New Developments in Cognitive-Behavioural Therapy for Mood Disorders

Abstract

Cognitive-behavioural therapy (CBT) for depression is an empirically validated, time-limited psychotherapy that leverages awareness of mood-linked changes in cognition and phenomenology to teach patients suffering from depression effective means to regulate affect and reduce symptoms. Its current standing as a front-line treatment for mood disorders can be traced to changes in the scientific study of psychotherapy outcomes that began over 30 years ago. was one of the first psychotherapies for depression to be evaluated against contrast conditions such as antidepressant pharmacotherapy. When the results of these trials indicated a rough parity in clinical outcomes,1-3 the efficacy of psychological treatment for depression could no longer be dismissed. In the same vein, the publication of Cognitive Therapy for Depression4 represented one of the first attempts to detail step-by-step therapy procedures for conceptualizing depression as the product of biased mental representation as well as behavioural and cognitive strategies designed to address this. The expansion of treatments for anxiety, eating, and substance use disorders was premised on the same combination of compelling clinical evidence and the explication of technique. Well over a quarter of a century later, it might be tempting to conclude that the treatment of mood disorders within a cognitive-behavioural frame is a project largely completed-yet challenges do remain. This issue's In Review section provides a view of the field that is both prospective and retrospective. It strives to look beyond the modal applications of in mood disorders to highlight areas of potential future investigation and application. The section's pair of articles speak to the ever-expanding role of in mood disorders. Kuyken et al5 report the most up-to-date conceptualizations of unipolar depression in the context of the cognitive model. In particular, they emphasize the diathesis-stress approach and multilevel schematic models to illuminate the intersection between biological vulnerability and psychopathology. Their writing also touches on some exciting new lines of evidence exploring the active ingredient in CBT and predictors of outcome. We are now beginning to collect evidence from neuroimaging studies to illustrate brain changes associated with effective CBT. These kinds of studies are at the vanguard of psychotherapy research. In particular, Goldapple et al6 have used functional imaging studies to demonstrate a different pattern of response in the brain when is compared with paroxetine in the context of unipolar depression. Brain images of depression patients treated with paroxetine showed increased brain activity in the lateral cortices and suppression of limbic circuits in both the hippocampus and the subgenual cingulate, Area 25. In the same study, treatment response was associated with significant increases in hippocampal and dorsal cingulate activity and decreased activity in the dorsal, ventral, and medial frontal cortex. These opposite changes with (relative to medication) in predominantly cortical brain regions, such as the medial frontal and dorsal cingulate, have been postulated to reflect regions primarily associated with attention, self-references, and reappraisal-areas specifically targeted by this form of psychotherapy. Characterization of adaptive and maladaptive functional interactions among these pathways is a critical step toward future development of evidenced-based algorithms that will optimize the diagnosis and treatment of individual patients suffering from depression. Further work by Siegle et al7 with fMRI has shown that patients whose sustained reactivity to emotional stimuli was low in the subgenual cingulated cortex and high in the amygdala displayed the strongest improvement with CBT. These novel lines of research are beginning to narrow the gap between brain and mind, informing not only an integrated depression network model but also clinical choices for treatment suitability and prognosis. …