Treatment Of Chronic Depression

The application of the standard cognitive model in the treatment of chronic depression can result in confusion and frustration for both patient and therapist. For treatment to be effective, a number of adaptations need to be made in the application and delivery of standard interventions. Our starting point in approaching treatment of chronic depression is to retain the essential features of CT that have contributed to its established efficacy in treating acute depression. In particular, we endorse a highly structured and focused intervention, both in individual sessions and across the intervention. We advocate actively fostering a collaborative therapeutic relationship and explicitly sharing a formulation of the factors that maintain the patient's current difficul ties. Realistic problem and target lists are used to guide treatment, and an explicit treatment contract (between 18 and 25 sessions) is negotiated with the patient. Initially we advocate twice-weekly sessions for 2-3 weeks. This disrupts avoidant coping strategies sufficiently to promote active engagement in treatment. This is followed by weekly sessions for 10 weeks and, subsequently, sessions every 2 weeks for 4 weeks. Finally there is a graded reduction in frequency 1-month and then 2-month intervals. Standard, session length is 60 minutes, although extending the session length to 75 minutes has in some cases proven to be clinically very productive with highly avoidant patients who take time to break through avoidant coping tactics.

In terms of standard interventions, equal weight is given to behavioral interventions, such as activity scheduling and graded task assignment (although these would be used within a cognitive treatment rationale), and standard cognitive interventions, such as identifying and modifying automatic thoughts with behavioral experiments. However, within this a great deal of emphasis, both within and outside of sessions, is placed on action-oriented behavioral experiments to test out predictions and to act against avoidant coping strategies. In addition, we advocate the following essential components:

• Each session is audiotaped, and the patient is encouraged to listen to this tape between sessions.

• The patient is encouraged to develop a personal therapy folder containing all written materials used in the course of therapy. This acts as a self-help folder once therapy is completed.

• Homework is an integral aspect of every therapy session.

• A written handout supports every intervention, with guidance on how to implement the intervention outside the session.

• Written summaries of learning are made from homework assignments and at the end of each session.

As a rule of thumb, patients with chronic depression may present three obstacles to successful therapy. First, patients with chronic depression may lack motivation to engage in a treatment they perceive as bound to fail. Second, their level of passivity and avoidant coping strategies may make therapy more difficult. Third, their negative thoughts may be more refractory to disconfirmatory evidence. We recommend the following adaptations as ways of dealing with these obstacles (for more details, see Moore & Garland, 2003).

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