cbt treatment depression case study

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• Case study: How CBT can be applied in the treatment of depression

The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy ( CBT ) can be applied in the treatment of depression . The patient is a woman with a 2-year history of depression connected with low self-esteem , guilt and shame. An account of the CBT treatment carried out over 12 sessions is given. Noticeable improvements on measurements of mood and hopelessness, with an improvement in social and occupational functioning were achieved.

Mary is a 26-year-old nurse, who was referred for treatment for the management of depression. She presented with a 3-year history of depression along with issues related to low self-esteem and relationship problems, she was referred by her GP after being prescribed various forms of antidepressant medication over a 2-year period, this medication did not seem to be effective.

Presenting problems

Mary’s depressive symptoms lead to her social and occupational functioning being impaired. She found it difficult to complete tasks related to her job, and had been disciplined at work even though she had previously excelled in her role. She explained that she felt somewhat uncomfortable at work and found making conversation with colleagues quite challenging. She considered herself to be ‘dull’, ‘boring’ and ‘unlikeable’, which as a result lead to her isolating herself socially. Over the course of her depression she decreased her pastimes and social activities, and started to use all her free time on her own, in bed or “attempting to catch up on tasks related to her job.”

Mary was in a relationship with Angela, who lived in Scotland with her two year old son. Angela was still married to her husband when they first met and Mary felt guilty for “ruining a marriage,” and “being involved in a same-sex relationship”, therefore, this was a part of her life that she didn’t tell people about. She explained her reason for keeping this to herself was due to a fear of people judging and rejecting her over it. She also did not feel secure in the relationship and had fears about Angela’s commitment to her although she did not want to end the relationship.

Mary has a sister who is two years older than her who also has a history of depression, she sees this sister as being a good form of support. She states that she also has a good relationship with her father although “he is not in touch with my generation” and therefore “he’s not really able to understand me”.

Mary’s mother died in a car crash when she was 10 years old. She described them as having a close relationship and found the first year after her mother’s death a particularly difficult time. Mary remembers her childhood as being a happy one where she spent lots of time with her parents, who had a good relationship with one another.

Mary has no previous history of therapy but had a good awareness of her difficulties and was willing to engage in a time-limited treatment of CBT as well as continuing to take the antidepressants which her GP prescribed.

Treatment outcome measures

Variations in levels of depression and anxiety were assessed using the Beck Depression Inventory (BDI) (Beck & Steer, 1993a), and Beck Hopelessness Inventory (BHI), (Beck & Steer, 1993b). Both the BDI and the BDI have been extensively tested for reliability and validity (Conoley, 1987; Dowd, 1992; Owen, 1992). These Measures were administered pre-therapy, mid-therapy, and post-therapy. The Improving access to Psychological Therapy service (IAPT) also recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia) as well as the Work & social adjustment scale which assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships and therefore these measure were administered at the start of each session. Mary’s score on both phq-9 (16) and the BDI (32) indicate moderately severe depression, her GAD-7 score was 9 which translates as mild anxiety, WSAS scores for Mary were 18 which is associated with significant functional impairment. The IAPT phobia measures indicated that she would markedly avoid social situations and she would definitely avoid certain situations for fear of having a panic attack. Becks Hopelessness scale which was administered in order to help assess where she was at risk of suicide, Mary scored 17 on this scale which identifies severe hopelessness, Mary confirmed occasional thoughts of a suicidal nature however she denied any intent to act on these thoughts as she felt she would be letting everyone down.

FORMULATION

Case Conceptualisation

A cognitive case conceptualisation is a method of considering a client’s problems and issues using the cognitive model of emotional disorders (Beck, 1987). It includes beliefs (automatic thoughts, underlying assumptions, and schemas), emotional reactions, behavioural strengths and deficits, social factors that influence problems, and consideration of biological factors and maintaining cycles of the client’s difficulties. The conceptualisation, constructed with the client, can be amendment through the course of treatment and can used as a directive for any problems that arises for the client both outside of therapy and in the therapeutic relationship, it can also can act as a   “map” for the therapist (Persons, 1989).

Figure 2. The cognitive model as applied to depression (Persons, 1989).

After Mary’s initial assessment the therapist drew up a longitudinal formulation to help her consider Mary’s difficulties and plan treatment. This longitudinal formulation included the following.

Early experiences: Need to please mother, parents not socializing outside family home, loss of mother.

Core beliefs :

I am not likeable (As I’ve never had a lot of friends at any time in my life), I am not good enough and can never achieve enough (My sister and classmates were always better than me), I am a bad person (As I started a relationship with person of the same sex).

Irrational Rules/Assumptions :

‘If I date someone of the same sex, I am a bad person’, ‘If I tell my friends about my same sex relationship, they will disapprove and reject me’, ‘If I take on all the duties assigned to me at work’ (regardless of my large workload), ‘my workmates will like me, If I tell anyone that I suffer from depression, they will think that I am crazy’.

Precipitating factors :

A precipitating factor for Mary’s in her life was the start of a same sex relationship. Mary feels that people would not accept her because of this. As a result she prevented others from becoming to close to her to avoid having to reveal her secret.   This avoidance of social activity resulted in her spending more time at home by herself which precipitating her depression.

Figure 3. Formulation drawn up collaboratively with Mary based on Mooey’s (2010) depression model.

Perpetuating factors

The therapist used Mooray’s (2010), “The Six Cycles Maintenance Model” model to investigated Mary’s thoughts, feelings, behaviour and physical response (Figure 3) and collaboratively conceptualize Mary’s presenting difficulties while socializing Mary to the cognitive model by showing links between thoughts, feelings, behaviours and physical sensations. This diagram was used as a “road map” to help the therapist identify and focus on factors that are likely to be important in Mary’s depression and a rationale for the therapy interventions that the therapist would include in treatment (see figure 3).

The therapist helped Mary looked at a number of maintenance cycles which were feeding back into Mary’s difficulties, for instance when Mary is around her workmates she often has the automatic thought “Nobody likes me, I will never be able to form friendships”, as a result she becomes upset and feels rejected and goes on to isolate herself from workmates by avoiding them and having lunch on her own and therefore does not break the pattern of feeling uncomfortable around her workmates and rejected by them.

1. Negative Automatic Thoughts

As a consequence of feeling low Mary’s was having more negative automatic thoughts (NAT’S) about particular situations. These NAT’S seemed highly credible to her and came up regularly without much of her awareness. These NAT’s may have kept Mary’s negative core experiences going.

2. Ruminations and self-attacking

Mary sometimes found herself getting locked in ruminative, self-attacking thinking cycles of how she made so many mistakes and should have done things differently along with other self-attacking thoughts related to being weak and not good enough as a person.

3. Mood/Emotion

Mary identified various emotions connected to her depression which she frequently experienced such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad about feeling sad all of which feed back into the her difficulties.

4. Withdrawal and avoidance

Throughout Mary’s depression she had isolated herself from others and avoided socializing and did not allow others to become close to her. She believed that she would not enjoy activities or be able to accomplish the things she wanted to. As a result of this avoidance she was not allowing herself the opportunity to test the truth behind her negative beliefs and limited her opportunity to find enjoyment or a sense of achievement from activities.

5. Unhelpful behaviours

Mary’s attempts to improve her emotions or balance her negative beliefs included taking on excessive work loads and seeking approval from others. These behaviours made her feel better in the short term but were part of what maintained her difficulties in the long term.

6. Motivation and Physical Symptoms

Mary’s physical symptoms of depression included feeling tired, tearful, on edge and having sleeping difficulties. These physical symptoms feed back into Mary’s depression leading to even less activity and contributing to a downward spiral

Therapeutic goals

Mary stated that through therapy she would like to focus on achieving the following:

• To disclose to her sister and friends about her relationship with Angela;
• To feel more secure with Angela, to discuss their relationship and plans for the future;
• To achieve better ways of managing her time, and allocate more time for leisure activities;
• To become better at communicating with people at work and no longer take on an excessive workload; and
• To feel more at ease in social situations particularly at work.

Treatment contract

Guidelines on the duration of treatment length suggest that most of the progress made in CBT treatment is thought to take place in the first twelve treatment sessions, and additional improvements are moderately low when treatment carries on for further sessions (Barkham & Hardy 2001). If this is the case, the duration of the CBT treatment offered should be kept within this time frame. With this in mind an initial contract of 6 sessions was agreed on which was extended for a further 6 treatment sessions.

Assessment sessions 1-3

The early sessions were spent collecting client information, building therapeutic rapport, discussing issues around confidentiality and taking baseline treatment measures (see table 3). The therapist and Mary also looked at the foundations of the CBT approach and how it might be useful, the idea of working together using a structured, and focused method, with the requirement of weekly out-of-session assignments, and the opportunity to regularly review the treatment. The meaning of core beliefs, assumptions, and NAT’s were looked at and Mary started to recognize and document a number of these, many of which the therapist and Mary planned on returning to later when completing thought Records and developing Behavioural Experiments in sessions. The therapist and Mary also constructed the cognitive case conceptualisation (Figure 2.) over the three assessment sessions drawing up maintenance cycles and getting Mary to consider what could be done to try and break out of these patterns.

