Negative thinking in depression can result from biological sources (i.e., endogenous depression), modeling from parents, peers, or other sources. The depressed person experiences negative thoughts as being beyond their control. The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting "cognitive distortions" or correcting thinking errors that abet such distortions, in a process called cognitive restructuring.

Negative thoughts in depression are generally about one of three areas: negative view of self, negative view of the world, and negative view of the future. These constitute the cognitive triad.

The four column technique

A major technique in cognitive therapy is the four column technique. It consists of a four step process. The first three steps analyze the process by which a person has become depressed or distressed. The first column records the objective situation. In the second column, the client writes down the negative thoughts which occurred to them. The third column is for the negative feelings and dysfunctional behaviors which ensued. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. Finally, the fourth column is used for challenging the negative thoughts on the basis of evidence from the client's experience.

Treating depression with CBA

The newest and most effective cognitive and behavioral therapy for depression is the cognitive behavioral-analysis system of psychotherapy (CBASP). When combined with appropriate antidepressants, it can be extremely effective.

A study published by Martin Keller MD of Brown University and others in the May 18, 2000 New England Journal of Medicine compared the antidepressant Serzone with the talking therapy CBASP. CBASP is largely derivative of other talking therapies such as cognitive, behavioral, and interpersonal therapy. Six hundred eighty-one patients with severe chronic depression (some with other psychiatric illnesses) were enrolled in the trial, and were assigned to either Serzone, CBASP, or combination Serzone-CBASP for 12 weeks. The response rates to either Serzone or CBASP alone were rather underwhelming - 55 percent and 52 percent, respectively, for the 76 percent who completed the study. In other words, a little more than half of the completers in those two arms of the trial reduced their depression by 50 percent or better.

The Serzone findings roughly correspond with many other trial results for antidepressants, and underscore a major weakness in these drugs - that while they are effective, the benefit is often marginal and the treatment outcome problematic. Similarly, the CBASP findings validate other studies finding talking therapy about equal in efficacy to taking antidepressants.

The results for the combination drug-therapy group, however, were surprising, with 85 percent of the completing patients achieving a 50 percent reduction in symptoms or better. Forty-two percent in the combination group achieved remission (a virtual elimination of all depressive symptoms) compared to 22 percent in the Serzone group and 24 percent in the CBASP group.

The authors of the study confessed to being caught by surprise by the results, acknowledging that "the rates of response and remission in the combined-treatment group were substantially higher than those that might have been anticipated".

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