markowitz, J. C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest, 3, 39-77.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., et al. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R).JAMA, 289,3095-3105.

Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behavior, 40, 208-230.

Kessler, R. C., Nelson, C. B., McGonagle, K. A., Liu, J., Swartz, M., & Blazer, D. G. (1996). Comorbidity of DSM-III-R major depressive disorder in the general population: Results form the U.S. National Comorbidity Survey. British Journal of Psychiatry, 168, 17-30.

Stevens, D. E., Merikangas, K. R., & Merikangas, J. R. (1995). Comorbidity of depression and other medical conditions. In E. E. Beckham & W. R. Leber (Eds.), Handbook of depression (2nd ed., pp. 147-199). New York: Guilford Press.

Whisman, M. A. (1993). Mediators and moderators of change in cognitive therapy of depression. Psychological Bulletin, 114, 248-265.

Zimmerman, M., & Chelminski, I. (2003). Clinical recognition of anxiety disorders in depressed outpatients. Journal of Psychiatric Research, 37, 325-333.

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