Sessions 4-8

As part of her out-of-session assignments Mary completed Weekly Activity Schedules (WAS) in order to monitor the activities she was involved in for each hour of each day, and to note the amounts of pleasure and mastery (feelings of accomplishment and effectiveness) actually experienced during each activity. She assigned a percentage rating to her mood for each activity she participated in and we made the connection between her mood and the activity. It discovered that Mary’s mood was worst when she was least active. After making this discovery the therapist worked with Mary to help her come up with a list of activities that she currently enjoys or used to enjoy as well as activities that gave her a sense of achievement. The therapist used Beck’s (1987) evolutionary model of depression to explain to Mary that when people have depression these activities might not be easy to do but if there is no investment there is no return. Therefore it can be useful to plan these activities in an attempt to strike a balance between pleasure and achievement. The therapist encouraged Mary to make time for these activities several times a week and explain how scheduling something makes people more likely to commit to it and that she should try to do the activities she has planned regardless of her mood. Mary monitored the outcome of this activity scheduling by taking regular mood ratings and noticed her mood ratings improved on the days she engaged in the pleasurable activities she had planned.

Mary completed a Daily Thoughts Record (DTR), which we used to investigate her thinking patterns. At first she found it hard to recognize her “hot thoughts” (automatic thoughts that carry the strongest emotional charge) and “alternative balanced thoughts.” To overcome this difficulty the therapist suggested that Mary try to note down the thoughts and feelings that go through her mind as close to the time she is feeling the strong negative emotion as possible. Mary started to enter brief notes onto her mobile phone when she felt a strong negative emotion and would later enter the information into a thought record. The therapist helped Mary use the items she had identified on the DTR as a ‘courtroom’ to challenge her hot thoughts by looking at evidence to support the hot thought and evidence that does not support the thought and consider a more balanced alternative. One of the ‘hot thoughts’ that Mary identified was on the DTR was ‘All hell will break loose if tell anyone about my partner’. After identifying this thought the therapist helped Mary consider further what might take place if she were to disclose to her housemate Tamara about her partner Angela. The therapist asked her to think about how Tamara might respond if roles were reskilled and if Tamara was the one who disclosed the information; or how Mary would react if her friend did not choose to reveal the information to her? Mary was amazed at how her beliefs and automatic thoughts as well as the intensity of her feelings could change so much.

In session seven the therapist and Mary set up a behavioural experiment to test out what would happen if she disclosed her sexuality to her flatmate. Despite the previous work on Mary’s thoughts related to this she still believed 90% that people would reject her in some way if she disclosed her sexuality. In relation to her flatmate she believed in the worst case she would chooses to move out after the disclosure or in the best case she would start spending less time with her. An alternative belief that Mary considered was that people would be surprised at the disclosure but they would not treat her any differently which she stated she believed 10%.

Mary returned in session 8 and had revealed the truth about her relationship with Angela to her housemate who at first became angry that Mary had hid it from her. During further talks with her housemate, Mary told her about her depression, the fact that she was seeing a therapist, and her problems coping with the death of her mother. Mary was surprised by her roommate’s positive reactions and later went on to share similar information with her sister. Mary re-rated her belief that people would reject her in some way if she disclosed her sexuality as 40% and re-rated the alternative believe as 60%.

Sessions 9-12

We looked at the beliefs Mary’s held regarding how she thought others saw her. She believed that everyone she knew found her boring, and then gave an account of how someone would act if they found someone “boring.” We agreed on carrying out a behavioural experiment that could be done during her break at work. This consisted of her observing her workmates and purposely watching for any proof of them being bored by what she was saying. Before the experiment, she assigned a rating to her belief (on a scale of 0-100%). After doing the experiment, she found no definite confirmation of people being bored and she rated her belief again. The rating of her belief after the experimental belief was less (55%) than before the experiment (95%). She carried out the behavioural experiment a few times in different situations, which eventually helped her see that in fact people did not regard her as boring. As a result Mary started to engage more in conversations with her workmates and attended a social event that her colleagues invited her to outside of work.

TREATMENT OUTCOME

At the time of discharge, there were noticeable improvements in Mary’s mood, levels of hopelessness, as well as overall social and occupational functioning. Mary became able to discuss her history of depression, the relationship with her partner , and the bereavement of her mother with people in her life. She disclosed her depression to her manager, who was understanding and compassionate. He arranged to temporary decrease her workload and planned regular meetings to talk about any difficulties at work. She was able to manage her time better and included leisure activates into her week. This progress can also be seen in the scales that were administered at intake, mid-therapy and discharge (seen table 4).

Table 3. Treatment outcome measures. (Beck & Steer RA, 1993a, 1993b & 1993c; Saunders et. al, 1993), (PHQ-9, GAD-7 & WSAS; part of the IAPT Minimum data set).

The rating of depression decreased significantly over time, shifting from being in the severe depression range to being in the mild depression range (BDI: 15, PHQ-9:4). The BHI scores also improved over time, showing a decline in the intensity of hopelessness. The score on the BHI of 6 was no longer showing an indication of high psychological distress. Mary’s GAD-7 (4) and Work   and Social Adjustment Scale scores (2) also decreased to subclinical levels.

Relapse prevention

In relation to preventing set backs she has kept records of material from the therapy sessions (homework and sheets from sessions) and a relapse prevention plan and states that she looks over them at times, particularly when she is experiencing low moods or particular difficulties. This self-conducted regular review of therapy sessions may assist in increasing her chances of maintaining the improvement achieved.

The ending of therapy with Mary was carefully thought out particularly because of the losses she experienced in the past. At the start of treatment we block booked all the dates we would meet on and Mary was reminded by the therapist midway through the sessions of the date they would end therapy on, the therapist again reinstated this a number of weeks before the end. The therapist regularly checked out how Mary was feeling about ending therapy and allowed Mary the space to discuss any fears she had about ending.

This case study looked at using a cognitive behavioural approach with a client with depression. The client improved in terms of mood, hopelessness, and overall social and occupational functioning. This outcome backs up various published research findings which provide evidence for the benefit of CBT in treating depression, (Rush, Kovacs & Beck, 1981; Scott, 2001; Department of Health, 2001).

Mary stated that she views her positive outcome as being a result of a mixture of CBT and medication treatment; though, she expresses the CBT treatment as being the more beneficial. She stated that CBT had “changed her way of seeing things” and provided her with a “method or system,” allowing her to steadily sort through and resolve any difficulties she experienced. This schema modification together with the restructuring of her cognitive account of depression may reduce her risk of relapsing.

Upon receiving this referral the therapist had some initial anxiety about working with a case presenting with difficulties related to her sexuality as the therapist did not have previous experience of working with patients with this type of presentation. Another difficulty was that this was only the therapist’s second depression case she had treated and this lack of experience added further concern for the therapist initially. However the therapist found the support of supervision beneficial and quickly realised that many of the techniques she had used before could also be applied to this case.

A limitation to Mary’s treatment was that she was only offered 12 sessions of CBT due to organisational restrictions which is less than recommend dose of 16-20 weeks for moderate to severe depression, (NICE, 2007a). It may have been beneficial to offer a further four to six sessions to allow the opportunity to tackle some of Mary’s rules and assumptions and therefore reduce the risk of relapse. However evidence which is contrary to this suggests that most of the progress made in CBT treatment occurs in the first twelve sessions, and further progress is moderately low after this (Barkham & Hardy, 2001). It will have been interesting to follow-up the outcome of this case at a later date to investigate the long-term effects of the treatment.

***If you’re struggling with your mental health and think you might benefit from speaking to someone, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours  here.

About the author

Dr Becky Spelman is a leading UK Psychologist who’s had great success helping her clients manage and overcome a multitude of mental illnesses.

***If you think you might benefit from speaking to someone about the issues in this article, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours here

Barkham M, & Hardy GE. (2001). Counselling and interpersonal therapies for depression: towards securing an evidence-base. British Medical Bulletin. 57, 115-32.

Beck A.T. (1987) Cognitive models of depression, Journal of Cognitive Psychotherapy: An International Quarterly , 1, 5-37.

Beck AT, Rush AJ, Shaw BF, Emery G. (1979) Cognitive therapy of depression. New York: Guilford Press.

Beck A.T, Steer RA. (1993a) Manual for the Revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation,.

Beck A.T, Steer RA. (1993b) Manual for The Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation.

Beck, A. T. (1967). Depression: clinical, experimental, and theoretical aspects . New York: Hoeber Medical Division, Harper & Row.

Burns, D. D. (1999). Feeling good: The new mood therapy . New York: Avon Books.

Champion, L. A., & Power, M. J. (January 01, 1995). Social and cognitive approaches to depression: towards a new synthesis. The British Journal of Clinical Psychology / the British Psychological Society, 34, 485-503.

Colman, I., Ploubidis, G. B., Wadsworth, M. E., Jones, P. B., & Croudace, T. J. (January 01, 2007). A longitudinal typology of symptoms of depression and anxiety over the life course. Biological Psychiatry, 62, 11, 1265-71.

Conoley, C. W. (1987). Review of the Beck Depression Inventory (revised edition). In J. J. Kramer & J. C. Conoley (eds.), Mental measurements yearbook, 11th edition (pp. 78- 79). Lincoln, NE: University of Nebraska Press.

