Single Case Design

A key to providing C-CT to patients with recurrent MDD is the single-case design (Hayes, Barlow, & Nelson-Gray, 1999). One of the most practical single-case designs is the A (baseline)-B (single-treatment) design. The absence of a control condition limits inference in the A-B design, but clini cians can extend the reversal design to include all treatment phases when monitoring the depressive episode and symptoms during A1 (initial evalua-tion)-B (A-CT)-C (C-CT) and A2 (treatment-free longitudinal evaluation or follow-up).

After diagnoses are established, one of the initial steps is for clinicians and patients to select and use a measure of syndromal status and severity. Ideally, charting or graphing scores at each visit result in a longitudinal snapshot of the course of disorder—a prospective extension of the retrospective lifeline developed during the initial evaluation. Along the way, they can mark when the criteria for MDD (and other psychiatric disorders) are and are not met, when treatment changes, when key psychosocial events or stressors occur, when critical CT skills are learned and used, and when therapeutic goals have been accomplished.

Teaching patients to monitor depressive symptoms and their own functioning (e.g., as family members, workers, or friends) is key to helping them to recognize when treatment may need to be reinitiated or changed, and to helping therapists decide which areas to target in sessions and as homework. Improvements in psychosocial functioning may be tied to the A-CT targets or goals that a patient has set in the areas of "love, work, and play." In addition, patients learn which psychosocial factors or stressors tend to increase the chance that depressive symptoms will progress into a full depressive syndrome, and which symptoms or type of functional impairment may be predictive of the entire syndrome recurring. Finally, patients learn which cognitive-behavioral strategies work best to promote return to full functioning and euthymia.

These single-case data that allow clinicians and patients to distinguish the phases and stages of treatment thereby determine whether treatment and homework need to be based on (1) engaging the patient in a treatment that reduces symptoms (acute phase); (2) achieving full remission and preventing relapse of the index episode (continuation phase); (3) preventing relapse and maintaining remission or achieving recovery (continuation phase); or (4) maintaining recovery and preventing recurrence or a new depressive episode (maintenance phase). Throughout the process, patients and therapists monitor levels of symptoms and functioning, and remain vigilant for increases in risk factors (i.e., predictors).

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