Clinical Psychology Of Depression Research Paper

People diagnosed with Major Depressive Disorder show marked impairment in their social and occupational functioning; they also have an elevated risk of death from a number of causes. In fact, the World Health Organization Global Burden of Disease Study recently ranked depression as the single most burdensome disease in the world in terms of total disability-adjusted life years among people in the middle years of life (Murray and Lopez 1996). To give but one example of the consequences of this disorder, a recent economic analysis of depression in the workplace estimated that the annual salary-equivalent costs of depression-related lost productivity in the United States exceeds $33 billion (Greenberg et al. 1996). Moreover, because this figure does not take into account the impact of depression on such factors as the performance of coworkers, turnover, and industrial accidents, it is likely to be an underestimate of the overall workplace costs of depression.

People who become depressed rarely experience only a single episode; depression is a highly recurrent disorder. In fact, over 80 percent of depressed patients will have more than one depressive episode during their lifetime. The interval between episodes is generally short: over half of depressed patients will have at least one relapse within two years of their recovery from a depressive episode. This pattern of recurrence also appears to intensify over time: individuals with three or more previous episodes of depression may have a relapse rate as high as 40 percent within only three to four months after recovery. The high recurrence rate in depression points to the existence of factors that serve to increase people’s risk for developing this disorder. In attempting to understand this vulnerability to depression, clinical psychologists have focused on two broad areas in which depressed individuals seem to experience particular difficulties: cognitive functioning and interpersonal functioning. In Sects. 2 and 3, therefore, we describe the results of research conducted to examine the cognitive and interpersonal functioning of depressed persons and of individuals who are at risk for becoming depressed.

2. Cognitive Functioning In Depression

In many ways, depression is a disorder of thought. Depressed individuals typically think negatively about themselves, believing that they are useless, deficient, and unattractive people. Depressed persons also express bleak views of their immediate surroundings and of their future prospects. Given the pervasiveness of these dysfunctional cognitive characteristics, scientists have theorized about the importance of cognitions in depression and have conducted considerable research examining how depressed individuals perceive and evaluate information from their environment.

The cognitive theory of depression that has had the greatest impact on research and treatment is that formulated by Aaron Beck (1976), who ascribes the onset of depression to dysfunctional cognitive processes. Beck hypothesizes that individuals who experience loss or adversity in childhood develop a set of negative expectancies, or ‘schemas,’ concerning loss, failure, or abandonment. These schemas serve as filters through which stimuli and events in their environment are perceived, evaluated, attended to, and remembered. The negative schemas of depressed persons lead them to perceive and evaluate neutral stimuli as negative, guide their attention to negative aspects of their environment, and facilitate their memory for negative experiences. Perhaps most importantly, Beck believes that these negative schemas characterize not only currently depressed persons, but also nondepressed people who are at a high risk for developing depression in the future. Indeed, the negative schemas are the risk factor. In these individuals, the negative schemas remain inactive until the person encounters a relevant stressful event or experience. The stressful experience serves to activate the negative schema, which leads the individual to process information in a negative manner, in turn leading to ineffective coping, culminating in a depressive episode.

Thus Beck’s theory, and other similar cognitive theories of depression, predicts that depressed individuals (and individuals who are at risk for becoming depressed) are characterized by negative schemas that lead them to be more attentive to negative than to positive stimuli in their environment and to have better memory for these stimuli. Early studies attempted to examine the cognitive schemas of depressed persons by assessing their responses to self-report questionnaires measuring the negativity of their beliefs. In fact, a large body of literature has now documented that depression is associated with high levels of self-reported dysfunctional attitudes and a negative explanatory style.

Although these studies were important in describing the cognitive styles of depressed persons, their reliance on self-report measures of cognitive schemas is problematic. Perhaps most importantly, it is unlikely that self-report questionnaire measures, which require subjects to make conscious, deliberate, and thoughtful responses, are able to assess the existence and functioning of cognitive schemas, which are hypothesized to be activated automatically and to operate outside of individuals’ awareness. Put more simply, because people are typically not aware of the content of their schemas, self-report measures cannot be used to assess them. To address this problem, clinical psychologists have adapted methodologies from research in experimental cognitive psychology to assess the schematic functioning of depressed individuals. Using such information-processing tasks as the emotion Stroop task and the dot-probe task, investigators have provided empirical support for Beck’s cognitive theory of depression, demonstrating that depressed individuals are characterized by negative cognitive biases in both attention and memory (see Gotlib and Neubauer 2000).