Dowd, E.T. (1992). “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 81-82

Moorey, S. (January 01, 2010). The Six Cycles Maintenance Model: Growing a “Vicious Flower” for Depression. Behavioural and Cognitive Psychotherapy, 38, 2, 173-184.

National Institute for Health and Clinical Excellence (2007a). ‘Depression: management of depression in primary and secondary care’. NICE website. Available at: https://guidance.nice.org.uk /CG23/quickrefguide/pdf/English ( accessed on 15 Nov 2010).

Owen, S.V. (1992) “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 82-83

Rush A, Kovacs M & Beck A. (1981), Differential effects of cognitive therapy and pharmacotherapy on depressive symptoms. Journal of Affective Disorders ; 3, 221-229.

Persons J.B. (1989) Cognitive therapy in practice: A case formulation approach. New York, Norton Press.

Scott, J. (2001). Cognitive therapy for depression. British Medical Bulletin. 57 (1), 101-113.

Categories: Cognitive Behavioural Therapy , Depression - By Dr Becky Spelman - March 1, 2024

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Professional Memberships

Telehealth cognitive behavioral therapy for depression in Parkinson's disease: A case study

Affiliation.

• 1 Department of Psychological and Brain Sciences.
• PMID: 34166038
• DOI: 10.1037/pst0000367

Parkinson's disease (PD) is characterized as a motor disorder, but the majority of individuals with PD also suffer from nonmotor symptoms, including mental health difficulties, such as depression, anxiety, and apathy, as well as decreased cognitive function, daily function, sleep quality, and quality of life. Cognitive behavioral therapy (CBT) is an effective treatment for depression in PD, but motor disability, work schedule, transportation issues, and care partner burden may cause difficulty in attending weekly face-to-face therapy sessions. A promising avenue in the delivery of CBT is telehealth. CBT administered live via videoconference technology may circumvent many of the barriers that prevent those with PD from receiving treatment. This case study evaluates the preliminary efficacy, feasibility, and acceptability of 12-week telehealth CBT for depression in PD. CBT administered via telehealth was feasible, acceptable, and efficacious for a study participant with PD and major depressive disorder. In addition to effectively treating depression, the telehealth intervention improved quality of life and aspects of cognitive functioning, as well as symptoms of anxiety, apathy, and subjective cognitive impairment, all of which are prevalent nonmotor symptoms of PD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

• Cognitive Behavioral Therapy*
• Depression / therapy
• Depressive Disorder, Major* / therapy
• Disabled Persons*
• Motor Disorders*
• Parkinson Disease* / complications
• Parkinson Disease* / psychology
• Parkinson Disease* / therapy
• Quality of Life / psychology
• Telemedicine*

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Max G. Levy

Saunas Are the Next Frontier in Fighting Depression

Depression runs hot. In the 1980s, psychiatrists began noticing that patients with depressive symptoms had higher body temperatures compared to people without, and that their body temperatures didn’t ebb and flow as much throughout the day. The more severe a patient’s depression, the higher their temperature tended to be.

Researchers have since noticed that when someone’s depression improves, their body temperature regularizes, “no matter how their depression got better—electroconvulsive therapy, psychotherapy, antidepressants, whatever,” says Ashley Mason, a clinical psychologist at the UC San Francisco Osher Center for Integrative Health. This got Mason thinking: If the two are linked, what happens to a depressed person’s symptoms if you provoke a change in their temperature?

There’s a sizable group of people who already play around with their core temperatures regularly who can help answer this: sauna users, who whip their temperatures up, and in doing so, also push their bodily cooling systems into overdrive. Anecdotally, saunas are associated with elevated levels of well-being, but there’s only been limited research into their impact on mental illness.

In a small 2005 study , sauna sessions appeared to help mildly depressed people recover lost appetite, feel more relaxed, and feel a small improvement in their symptoms. And in a 2016 piece of research , 30 people with major depressive disorder completed a six-week-long clinical trial of infrared “hyperthermia”—that is, raising their temperatures in an infrared chamber—and, again, their depression appeared to wane. These results caught Mason’s eye. “I was bewitched by the finding,” she says. “When you see an effect like that, you don’t really want to let it go.”

That work inspired Mason to investigate the relationship between body temperature and depression more deeply. First, she analyzed seven months of daily temperature readings and monthly depression symptoms from more than 20,000 people to demonstrate the strength of the connection— sure enough , higher body temperatures correlated with depressive symptoms.

Following this , her lab ran a clinical trial to begin testing the antidepressant power of being exposed to extreme heat. Preliminary results of the small study, published Tuesday in the International Journal of Hyperthermia, suggest that a form of heat treatment that Mason’s team calls “whole body hyperthermia” may reduce depression symptoms—potentially significantly.

In the study, 12 adults with depression received eight weekly cognitive behavioral therapy (CBT) sessions, accompanied by at least four heat sessions over this period. Heat sessions lasted up to 140 minutes, or until participants’ core temperatures reached 38.5 degrees Celsius—1.5 degrees above the average human body temperature. Each person had been diagnosed with major depressive disorder based on clinical interviews and a questionnaire known as the Beck Depression Inventory-II, or BDI-II, where higher scores indicate higher severity of depression.

Mason’s team hoped to observe mood changes in their post-treatment interviews, as well as lower BDI-II scores; a three-or-more point drop on the BDI-II is considered clinically meaningful, and CBT trials sometimes reduce BDI-II scores by five to nine points. What they saw was bigger: The participants’ scores fell by an average of 15.8 points. Scores on separate questionnaires about “negative automatic thinking”—involuntarily biased thoughts that are prevalent in depression—also decreased about 20 percent, hinting at potential improvement. And 11 of the 12 no longer met the threshold for major depressive disorder at the end of the eight weeks.

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“The premise of this is great,” says Earric Lee, a physiologist with the Montreal Heart Institute, who was not involved in the study but has led sauna studies since completing his doctoral research in Finland. “Trying to move away from pharmacology is a good thing.” More than 250 million people worldwide have major depressive disorder, and tens of millions of people don’t respond to any available treatment.

Such a small study doesn’t prove that sauna therapy can treat depression. “Single-arm studies have meaningful weaknesses,” Mason admits. The cohort was too small to test multiple scenarios, such as varying degrees of heating, CBT without heat, or an attempt at a placebo. (Tricking people into thinking they’ve had heat treatment when they haven’t is difficult, but not impossible—the 2016 study into hyperthermia had a placebo arm that subjected people to mild heat, and convinced 72 percent of participants that they were receiving the actual treatment.)

But these results harden Mason’s hunch that heat sessions may ease debilitating symptoms of depression, and that this is an avenue that needs to be better explored. Eight weeks of CBT alone shouldn’t achieve such high remission rates.

Adam Chekroud, an adjunct assistant professor of psychiatry at Yale University, appreciates the potential benefit of the hyperthermia routine, but remains skeptical about why Mason’s study produced the results reported. For one, some of the participants completed weekly sauna sessions in Mason’s study while others completed fortnightly sessions; Chekroud believes that the benefit of receiving a “higher dose” of heat would manifest itself if the intervention were as strong as effective antidepressants. “The placebo effect is powerful in mental health,” he says.

Still, Chekroud sees the value in these explorations. “So much of the history of the treatments for depression started out as a bit experimental,” he says. Exercise, meditation, and yoga are all potentially effective mind-body options. “Exercise is a phenomenally effective treatment,” Chekroud says, noting his own 2018 study in The Lancet analyzing data from 1.2 million people .

Comparing heat therapy to exercise is not totally unfounded. Beyond just sweating and increasing heart rate, exercise, like using a sauna, also requires getting out of bed, making a plan, and maybe interacting with people—actions that themselves may have an impact on mood. “You’re gonna go back home and feel proud that you’ve made a change in your life,” Chekroud says. “Psychologically, these are big similarities.”

But it’s plausible that the heat itself may contribute too, notes Lee, the sauna physiologist. We know that thermoregulation correlates with mood and moves in tandem with circadian rhythms: Your body typically cools down at night and warms in the early morning, but this temperature regulation turns wonky in severe depression. This might then impair sleep, which is also linked to mood.

Doses of extreme heat might have some sort of hacking or resetting effect on thermoregulation, which then changes mood. Sauna can kickstart the body’s “cool down” programming, Lee says. “You fake it into thinking that it needs to lower its temperature much more,” he says. “So it will get there quickly.”

Whatever the mechanism, heat therapy may be more accessible to people than pharmaceuticals, talk therapy, or vigorous workouts. “We know exercise works for depression,” Mason says. “It’s just much easier to get someone to lay down in a sauna for a while than to go on an hourlong run—especially if they have depression.” Ditto for people with disabilities.

Mason’s trial is still several years—and many grant dollars—away from really nailing down the efficacy of antidepressant heat, though the new results have bolstered her optimism. “A mind and body treatment with that kind of outcome is surely worthy of further study,“ she says. “I hope that grant reviewers and funding agencies will agree.” Her long-term goal is to amass enough convincing evidence for insurance companies to cover practices like sauna, “so that when a person with depression is considering a menu of treatment options, this is on the menu.”

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Cognitive group therapy for depressive students: The case study

Juhani tiuraniemi.

