Mood Disorders and Suicide 213
circumvent or eliminate those obstacles. For instance, a depressed college stu-
dent may feel overwhelmed at the thought of asking for an extension for an
already overdue paper. The student and therapist work together to solve the
problem of how to go about asking for the extension—they come up with a re-
alistic timetable to complete the paper and discuss how to talk with the profes-
sor. Behavioral activation techniques may initially feel aversive to a person with
depression because they require more energy than he or she feels able to sum-
mon; however, mood improves in the long term. In fact, behavioral activation is
superior to cognitive techniques in treating both moderate and severe depression
(Dimidjian et al., 2006).
Cognitive Methods
Based on the premise that depressing thoughts lead to similar feelings and behav-
iors, cognitive methods aim to diminish or change such thoughts, which are often
distortions of reality (see Chapter 4). Patients are encouraged to conduct their own
experiments by collecting data to assess the accuracy of their beliefs, which are
often irrational and untrue (Hollon & Beck, 1994). This process can relieve some
patients’ depression, and can prevent or minimize further episodes of depression
(Teasdale & Barnard, 1993; Teasdale et al., 2002).
Consider Kay Jamison: She felt that she was a burden to her friends and family,and that they would all be better off if she were dead. Cognitive therapy would ex-
plore the accuracy of these beliefs: Why did she think she was a burden? What evi-
dence did she have to support this conclusion? How might friends or family react if
she told them that they’d be better off if she were dead? A cognitive therapist might
even suggest that she talk to them about her beliefs and listen to their responses—
was she accurate in her beliefs? Most likely, her friends and family would not agree
that they’d be better off if she were dead.
However, successful short-term cognitive therapy is not necessarily a perma-nent cure. A meta-analysis of studies of manual-based, short-term therapy (usually
12–20 sessions) found that although CBT decreased symptoms, many patients still
had signifi cant symptoms at the conclusion of the treatment and were at risk for
relapse. Of the patients who had improved, only about 35% retained that degree of
improvement 18 months later; the others had at least some relapse of their depres-
sive symptoms (Westen & Morrison, 2001).
Cognitive-Behavior Therapy Compared to Medication
CBT, particularly when it includes behavioral activation, is often about as success-
ful as medication (Dimidjian et al., 2006; DeRubeis et al., 2005; Sava et al., 2009;
TADS Team, 2007). In some ways CBT may be better than medication: The side
effects of medication may lead patients to stop taking it; various studies have found
that about 75% of patients either stop taking their antidepressant medication within
the fi rst 3 months, or they take less than an optimal dose (Mitchell, 2007). And when
patients stop taking medication, a high proportion of them relapse. Furthermore,
even when medication is successful, some research suggests that people at risk for
further episodes should continue to take the medication for the rest of their lives to
prevent relapses (Hirschfi eld et al., 1997).
In contrast, the beneficial effects of CBT can persist after treatment ends(Hollon et al., 2005); CBT is an alternative that need not be administered for life.
Moreover, medication and CBT can be used together. In fact, studies have shown
that a combination of medication and CBT is more effective than medication
alone—even for severely depressed adolescents and adults (Macaskill & Macaskill,
1996; TADS Team, 2007; Thase et al., 1997). In addition, after treatment with
antidepressants has ended, a patient’s residual symptoms of depression can be re-
duced through CBT; this supplemental CBT can reduce the relapse rate (Fava et al.,
1998a, 1998b).