Whether measured by self-report or by information-processing tasks, there is now little question that depression is associated with negative cognitive biases, a conclusion that supports a major tenet of cognitive theories of depression. Importantly, however, the causal status of these negative biases is still an open question. Cognitive theories of depression also hypothesize that negative schematic functioning is a trait-like characteristic that increases an individual’s risk for developing depression. There are very few empirical studies in which investigators have attempted to predict subsequent depression from earlier measures of schematic functioning. Moreover, studies of formerly depressed persons have generally found that cognitive functioning normalizes with recovery from depression. A number of researchers have demonstrated, however, that the presence of negative mood in formerly depressed individuals can reinstate negative cognitive processing which was not observable in the absence of negative mood (Haaga et al. 1991). If this proves to be the case, it is not difficult to see how stressful life events could generate a negative mood state, which, among vulnerable individuals, also activates a set of dysfunctional cognitions that lead to depression. Thus, although much more work remains to be done, it is clear that depressed individuals are characterized by negative schemas, and it is possible that this schematic functioning plays a causal role in the onset of depression.

3. Interpersonal Functioning In Depression

As is the case with cognitive functioning, depressed individuals have consistently been found to experience difficulties in their interpersonal relationships. While there is no single guiding theory of the social functioning of depressed persons that is analogous to Beck’s cognitive theory, empirical research has nevertheless implicated interpersonal dysfunction as important in understanding the etiology and maintenance of depression, as well as relapse of this disorder. Early behavioral formulations of depression viewed the depressed state as resulting from a lack of environmental reinforcement, stemming in part from an inability of depressed persons to elicit reinforcement from others (e.g., Lewinsohn 1974). Indeed, numerous studies have demonstrated that depressed persons exhibit social skill deficits during interactions with others. For example, compared to nondepressed individuals, depressed persons have been found to speak more slowly and with less volume and voice modulation, to show longer pauses in their speech patterns, to take longer to respond to others, and to engage in less eye contact. They are also more self-centered in interactions and steer conversations to more negative content. Finally, and understandably, depressed persons seem to induce feelings of depression, anxiety, and hostility in those with whom they interact. It is not surprising to learn, therefore, that people ultimately withdraw from interactions with depressed individuals (Segrin 2000).

Although this negativity seems to permeate the full range of depressed individuals’ social interactions, it is especially pronounced in intimate relationships. In this context, a number of investigators have focused on the nature of the relationships between depressed persons and their spouses and children. There is good reason for concern in these areas. For example, the divorce rate among individuals who have been diagnosed with depression is nine times higher than the rate in the general population (Merikangas 1984). Moreover, children of depressed parents are two to three times more likely experience a psychiatric diagnosable disorder at some point in their lives than are offspring of nondepressed parents (Gotlib and Goodman 1999). In attempting to understand the processes underlying these findings, researchers have systematically observed the interactions between depressed people and their spouses, and between depressed parents and their children.

The marital interactions of depressed persons are characterized by high levels of anger, conflict, and negative affect. Depressed spouses derogate themselves and their partners, and both spouses escalate their negative affect and behaviors over the course of the interactions. Interestingly, expressions of sad affect in the depressed spouse appear to have the effect of suppressing anger and aggression in the partner, suggesting that depression may play a functional but maladaptive role in the marriage. With respect to their children, depressed individuals report that they find it difficult to be warm and consistent parents, that they do not derive satisfaction from their children, and that they feel inadequate in their parenting role. Consistent with these self-reports, in interactions with their children, depressed mothers display sad and irritable affect and are either unresponsive or intrusive. In short, depressed parents appear to be difficult or inadequate social partners for both their spouses and their children, although it is important to also recognize the likely reciprocal nature of these problematic relationships.