University of Turku, Department of Psychology, University of Turku, Finland

Jarno Korhola

The aims of this study were to assess whether a course of cognitive group therapy could help depressed students and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. “Johanna” was a patient in a group that was designed for depressive students who had difficulties with their studies. The assimilation of Johanna's problematic experience progressed as the meetings continued from level one (unpleasant thoughts) to level six (solving the problem). Johanna's problematic experience manifested itself as severe and excessive criticism towards herself and her study performance. As the group meetings progressed, Johanna found a new kind of tolerance that increased her determination and assertiveness regarding the studies. The dialogical structure of Johanna's problematic experience changed: she found hope and she was more assertive after the process. The results indicated that this kind of psycho-educational group therapy was an effective method for treating depression. The assimilation analysis offered a useful way of analysing the therapy process.

Introduction

Clinical depression is one of the most common mental disorders (Kessler, Berglund, Demler et al., 2003 ). Approximately 5–6% of Finns suffer from depression (Isometsä, 2001 ; Isometsä, Aro & Aro, 1997). Students suffering from depression often have difficulties in coping with their studies (Brackney & Karabenick, 1995 ; Kessler & Walters, 1998 ; Lyubomirsky, Kasri & Zehm, 2003 ), and a strong association has been found between depressive symptoms and stress (Mikolajczyk, Maxwell, Naydenova, Meier & Ansari, 2008 ). According to their own estimation, 53% of American college students had suffered from depression during their studies (Furr, Westefeld, McConnell & Jenkins, 2001 ). Over half of those who had experienced depression stated that problems related to studying were the most important depression-inducing factor. Therefore, there is a close connection between depression and studying difficulties.

According to Isometsä et al. ( 1997 ), of those who suffer from depression, 50% feel they need mental health services. Of depressed students, 17% seek help for their problems (Furr et al., 2001 ). Depression diminishes a person's ability to act through various mechanisms. Being depressed has a lowering effect on a student's sense of self-efficacy (Beck, 1976 ) and it lowers the expectations of doing well with one's studies (Brackney & Karabenick, 1995 ). A depressed student may feel that he/she will not complete his/her studies like everyone else. The fatigue, the powerlessness and the lack of concentration that accompany depression also reduce the student's ability to function.

Depression affects academic performance and ability to act through the students' motivation and their use of studying strategies (Brackney & Karabenick, 1995 ; Lyubomirsky et al., 2008). Often, depressed students are not able to plan their studies efficiently or observe their own work. They may have difficulties in sufficiently regulating their time-use, their study environment or the amount of work they pour into their tasks. Cognitive-behavioural therapy resulted in a significant improvement in perceived stress, depressive symptoms, reduced use of avoidance coping strategies, and more use of approach coping strategies among university students (Hamdan-Mansour, Puskar & Bandak, 2009 ).

Persons with depressive symptoms often seek validation for their own needs and actions from other people (Clark & Beck, 1999 ). In this manner, they strive to prove their worth, their competence or their likeableness. Those suffering from depression often have limited social skills (Segrin, 2000 ). This leaves a student in an adverse position, because there is an inseparable social side to student life.

Sometimes a depressive person is troubled by the aspiration to be extremely competent and efficient. Perfectionist tendencies involve high expectations of oneself, and an individual's self-respect is based on the perception of one's own efficiency and competence (Chang & Sanna, 2001 ; Cox & Enns, 2003 ). Perfectionists have difficulty working with others and find asking for help very difficult (Brackney & Karabenick, 1995 ). In a student, high expectations of competence may be manifested as, for example, a great amount of work done, good marks and dissatisfaction with a performance that did not reach the desired level and is not consistent with one's self-image.

There has been quite a lot of research on the effects of cognitive-behavioural group therapy as a treatment for depression. According to the extensive mapping by DeRubeis and Crits-Christoph ( 1998 ), treating depression with cognitive-behavioural group therapy is efficient and useful. Kush and Fleming ( 2000 ) have had similar results. In their therapy, they tried to teach the patients skills that diminish depression and anxiety. For example, they tried to develop the patients' problem-solving skills. Treating depression with cognitive-behavioural group therapy has proven efficient and useful (Bright, Baker & Neimeyer, 1999 ; DeRubeis & Crits-Christoph, 1998 ; Kush & Fleming, 2000 ; Kwon & Oei, 2003 ). Cognitive behavioural group therapy has led to reduction in the levels of depression, negative automatic thoughts, and students' dysfunctional attitudes (Hamamci, 2006 ). It has been proven that the symptoms of depression lessen during therapy.

Brackney and Karabenick ( 1995 ) stated that psychotherapy aimed at students suffering from depression should contain instruction on structuring one's studies and on life-control skills . The patients should also be taught means of mood-control to improve their concentration and they should be encouraged not to ruminate and wallow in their depression (Lam, Smith, Checkley, Rijsdijk & Sham, 2003 ). Certain group-members' individual factors can predict their benefit from group therapy: mild depression in the beginning of the group work, a feeling of being in control of the situation, the group's cohesiveness and the ability to function as a group (Hoberman, Lewinsohn & Tilson, 1988 ). According to Pace and Dixon ( 1993 ), short-lived cognitive therapy lessens the depressive symptoms and also helps the schemata related to a more positive self-image.

Greenberg ( 2002 ) has stated that the change happens by activating an unadaptive schema to which an adaptive feeling is then attached. For instance, an unadaptive schema created by loss can be changed by grieving, that is, by adding the feeling of grief to the schema. According to Guidano ( 1991 ), the superficial and deep level change-processes do not exclude each other; in fact, superficial changes may promote deep level changes. In the assimilation model (for example Stiles, 2002 ; Stiles et al., 1990 ; Stiles et al., 1991 ), the change occurs by the assimilation of problematic experiences into a particular schema or schema chart. This can be described in eight different stages.

The change has been described in stage theories. The transtheoretical model posits that health behaviour change involves progression through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997 ). Precontemplation is the stage wherein individuals are not aware of their problems, and they are resistant to change. In the contemplation stage, they are aware of their troubled behaviour but they are not committed to action. In the action stage, they change their behaviour and in the maintenance stage they try to prevent relapse. The assimilation model is more detailed and the description of cognitions and emotions is more specific. With the aid of the assimilation analysis, it is possible to delve into the cognitive and emotional changes that occur in the patient's problematic experiences and to evaluate the change process. The analysis is not just about the final result of the therapy: the problematic experience and the stages of changes the individual goes through are observed and assessed at different phases of therapy (Stiles et al., 1990 , 1991 ; Stiles & Osatuke, 2000 ).

A series of case studies has been executed using assimilation analysis (e.g. Brinegar, Salvi, Stiles, & Greenberg, 2006 ; Leiman & Stiles, 2001 ; Stiles et al., 2006 ). Assimilation analysis allows for focus on the focal points of the process. Using a case study has some advantages, e.g. the possibility to describe detailed process in psychotherapy, but there are some limitations. Behaviour can be described, not explained, and a case study cannot be representative of the general group or population. However, there is a need for process descriptions when we want to find a means to help depressive students who have problems in their studies. The evaluation of the case can also be susceptible to mistakes. For example, the researcher can see the change more positively or in the perception that other psychological phenomena can happen. In the evaluation, one must indeed be conscious of this , and be able to change a perspective for a subject so that mistakes in the evaluation do not take place (Montgomery & Willen, 1999 ).

This study depicts the change process of a student's psyche. The aims were to assess whether a course of cognitive group therapy could help depressed students with their problems affecting their studies and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. This study was carried out using assimilation analysis to try to interpret and understand the contents of the subject's problematic experiences and the change she underwent through the sessions.

Research methods

The basic materials of this study are Johanna's (the name has been changed) discussion contributions that were singled out from taped group sessions. Johanna is a university student suffering from depression.

The group consisted of six students suffering from depression and studying difficulties. Altogether, the group met 16 times and the sessions lasted two hours each. In its final form, the group was composed of five women and one man. One student stopped attending the course after four times. The members' ages varied from just over 20 to a little over 40 years of age. Five of the members were at the final stages of their studies, and one was at the beginning of them. Some students were receiving treatment elsewhere, but we had no exact information about other care or treatment. Those who were at the final stages of their studies had particular difficulties with their theses and their studies had been delayed. The research subjects were referred to take part in the course and in this research by the Turku branch of Finnish Students Health Service (FSHS).

In the beginning of the course, the goal was to activate the participants. At a later stage, more attention was paid to the feelings of helplessness and powerlessness and how these feelings affected the participants' studying performance. The contents of the group sessions and the themes covered in each of them are depicted in Table I . In the beginning of the course, students made exercises in problem-solving methods. The basic elements in cognitive therapy are behaviour techniques, methods for studying beliefs and thoughts and techniques for managing emotions and feelings. The students analysed the things that hinder their studies and goals. After that, they analysed their daily activities and planned new strategies for their actions and studies. They analysed the effect of thought and worked with their beliefs and thoughts. They made assertiveness exercises and learned new strategies for managing their emotions. At the end of the course, they evaluated what they had learned and what they have to do in the future.

Cognitive group therapy for depressive students: Course program and contents.

The criteria for participating in the course were: (1) depression (at least 13 points on the BDI-scale); and (2) constant absences from lectures or delay of studies. It was stipulated that suicide risk, bidirectional affective syndrome and acute crisis would prevent participation in the course. In addition, it was expected of the attendees that they possess enough concentration to carry out the assignments required by the course programme.

The preliminary interviews were conducted to assess who could benefit from this short-term, psycho-educative course. To have successful group therapy, preliminary interviews and the composition of the group have to be carried out with utmost care (Bernard et al., 2008 ). The group meetings were referred to as a course instead of group therapy, because its purpose was to be as non-labelling and as easily approachable as possible. The interviews and the composing of the group were conducted by the group leader.

The course consisted mainly of different assignments that the participants completed on their own time. At the sessions, the group leader led discussion about the assignments. The participants were given assignments such as mapping out their social network and thinking about problems that complicated their studies. The assignments were based on a book of exercises called Depressiokoulu (Depression School) by Koffert and Kuusi ( 2003 ). The depression school introduced in the book consists of ten lessons that were used in the course when planning the 16-session programme. The group leader's role was active and encouraging.

The therapist had six years of therapy education in cognitive therapy, and six years of education in family therapy. Furthermore, he had experience from working with the groups. The supervisor had qualifications of the trainer psychotherapist (cognitive therapy) and the work supervision was carried out during the group process.

The case discussed in this study was chosen on the criteria of informativeness and representativeness compared to other group members. Johanna (the name has been changed) was a university student suffering from depression. At the beginning of the course, Johanna was just under 30 years of age and living with her significant other. She was a student of natural sciences and her studies were at the stage where she was to write her thesis.

Johanna's studies had been stuck for 18 months. Carrying out the studies seemed utterly overpowering to her. She had found other things to do instead of studying, such as household chores. Johanna felt that she no longer had any ambition to study and in addition, her motivation to study her chosen field was running low. This was, at least in part, due to the lack of jobs in the field.

Johanna felt that she had fallen hopelessly behind from her fellow students. She avoided meeting her course mates and spoke to virtually no one about her studying difficulties. She said that she lacked concentration. Johanna felt she was lazy and inefficient. She described herself as bad and a failure, both as a student and as a person. She had worked during the summers and the work had gone well.

Depression represents a mode that has been named loss or deprivation mode (Clark & Beck, 1999 ). There were indications of each of the schemata included in the mode in Johanna. In Johanna's case, feelings of hopelessness and the loss of pleasurable feelings (motivational scheme) were particularly noticeable, in addition to passiveness and withdrawal (behavioural scheme). Johanna felt dispirited (affective scheme) and she had difficulty in coping with her studies (physiological scheme). The threat of loss (cognitive-conceptual scheme) was only suggestive, which in Johanna's case would have meant possibly giving up her studies entirely.

The subject's depression was assessed with the Beck Depression Inventory self-assessment form that had been translated into Finnish (Beck et al., 1961 ) that comprised of 21 items. In each item, there are 4–7 alternative statements that have been awarded points from 0 to 3. The items depict attitudes and symptoms related to depression and the severity of the depression from neutral to severe (0 = neutral, 1 = mild, 2 = relatively severe, 3 = severe). The full score of the BDI is 63. The clinical norms of the Inventory are: neutral or not depressed (0–9 points), mildly depressed (10–18), relatively severely depressed (19—29) and severely depressed (30 to 63) (Beck, Steer & Garbin, 1998). The form is a reliable and valid tool for assessing the severity of depression (Beck et al, 1988 ; Beck, Ward, Mendelson, Mock & Erbaugh, 1961). The indicator also gives information on changes in the severity of depression, so it is also a reliable aid when examining the effects of therapy (Beck et al., 1961 ).

The BDI-form was used to gather information in the middle of the course, both midways through it and at the end of it. The subjects were also given a form to fill out approximately two months after the group sessions had ended. In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe.

Assimilation analysis is a research methodological trend used for measuring the effects of psychotherapy. According to Stiles et al. ( 1990 , 1991 ), the client's troubling experiences assimilate into already existing knowledge structures in successful psychotherapy. In the course of the therapy, the client aims to give his/her experience new meanings and the experience integrates into a part of the client's schema structures. The assimilation model takes into account both emotional and cognitive change processes. To analyse the stages of assimilation, we can use the APES (Assimilation of Problematic Experiences Scale) developed by Stiles et al. ( 1990 , 1991 ). The stages of assimilation are demonstrated in Table II .

Summary of the stages of assimilation of problematic experiences scale (APES).

Assimilation can be examined as a continuum in which the assimilation of the problematic experience progresses with the progression of therapy. Assimilation progresses in stages and it is notable that the patient's assimilation process can be at any stage when the therapy begins (Stiles et al., 1990 , 1991 ). Assimilation does not progress rigidly and systematically; there can be regressions.

The closer the client is to understanding the problem, the more focal the problematic experience becomes in his/her consciousness (APES 4, Table I ). From this stage onward, the amount of conscious effort aimed at the problematic experience begins to decline. The neutral state of mind in the beginning of the assimilation process reflects a successful denial of the problem. As the client becomes increasingly aware of the problematic experience, the tone of the emotions becomes more negative. As the assimilation progresses, the anxiety will gradually lessen and the mood becomes more positive: the problem is understood and solved. When the problem is under control, emotions regarding it become neutral.

Data collection

The assimilation analysis can be carried out in many different ways (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). However, it is possible to separate four steps that one can follow to ease the process.

I Getting to know the data and listing

In this study, the basic data consisted of videotapes, consisting of approximately 30 h of footage. The analysis was begun by watching all the tapes through carefully (carried out by JK, the other author of this article). He noted the topics the subject addressed in the order they were discussed. The topics noted were attitudes or actions directed at a specific object. The topic could be, for instance, hopelessness in regards to writing the thesis and studying. The main purpose of this work stage is that the researcher acquaints himself with the data as much as possible.

II Recognizing and choosing the themes

The theme that will be examined can be a repeatedly expressed attitude or object (Stiles et al., 1991 ; Stiles & Osatuke, 2000 ). The research problem directs the choice of theme. The researcher can choose a theme that is (a) focal or important in the therapy, regarding which; (b) there has been remarkable progress, regarding which; (c) there has been little or no progress; or (d) some other interesting theme. It is best to describe the chosen theme's contents as clearly as possible, for example, by using certain key words.

In this study, the themes were chosen on the grounds that these topics seemed to emerge as focal and important for the subject. In this subject's case, her relationship with herself as a student was most prominent, because the subject brought this topic up constantly when she spoke up. The course dealt with many factors related to studying difficulties. Mainly because of that, the central themes, such as problematic experiences of the subject, were related to studying and difficulties therein.

III Separating parts related to the theme

At this stage, the parts of the material that deal with a certain theme or problematic experience are collected from the material (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). In practice, at this stage the footage was viewed again. By now, the material had already been quite well outlined since the subject's topics had been listed. At this stage, the subject's addresses were actually transcribed word for word.

IV Description of the assimilation process

At the final stage of the analysis, the assimilation is examined from a theoretical point of view. The examination is based on what happened to the problematic experience during therapy. In this study, the examination was performed by classifying the parts that dealt with the themes according to the theoretic stages of assimilation (APES).

Ethical considerations

Names and identification data were changed so that the person is not recognizable. The students were told that the sessions were videotaped for the purpose of the study and the data would be published in a scientific forum. After that, all information would be destroyed. The information was also given in the paper, and they signed on the dotted line.

We named Johanna's problematic experience as a difficult relationship with herself. In the beginning, this was unclear. Johanna's APES was 1/7: she preferred not to think about her problematic situation and her feelings were anxiety and anger. The connection between Johanna's feelings and the problematic experience was unclear. In the fourth session, the problematic experience was identified for the first time. In the seventh and eighth sessions, her understanding of her problematic experience increased. Her understanding fluctuated back and forth. At the end of the course, her attitude gradually became assimilated into her schemas: she found new perspectives on her academic problems. The connection between intervention and its results can be found by describing the therapy process and reporting the relevant utterances (McLeod, 2001 ). In the next section, we describe the process by showing some of Johanna's comments during different sessions (APES number shows the stage in assimilation model, Figure 1 ).

The results of APES analysis over the course of the 16 group sessions. The Y axis shows the stages in the assimilation model. The X axis shows the number of the sessions.

In the first session, Johanna expressed her hopelessness regarding her thesis. In her speech, there was also an emphasis on her sensitivity to criticism and to other people's advice. The connection between Johanna's feelings and the problematic experience was unclear (APES 1: unwanted thoughts):

Johanna: …I've been studying seven years or started these studies seven years ago. And the thesis I've been doing for a bit over a year [is] going nowhere. It's like that no one can say anything about it. I can't listen to any advice on it and the like. And no one close to me can say anything like now I'll get so down if I can't get it done. And then I really can't get it done.

In the second session, Johanna expressed that she was very critical of herself and of her progress in her studies (APES 1.5: unwanted thoughts and vague awareness):

Johanna: …Now I've totally been lazin' and stuff. Like I left my job last year so that I could work on that thesis. I haven't been working on it. I haven't been able. Then it becomes like kinda …that you can't like …like, you can't allow anything nice to yourself, you know. It's like I should be doin' it now that I got the time. Therapist: Let me clarify, you mean that when you feel you haven't done enough, then you can't like enjoy yourself or just do nothing.