Thus there is consistent evidence that depression is associated with deficits in interpersonal functioning. There is less support for the position that difficulties in social functioning serve as risk factors for the onset of a first depressive episode, although some investigators have reported that the lack of a supportive intimate relationship may leave individuals particularly vulnerable to the effects of life stress. Importantly, however, many of the interpersonal problems that characterize people while they are depressed have been found to persist following recovery. For example, in contrast to other disorders such as alcoholism, the marital relationships of people who have been depressed continue to be strained even after they have recovered from their depressive episode. In fact, like currently depressed individuals, people who have recovered from depression also report having fewer friends and close relationships than do individuals who have never been depressed. Interestingly, recovered depressed individuals do not show deficits in the overall number of their network contacts, suggesting that the interpersonal difficulties of formerly depressed persons—like those of currently depressed individuals —are most pronounced in intimate relationships. Finally, and further underscoring the importance of focusing on intimate relationships in understanding the role of interpersonal deficits in depression, the degree of hostility or criticism expressed by spouses about their depressed partners is a strong predictor that the partner will relapse into another episode of depression (Hooley and Gotlib 2000).

As is apparent from this brief review, individuals who are experiencing clinically significant depression are characterized by negative cognitive biases in their perceptions and evaluations of their environment and by impaired interpersonal functioning. Consistent with depressed persons’ difficulties in these areas, two of the most effective psychological treatments for this disorder are cognitive therapies and interpersonal therapies. In the following sections we describe these two approaches to the treatment of depression.

4. Cognitive Treatments For Depression

Cognitive therapies are based on the formulation that individuals’ affect and behavior are largely determined by how they interpret events in their world. As we have seen, clinically depressed individuals are characterized by negative perceptions of the self, the world, and the future. Therefore, a critical premise of cognitive therapies for depression is that replacing maladaptive thoughts with more positive cognitions will result in a significant reduction in depressive symptoms. Cognitive therapies often incorporate behavioral interventions to help in altering the patient’s cognitions; for this reason, these therapies are often referred to as cognitive-behavioral treatments.

Cognitive therapy for depression is time-limited, rarely exceeding 30 weekly sessions and ranging most typically from 15 to 25 sessions. The therapist and patient work together in a process referred to as ‘collaborative empiricism’ (Beck et al. 1979) to identify, evaluate, and change the patient’s negative thoughts. The therapist teaches the patient behavioral coping strategies, such as problem-solving skills and assertiveness training, to help him or her bolster new positive cognitions. Often homework is assigned to help the patient identify negative thoughts and beliefs and practice adaptive behaviors that the patient has learned with the therapist. Finally, because depression has a high relapse rate, in the final sessions of cognitive therapy, the therapist works with the patient to anticipate the kinds of life stressors that he or she may encounter in the future to prevent the recurrence of depression.

Cognitive therapy and cognitive-behavior therapy for depression have been evaluated in over 80 controlled studies (American Psychiatric Association 2000). The results of these clinical trials are consistent: cognitive therapy is an effective treatment for depression. In fact, cognitive therapy is considered by the American Psychological Association to be a ‘well-established treatment’ for depression (Chambless and Hollon 1998). Although there have been exceptions, cognitive therapy has generally been found to be as effective as (and sometimes more effective than) alternate forms of treatment for depression, including antidepressant medication. Moreover, several studies have shown that depressed patients who received cognitive therapy are less likely to relapse following treatment termination than are patients treated with medications. Finally, there is now evidence that cognitive therapy can prevent or delay the onset of depression in persons who are at elevated risk for the disorder (Hollon et al. in press).