During the third session, the group discussed the fact that it would be good to commend oneself every day for the things one has done. Johanna found it quite hard to give herself credit (APES 1.5: unwanted thoughts and vague awareness).

Therapist: How can you give credit? What could you tell yourself, for example, Johanna? Johanna: I dunno. Therapist: Try it. …Or think about it. Johanna: Well maybe like that you've been doin' stuff all day. That you haven't like ran outta steam in the middle. Therapist: Yeah. So you could say daily that you've done well.

In the fourth session, Johanna disclosed that she felt she lacked the self-discipline required to write the thesis. The problematic experience began to take shape (APES 2: vague awareness/emergence):

Therapist: Johanna, would you like to say something to this? Johanna: I dunno, I got like …that thesis; it's like mainly the self-discipline. …That I'd like have enough discipline to, like, take a hold of it. Cos sure I'd rather be somewhere else doin' somethin' fun.

The difficulty that Johanna experienced in giving herself credit came up again during the fourth session. She expressed the existence of a problematic experience quite directly (APES 3: problem statement/clarification):

Therapist: And Johanna, have you remembered (to give yourself credit)? Johanna: [Shakes her head] No. Therapist: You haven't? Johanna: It's somehow not. …It goes against my nature. I don't know how. …I can't. Therapist: That, that when you try, then you've done so much everyday stuff. Then you do a huge amount. It's like an employer not paying salary. So then … You get through so many, many difficult things.

In the seventh session, Johanna told the group that undone work dampened her spirits and paralyzed her from acting. Her understanding of the problematic experience was improved (APES 4: Understanding/insight):

Johanna: My last week was like, that I was sick on the weekend and early in the week … Therapist: When you got better, what was the biggest obstacle that you didn't touch those papers? Johanna: I dunno. Maybe it was a kinda feeling of incapability that just like took me with it. Therapist: Did you then have this feeling like everything's gone to waste or? Johanna: Yeah. Not when I was sick, then I just didn't have the energy. So that, I just let slide. But um then that … Then after it I'd just lost that whole week. It's like, it's gotta start with Monday or it won't start at all. I just got that feeling. Therapist: It's funny, that it's kinda like a sort of programming. But d'you think that this thought of everything going to waste paralyzed you? Johanna: Yeah, probably.

In the eighth session, Johanna groped for words as she tried to describe her new views on studying and writing her thesis that she had learned from the course. Here, Johanna's newly-found tolerance toward herself and her behaviour was apparent. Writing her thesis no longer seemed completely mandatory; instead, Johanna felt that she could do other things, even if she was not working on her thesis. She worked on her problematic experience further (APES 5: application/working through):

Johanna: …I got a lot of new views from others and stuff to think about. Therapist: Which new views did you get? Johanna: Well … The one about that um … you do little by little and then you can like rest. And like that when you don't give yourself permission to do. That it would be like important just so that you can stay in shape and then work again. Therapist: Wait, did I get this right, that when you something, you'd do it. But then on the other hand you'd give yourself permission to do other stuff and enjoy that too. Was that what you meant? Johanna: Wait a sec …I meant that like, if you're not doing the thesis, it's still okay to do something else.

In the ninth session, Johanna felt that giving herself positive feedback was quite difficult. She was, however, able to give herself some positive feedback, but negative thoughts and criticism took over her mind very easily. This depicted Johanna's severity on herself (APES 4.5: understanding and working through).

When the group had met ten times, Johanna had been able to become more active with her thesis. She still felt, however, that the more she focused on studying, the lower and the more desperate she felt. Criticism and severity could be heard in Johanna's speech (APES 3.5: problem statement and understanding).

In the eleventh session, Johanna said that she needed instruction on her thesis, but she was afraid of going to meet her instructor. Here, Johanna's feelings of hopelessness with her studies and her thesis became apparent. Alternatively, it seemed that she was ashamed that she had not achieved what she thought was enough (APES 4: understanding/insight):

Johanna: I'd really probably need like my own field's point of view at this stage and …I just somehow don't dare to go to the department. …I just don't dare go there. Therapist: What scares you? Johanna: I dunno. It just makes me feel like that, I'm a loser and I'm so totally lousy, and now it's been so long, and more time just keeps passing. It's like this endless circle … or kinda like, it's too late now.

Later in the same session, Johanna said that she felt she got support from the group. She worked on her experiences some more. The emotional tone was positive and optimistic (APES 5: application/working through):

Therapist: What do you hope from us (the group)? Johanna: Well, I hear all kinds of … well I hear stories here, survival stories. [Laughs.] Therapist: [Laughs.] This is a survivors' club. Johanna: Maybe that kinda gives hope, that maybe I'll be brave enough to go there [to the instructor], because now I've got it figured out what my next step is, that I should take to get forward.

In the twelfth session, Johanna reflected upon her determination to work on her thesis (APES 5: application/working through):

Therapist: …Now that you've been more active, what's helped you? Johanna: Well just that like you've decided once and for all that now you gotta do it. That I … well first of all, I went to see the professor right then, that week [Therapist: Yeah.] when we talked here. Therapist: Good, great. Yeah. And you didn't get eaten there. Johanna: Right. And now I have this like …or that kinda feeling that it's now or never. That otherwise it will just stay here, and I can't leave it now. It'd be even harder to start. Therapist: So does that mean that you've made yourself an action plan? Johanna: Well, a bit like that, yeah. That I don't have to have like a schedule [Therapist: On how you'll go on.] but just so that …. Johanna: Every day I should get something done. –

In the thirteenth session, Johanna brought up the fact that she could get studying done little by little. She had learned to have mercy on herself (APES 5.5: application/working through and problem solution):

Therapist: How about your studies this week? Johanna: Well. I studied stuff on Tuesday and Wednesday. Therapist: Great. Johanna: But then I've had these gap days. Therapist: Have you given yourself credit? Johanna: Well, I have tried or at least be happy even if I don't do a lot. Cos I get something …like reading stuff. Therapist: This sounds great. So what's your recipe now? Johanna: Like one day at a time. If it feels bad, then you can like …give it a rest, you know, and do something else.

In the fourteenth session, Johanna listed her short-term priorities. Her short-term aims reached the time-line of approximately six months. In addition to working on her thesis, Johanna mentioned recovering even further from her depression as a goal. In addition, the fact that Johanna was happier with herself was clear; this had increased during the group sessions (APES 5.5: application/working through and problem solution):

Therapist: How about Johanna? Johanna: Well I pretty much have the same things [as the others] that I've put down. I wanna have the thesis like up and running, so that it kinda takes care of itself or that like …I could see the end of it already. And that I'd move past the depression, that I'd be like rid of it already. I dunno. That I'd be happy with myself. Therapist: You have that too, to be happy with yourself. Johanna: Yeah. Or like, yeah. Therapist: Yeah. Do you feel that it's increased during this group, that being happier with yourself? Johanna: Yeah, probably.

The fifteenth and the sixteenth meetings of the course were held together as a single four-hour session. During this session, it came up that Johanna was less critical of herself. She said she could write her thesis gradually (APES 6: problem solution):

Therapist: What have you done lately when you said ‘I've done’? Johanna: And that um …I've been reading. Reading some of the stuff I got, some materials. And then I've just written straight to the computer. And that text doesn't matter at this stage that it's just like some text. Therapist: Yeah. Johanna: That I can like mould it later into what I want. That's just it, cos it's that starting up that's hard for me, that writing is kinda hard. I could really think about one sentence for half an hour. Then it's just gonna go nowhere. So I'll just write then, even if it's not perfect language yet. Therapist: It's probably good that you do it like that. Johanna: It's like I get something done. I get that kinda … Therapist: So is this a new method that you've developed, that you just write ahead? Johanna: Well, yeah. I think it kinda is. The whole time it just kinda gets more fluent and like um …the text [Therapist: Yeah.] and the like, the way it comes out. [Therapist: Yeah.] And It's probably the reading too that does it, the more familiar the thing is the easier it gets, of course and the easier it maybe is to write.

Johanna felt that her beliefs regarding her own actions had changed. She had found new perspective and relief for her problems from the group (APES 6: problem solution):

Therapist: But Johanna, is it kinda like, you've seen that these kinda things don't have to knock you down, that you've then changed your beliefs on your own actions? Johanna: Yeah. Or like. … That this [problems with the thesis and depression] isn't such a big monster anymore. Then when here you've had to and it's been okay to talk about it, then it's not. … It's like easier to take that thing. It's not so big anymore. That you can talk about it. You gotta bring it up once a week anyway, it gets smaller. I don't really know.

As the course went on Johanna was increasingly vocal about having mercy on herself and being happy with herself. She spoke about having received support from the group and was learning to commend herself. Little by little, she became less critical toward herself. She had more room in her inner world. Her tolerance toward herself had a positive impact on Johanna's ability as an actor. She began to work on her studies gradually and it also became easier for her to do other things besides studying.

Finding the ability to be merciful led, in Johanna's case, to increased determination and assertiveness regarding her studies. She wanted to finish her thesis and felt that the thesis was no longer “some monster.” In other words, Johanna got more motivation to continue her studies and to finish them. These new views formed another self-state in Johanna. Johanna's symptoms of depression eased and her ability to act improved.

In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe. Four months later, the score was 23 and two months after that, it was 19. At this point the course was finished. A follow-up measuring three months later showed the score was 12, which meant that Johanna was, according to the BDI-indicator, only mildly depressed. Johanna's BDI-score kept decreasing throughout the course, and also after it. She felt that her depression eased during the group meetings.

Johanna's problematic experience (APES) progressed as the meetings continued from level 1 (unpleasant thoughts) to level 6 (solving the problem) ( Figure 1 ). In the beginning, Johanna's problematic experience manifested itself as severe and excessive criticism toward herself and her study performance. The assimilation of Johanna's problematic experience was facilitated by learning different methods of depression control in the group.

Discussion and conclusions

During the course, Johanna directed her energy toward surviving depression, finishing the course and carrying out the assignments given in the group. If working helped in recovering from depression, we can assume that after the course, Johanna had even more resources to direct her actions at, for instance, her studies and particularly on writing her thesis.

Johanna expressed plenty of severe and excessive criticism aimed at herself during the course. According to Guidano's (1991) theory, “I” represents the experiencing and reacting side of the human mind and “self” represents the evaluating and observing side. In Johanna's case, “me” was very rigid and severe, even merciless. This side of her mind attributed that the lack of progress in her studies and other negative experiences were her own fault. Depressive, negative attribution style is a central method of self-regulation in depression (Beck, 1976 ; Beck, Rush, Shaw & Emery, 1979 ). In Johanna's case, the rigid and severe “me” produced negative, permanent inner attributes. These assessments were the source of the severity and harsh critique she directed at herself. By examining this according to Guidano's (1991) theory, Johanna became more lenient in the assessments “me” made of the actions of “I”. This was seen in Johanna's case as the depressive, negative attributions becoming less prevalent.

Of the schemata belonging to the loss or deprivation mode, the behavioural scheme, in particular, changed in Johanna's case during the course. Passiveness and withdrawal made way for her new determination and assertiveness toward her studies. The feelings of hopelessness seemed to go away, so the motivational scheme can also be said to have changed for the better. Alternatively, Johanna reported that her role as an actor regarding her studies remained rather passive throughout the course. The contents of the affective and physiological schemata also underwent a positive change. Johanna's melancholia eased and she gained strength to continue her studies.

The assimilation of Johanna's problematic experience was facilitated by her learning different methods of depression control in the group. Treatment aimed at depressed students would do well to teach structuring one's studies and methods of mood-control and life-control skills (Brackney & Karabenick, 1995 ; Lam et al., 2003 ). The approach of this course was specifically psycho-educative. Johanna felt that she had also received peer support from the group: she had heard how the other group members had managed to get their studies started.

One of the focal questions in this study was whether or not finishing the course helped in combating depression and studying difficulties. The results indicate that the subject's depressive symptoms eased and her role as a student became more active. In the group, mood-improving techniques were also taught. The depression-control skills taught were important.

When examining the change process, we can distinguish two kinds of change processes: superficial and deep changes (Guidano, 1991 ). The group members' troubling feelings were not discussed at great length in the group. This can be a sign that the achieved changes happened mainly on the superficial level of the psyche. Deep level change cannot take place without active work on the emotions related to the problematic experience (Greenberg, 2002 ; Greenberg & Paivio, 1997 ; Guidano, 1991 ). Thus, the achieved changes are not necessarily very permanent. In the follow-up meeting, the subject's BDI-score had continued to decline, although she was still, according to the BDI, mildly depressed.

In Johanna's case, the single most important factor that promoted change was sharing and examining the contents of the problematic experience with the therapist and the group. The group members took turns in examining their problematic experiences in the group and in this way, they supported each other. All members felt that peer support was important. The group leader taught mood-control skills that each group member exercised independently outside the group. Johanna reported that she had found learning how to schedule her time particularly useful.

Johanna's problematic experience became less restrictive through the course. This led to more lenience toward herself and more determination and assertiveness toward her studies.

The downside of working in a group was the fact that the attention of the therapist and of the whole group was divided among six people. At times, it seemed that none of the group members had the opportunity to express and work on their issues adequately in the session time frame. The therapist took an encouraging and supportive approach: he actively strove to pay attention to each group member and to include them all in the discussions. On several occasions, however, it seemed that the two-hour session was far too short a time for this group.

Some of the group members were receiving treatment elsewhere while they attended the course. Consequently, in this study we could not control, for instance, the effects of medication on the lessening of a person's depressive symptoms. In addition, some group members had a discussion contact with a mental health professional outside the group.

In assimilation analysis, determining the subject's APES stages was sometimes rather difficult. At this point, the summary of the stages of assimilation ( Table II ) was quite helpful. It was often so that a seemingly essential utterance by the subject was found, but determining the APES stage was difficult nonetheless. Eventually, seemingly correct stages were found for all excerpts. Finding the correct APES stages was aided by repeatedly reading the subject's utterance and assessing the excerpt according to the amount of cognitive processing and in light of the emotional content. However, the final text probably contains utterances that could have been rated otherwise. Thinking critically, the data achieved by assimilation analysis could be said to be, in all its detail, merely approximate and dependent on the researcher's interests. Alternatively, we should, of course, bear in mind that the APES stage given to a single utterance is not very significant in the scale of the entire change process.

In Johanna's case, the conceptualized problematic experience could have been, for instance, hopelessness regarding studying, and the effect of negative thoughts on studying or getting support from other people. In this case, the research problem directed the choice of themes. Furthermore, the problematic experiences had to be such that they could be conceptualized into suitable units.

The fact that the analysed data is mainly linguistic can be seen as a weakness of the assimilation analysis. This deficiency is a drawback with most qualitative research methods. The verbal descriptions of the subjects do not always accurately convey the relevant contents of the meanings or the emotions related to them. However, if the analysis is to be successful, it has to recognize the subtle nuances and feelings from the material. That is why we used videotapes: the chance to check the process in video deepens the researchers' understanding.

The very concept of a problematic experience can easily be challenged. In this study, the subject's problematic experiences were the themes that were discussed often and at length. However, other criteria could have been used to choose the problematic experience. The themes conceptualized as problematic experiences could also have been, for example, themes for which there was great progress or for which there was little or no progress at all. Alternatively, another interesting theme could have been chosen.

From an economical point of view, it must be mentioned that with a course such as this, a large number of people can be treated relatively quickly. Nowadays, there is pressure to treat depression as cost-effectively as possible (Bright at al., 1999). Group treatment is substantially less costly than individual treatment. The studied group had 16 gatherings, and sessions were two hours each. The group had six members from beginning to end. If they had each had an individual appointment 16 times, there would have been 96 meetings altogether.

One viewpoint is that coping with depression can be taught. One outlook could be introducing depression school as a part of general, basic health care, for instance at schools. The aim could be to teach mood-control skills to persons predisposed to depression, before they become ill. It would be reasonable for the sake of these people themselves, because it would save them from a great deal of human suffering. In addition, this practice would be sensible for society as well, because economically, it would be much less costly than long-term treatments and sick leaves. However, more research is needed to determine this.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Tackling Treatment Resistant Depression with Multiple Tools

Ketamine changed lives and opened minds, but it's no panacea..

Posted May 6, 2024 | Reviewed by Kaja Perina

• What Is Depression?
• Find counselling to overcome depression
• Ketamine changed lives and opened minds to alternative treatments for mental health.
• Yet Ketamine is no panacea for treatment-resistant depression and other debilitating mental health conditions.
• Other solutions exist that are helping to make treatment-resistant conditions more treatable than ever before.

After administering more than 23,000 ketamine treatments over the past 5 years, we obviously believe in the drug’s importance—saving and changing lives of many patients who suffer from intractable mental health disease.

But ketamine is no panacea for treatment-resistant depression (TRD) and other debilitating mental health conditions. Other solutions exist that are helping to make treatment-resistant conditions more treatable than ever before. And while the explosion of ketamine-for-cash clinics did a lot to build awareness of ketamine, it also provided a myopic, wonder-drug view that overlooks alternatives.

In this blog, we will provide a quick overview of a few key treatments that are helping to make the term treatment-resistant somewhat archaic. We will omit treatments that are currently illegal or require hospitalization.

TMS–a non-drug, non-invasive alternative

Transcranial magnetic stimulation has long been a mainstay of our mental health practice. It’s been a completely noninvasive, non-drug, FDA-approved treatment for depression and OCD for nearly 15 years. According to a study published by the Journal of Neuropsychiatry , “Response to [TMS] treatment is variable, with response rates reported between 45% and 60% and remission rates between 30% and 40%.”

Why we choose this alternative: When a patient is treatment-resistant, having failed at least two traditional antidepressants , we often try TMS rather than continue to trial additional antidepressant medications. TMS is an important treatment for patients needing to avoid medications due to pregnancy or side effects.

Over the years, the technology and research behind TMS has steadily improved. Recently, researchers found that one of the many impacts TMS has on the brain is to correct the flow of brain signals. Researchers at Stanford Medicine studied 33 individuals with major depressive disorder and found that their brain signals were traveling in the wrong direction. After treating the participants with TMS, the flow of neural activity reversed directions and resulted in a lift in mood.