5. Interpersonal Treatments For Depression

Interpersonal psychotherapies were developed from broad interpersonal theories of psychopathology, such as those formulated by Adolph Meyer, Harry Stack Sullivan, and John Bowlby. These theories posited that the quality of current interpersonal relationships was critical in contributing to the development and persistence of many forms of psychopathology. From this perspective, therefore, the therapist’s primary goal is to change the patient’s patterns of self-defeating interpersonal interactions. The most systematic and widely used therapy in this area is Interpersonal Psychotherapy (IPT), developed by Gerald Klerman and Myrna Weissman for the treatment of depression (Weissman et al. 2000). Like cognitive therapy, IPT is conducted most frequently as a short-term therapy (approximately 16 weekly sessions), but it has also been modified for use as a ‘maintenance therapy’ for the longer-term treatment of patients with recurrent or chronic depression. A major goal of IPT is to improve the patient’s interpersonal functioning by encouraging more effective expression of emotions, clearer communication with significant members of their entourage, and increased understanding of the patient’s behavior in interpersonal interactions. The rationale underlying the use of IPT is that by solving interpersonal problems in therapy, the patient will improve their life situation and simultaneously decreasethenumberand intensity ofdepressivesymptoms.

IPT for depression is divided into three phases. In the initial phase of treatment (the first 3 sessions), the therapist conducts a diagnostic evaluation for depression, educates the patient about depression, and evaluates the patient’s current interpersonal relationships. The therapist then establishes which of four interpersonal problem areas are most closely related to the patient’s current depressive episode: grief, interpersonal role disputes, role transitions, or interpersonal deficits. In the middle phase of treatment (sessions 4–13), the therapist uses specific techniques (outlined explicitly in a treatment manual) that are designed to address these four problem areas. Although these techniques may involve changing the patient’s cognitions or having the patient engage in new behaviors, there is a clear and strong tie to the patient’s current interpersonal relationships. The final phase of treatment (sessions 14–16) focuses on consolidating the changes that the patient has made through therapy and helping the patient recognize and counter depressive symptoms should they arise again in the future.

In the 1980s and 1990s, IPT has been carefully evaluated in numerous research protocols and has been demonstrated to be effective in treating depression in a variety of populations, including adolescents, postpartum depressed women, married spouses, the elderly, and patients in primary medical care facilities. In fact, IPT was one of two forms of psychotherapy (the other was cognitive therapy) tested against antidepressant medication in a large-scale treatment study of 250 depressed patients (Elkin et al. 1989). The results of this study indicate that IPT is more effective than placebo, and as effective as medication and cognitive therapy in reducing depressive symptoms. In addition, IPT was found to be more effective than cognitive therapy in treating more severely depressed patients (Elkin et al. 1989). Importantly, IPT has been shown to prevent or delay the onset of relapse episodes of depression, demonstrating its utility as a maintenance therapy.

6. Conclusions And Future Directions

In the 1980s and 1990s, we have made significant progress in our understanding of psychosocial aspects of depression and in the treatment of this disorder. It is now clear that depressed persons are characterized by maladaptive cognitive schemas that guide their attention to negative, as opposed to positive, environmental information, and enhance their memory for this negative information. Depressed persons also have marked impairments in their interpersonal functioning, particularly in more intimate relationships. Despite this progress, however, there are several issues that remain unresolved.

In closing, therefore, we offer three recommendations for future research examining cognitive and interpersonal functioning in depression. First, much of the research that has been conducted in this area has been cross-sectional, essentially comparing samples of depressed and nondepressed participants at one point in time. We urgently need prospective, longitudinal studies in order to clarify the causal relation of cognitive and interpersonal dysfunction to the onset, maintenance, and relapse of depression. Second, while both cognitive and interpersonal therapies have been demonstrated to be effective in the treatment of depression, there are anomalies that need to be addressed. For example, cognitive therapy is not universally effective in the treatment of depression and research must begin to identify characteristics that differentiate treatment responders from nonresponders. Similarly, despite its focus on interpersonal functioning, IPT has been found to be no more effective in improving social functioning immediately following treatment than are medications or cognitive therapy. Therefore, for both cognitive therapy and IPT, research is needed to clarify the mechanisms by which the treatment reduces patients’ levels of depression. Finally, we have discussed cognitive and interpersonal functioning in depression as though they occur independent of each other. Clearly, this is not the case. It is only by explicitly integrating data concerning the cognitive and interpersonal functioning of depressed persons, and relating that data to their biological functioning, that we will be able to build a comprehensive understanding of depression allowing us to develop even more effective programs for the prevention and treatment of this disorder.

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