While not everyone with depression has an abnormal flow of neural activity, this is one possible cause of depression. In fact, we often begin our treatment intervention with TMS because it is well tolerated with minimal side effects and non-invasive.

Vagal Nerve Stimulation–an implantable option

Vagal Nerve Stimulation (VNS) is an FDA-approved, non- medication treatment option for severe or bipolar depression. Like ketamine, it has a 70% success rate when used for TRD, meaning the patient hasn’t responded to traditional antidepressants.

Vagus Nerve Stimulation for depression involves implanting a small device just below the skin in the upper chest, similar to a pacemaker. VNS stimulates the vagus nerve, triggering its natural process of sending electrical pulses to parts of the brain that control mood.

Why we use this alternative: One thing to note is that VNS is considered an adjunct treatment, meaning it is typically used in tandem with an antidepressant or other treatment. We believe VNS could be the ‘ketamine reduction’ device providing a safe, enduring treatment beyond medication options. It gives mental health patients another vital option that works with your body’s natural means of controlling mood.

VNS is a proven treatment that has been around for more than 25 years and has been used in over 130,000 people. With recent advancements in the VNS technology and implantable devices, it has become much more accessible to the patients who need it most.

A small 2022 study of TRD patients in China found that, after 9 months of treatment with VNS, the response and remission were 85.7% and 57.1%, respectively. Meanwhile, a much larger clinical trial is underway since 2019 and will run until 2028 to “determine whether active VNS Therapy treatment is superior to a no stimulation control in producing a reduction in baseline depressive symptom severity.”

Though VNS is not as fast acting as most other antidepressant treatments, it can be used safely in combination with transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and common antidepressant medications to provide patients an added boost to break through their symptoms.

Dextromethorphan/bupropion–a (not so new) drug alternative

A new oral antidepressant, Auvelity, was approved by the FDA in 2022 following a phase 3 clinical trial study titled: Efficacy and Safety of AXS-05 (Dextromethorphan-Bupropion) in Patients With Major Depressive Disorder . According to clinical trial data, MDD patients treated with dextromethorphan-bupropion showed significant improvements in depressive symptoms compared to a placebo :

“Remission was achieved by 39.5% of patients with dextromethorphan-bupropion versus 17.3% with placebo (treatment difference, 22.2; 95% CI, 11.7 to 32.7; P < .001), and clinical response by 54.0% versus 34.0%, respectively (treatment difference, 20.0%; 95% CI, 8.4%, 31.6%; P < .001), at week 6.”

The drug is a combination of dextromethorphan (the active ingredient in Robitussin) and Wellbutrin (bupropion), an antidepressant. This was an important development that substantiated what was believed for some time; namely that dextromethorphan may have an impact on mood by affecting similar receptors to ketamine, working differently than other antidepressants.

As with ketamine, the generic ingredients can be just as powerful and more affordable. In fact, we may combine generic dextromethorphan with alternative antidepressants if a patient doesn’t tolerate Wellbutrin due to side effects or allergies.

Why we use this alternative: Ketamine must be administered in a clinic setting, due to its short-lived hallucinogenic effects and the potential for abuse. Dextromethorphan, on the other hand can be prescribed, along with an antidepressant, as an at-home regimen for patients.

We should note that the trial did not include TRD and risk of suicide among its criteria for patient selection. This is called out in an editorial by Alan F. Schatzberg, M.D. in The American Journal of Psychiatry which cautioned that early enthusiasm over Dextromethorphan/bupropion “needs to be tempered until further clinical experience is gained and more studies in patients with treatment-resistant depression are accomplished.” And Psychiatry News said, “An Axsome-sponsored trial conducted solely in patients with treatment-resistant depression failed to detect a difference between Auvelity and placebo after six weeks.”

So with the jury still out, we’re happy (if not enthusiastic) to see promising results from some of our own TRD patients with dextromethorphan as an antidepressant adjunct treatment.

Although ketamine and esketamine have certainly changed lives and opened minds to alternative treatments for mental health. With a number of other advancements, we hope that the term treatment-resistant becomes a thing of the past.

Iosifescu DV, Jones A, O’Gorman C, et al. Efficacy and safety of AXS-05 (dextromethorphan-bupropion) in patients with major depressive disorder: a phase 3 randomized clinical trial (GEMINI). J Clin Psychiatry . 2022;83(4):21m14345.

Nina Bai, Researchers treat depression by reversing brain signals traveling the wrong way. Stanford Medicine News Center. Retrieved May 15, 2023, from: https://med.stanford.edu/news/all-news/2023/05/depression-reverse-brain…

Zhang X, Qing MJ, Rao YH, Guo YM. Adjunctive Vagus Nerve Stimulation for Treatment-Resistant Depression: a Quantitative Analysis. Psychiatr Q. 2020 Sep;91(3):669-679. doi: 10.1007/s11126-020-09726-5. PMID: 32144640.

Zhang X, Guo YM, Ning YP, Cao LP, Rao YH, Sun JQ, Qing MJ, Zheng W. Adjunctive vagus nerve stimulation for treatment-resistant depression: a preliminary study. Int J Psychiatry Clin Pract. 2022 Nov;26(4):337-342. doi: 10.1080/13651501.2021.2019789. Epub 2022 Jan 13. PMID: 35023429.

Schatzberg , M.D., Alan F. Understanding the Efficacy and Mechanism of Action of a Dextromethorphan-Bupropion Combination: Where Does It Fit in the NMDA Versus mu-Opioid Story? American Journal of Psychiatry. Jul 2022 Retrieved April 17, from: https://doi.org/10.1176/appi.ajp.20220434

Kelly MS, Oliveira-Maia AJ, Bernstein M, Stern AP, Press DZ, Pascual-Leone A, Boes AD. Initial Response to Transcranial Magnetic Stimulation Treatment for Depression Predicts Subsequent Response. J Neuropsychiatry Clin Neurosci. 2017 Spring;29(2):179-182. doi: 10.1176/appi.neuropsych.16100181. Epub 2016 Nov 30. PMID: 27899052; PMCID: PMC5592731.

Brian H. Johns, M.D., specializes in treatment-resistant depression and other mood disorders that haven't responded to traditional interventions.

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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Modified Cognitive Behavioural Therapy Shows Promise for Stroke Survivors with Aphasia and Depression

A recent study evaluating modified cognitive behavioural therapy (CBT) has shown promising results in treating depressive symptoms among stroke survivors with aphasia. Researchers from a number of institutions, including Monash University and the University of Technology Sydney, conducted the study, which emphasises the potential of specialised psychological interventions in addressing the complex needs of this vulnerable population.

The findings were published in the journal Neuropsychological Rehabilitation .

Depression affects approximately one-third of stroke survivors, significantly impacting their quality of life and social functioning. The condition is often exacerbated in individuals with aphasia, a communication disorder resulting from stroke that affects their ability to speak, understand, read, and write. Traditional psychological interventions, such as CBT, which focus on the “here and now” and problem-solving skills, are well-established for treating depression in the general population. But the cognitive and communicative impairments of stroke survivors with aphasia pose unique challenges that necessitate tailored interventions.

The study used a single-case experimental design with multiple baselines and a follow-up period of four weeks. The ABA withdrawal/reversal was used. It involved ten stroke survivors with aphasia who reported depressive symptoms. Following 10 individual therapy sessions with a clinical neuropsychologist, participants underwent a four-week post-intervention period.

The intervention was adapted to accommodate the cognitive and communicative challenges of the participants. It included behavioural techniques like activity scheduling and cognitive strategies such as thought modification. The primary outcome measure was self-rated depression, with secondary outcomes including observer-rated symptoms of depression and anxiety.

The findings revealed that the modified CBT was both feasible and potentially efficacious. Three participants reported a decrease in depression levels during the intervention, which was sustained for two participants. Four others showed improvement during the follow-up phase. Others of the participants also reported sustained improvements in both depressive and anxiety symptoms for six and seven participants, respectively.

Independent fidelity assessments showed that the intervention was carried out with enough skill and adherence, suggesting that this kind of customised approach can work well for stroke survivors with different levels of aphasia.

Detailed vignettes of participants highlighted the diverse experiences and outcomes of the intervention. For instance, participant JJ, a retired mental health professional with mild anomic aphasia, exhibited substantial improvements in subjective depression ratings during the baseline phase, with further gains observed during follow-up. Her progress was facilitated by her psychological-mindedness and prior experience with behavioural activation.

Another participant, II, who had moderate Wernicke’s aphasia, showed median-level improvement in mood from baseline to intervention, with gains maintained throughout the follow-up period. His wife played a crucial role in assisting with therapy tasks, which underscores the importance of involving close others in the therapeutic process.

The study’s results align with existing literature that supports the adaptation of CBT for individuals with cognitive impairments due to brain injury. The observed improvements in depressive symptoms and the feasibility of delivering modified CBT highlight the intervention’s potential in clinical practice. However, the study also faced challenges, such as the need for more flexible session numbers and the difficulty of addressing core beliefs and values in participants with severe aphasia.

The study underscores the importance of personalised treatment plans that consider individual circumstances and involve close others to support the therapy process. The use of digital tools and telehealth, particularly relevant during the Covid pandemic, also emerged as effective strategies for delivering CBT to this population.

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