Cognitive restructuring and improvement of symptoms with cognitive-behavioural therapy and pharmacotherapy in patients with depression

BackgroundSince 1960, psychological theories of maladaptivebehavior began to change their focus from enviornmentto expectation, control, decision and helplessness on theindividual level. After 1965, M.E.P. Seligman introducesthe concept of learned helplessness representing a givingup reaction determined by the belief that whatever youdo it doesn’t matter.According to theory [1] there are at least three typesof inferences that people can make and this, changes theway people develop or not hopelessness followed by thesimptoms of depressive lack of hope when confrontedwith negative life events [2]: 1) inference on the motivewhy certain events occur (inferated cause or causal attri-bution); 2) inference on the consequences which mightresult from events taking place (inferated consequences)and 3) inference on oneself given by events that havehappened to oneself at some point (inference of perso-nal characteristics).In this study we will investigate the efficiency of cog-nitive-behavioural and pharmaco-therapeutical interven-tions in changing depression symptoms and improvingcognitive, emotional disfunctions and perception ofsocial support.We investigate the relation between depression and dis-funtional causal attributions, perception of social support,self esteem, emotions and reaction to daily life stress.Materials and methodsPharmacotherapeutical group (PT). The study included13 patients diagnosed with depression and at the firsthospitalization they got disthimia or major depressiveepisode diagnosis, beeing subsequently treated.Cognitive-behavioural therapy group (CBT) had12 participants.Control group (C), 13 participants, was selectedconsidering their scores on SCL-90, DEP scale.In diagnosis phase, subjects were given to fill in a set ofscales similar to psychiatric patients, and it was appliedagain after 6-7 weeks and at the end of intervention. Agroup with high scores on BDI and SCL-90, indicating thepresence of depression symptoms were tested only in pretestand posttest phases without beeing subjected to any thera-peutical intervention. Participant admited into the studyformed three groups: pharmacotherapeutical group (PT),psychotherapeutical group (CBT) and control group (C).Psychiatric patients were administrated with anti-depressive medication. The psychotherapeutical groupfollowed 18-20 sessions of therapy (onehour average ses-sion) over a period of 15 weeks; twice a week in the firsttwo and once a week for the remaining.In this study we used the following scales: SCL-90;ASQ; SGC; SERV; POMS and SMSSP.Attributional Style Questionnaire (A.S.Q) is an instru-ment that measures the “explaning style” patterns repre-senting the tendency of selecting certain causalexplanations for favorable or unfavorable events.Symptom Check List 90-R [3] is an instrument whichevaluates the gravity of the symptoms reported bypatients. The internal consistency of its subscales is situ-ated between .75 and .86 and for ISG it is .97. Test-ret-est trust quotient of the two testing phases (T1 and T2)is between .77 and .87.Multidimensional Scale of Perceived Social Supportis an instrument projected to mesure the way people


Background
Since 1960, psychological theories of maladaptive behavior began to change their focus from enviornment to expectation, control, decision and helplessness on the individual level. After 1965, M.E.P. Seligman introduces the concept of learned helplessness representing a giving up reaction determined by the belief that whatever you do it doesn't matter.
According to theory [1] there are at least three types of inferences that people can make and this, changes the way people develop or not hopelessness followed by the simptoms of depressive lack of hope when confronted with negative life events [2]: 1) inference on the motive why certain events occur (inferated cause or causal attribution); 2) inference on the consequences which might result from events taking place (inferated consequences) and 3) inference on oneself given by events that have happened to oneself at some point (inference of personal characteristics).
In this study we will investigate the efficiency of cognitive-behavioural and pharmaco-therapeutical interventions in changing depression symptoms and improving cognitive, emotional disfunctions and perception of social support.
We investigate the relation between depression and disfuntional causal attributions, perception of social support, self esteem, emotions and reaction to daily life stress.

Materials and methods
Pharmacotherapeutical group (PT). The study included 13 patients diagnosed with depression and at the first hospitalization they got disthimia or major depressive episode diagnosis, beeing subsequently treated.
Control group (C), 13 participants, was selected considering their scores on SCL-90, DEP scale.
In diagnosis phase, subjects were given to fill in a set of scales similar to psychiatric patients, and it was applied again after 6-7 weeks and at the end of intervention. A group with high scores on BDI and SCL-90, indicating the presence of depression symptoms were tested only in pretest and posttest phases without beeing subjected to any therapeutical intervention. Participant admited into the study formed three groups: pharmacotherapeutical group (PT), psychotherapeutical group (CBT) and control group (C).
Psychiatric patients were administrated with antidepressive medication. The psychotherapeutical group followed 18-20 sessions of therapy (onehour average session) over a period of 15 weeks; twice a week in the first two and once a week for the remaining.
In this study we used the following scales: SCL-90; ASQ; SGC; SERV; POMS and SMSSP.
Attributional Style Questionnaire (A.S.Q) is an instrument that measures the "explaning style" patterns representing the tendency of selecting certain causal explanations for favorable or unfavorable events.
Symptom Check List 90-R [3] is an instrument which evaluates the gravity of the symptoms reported by patients. The internal consistency of its subscales is situated between .75 and .86 and for ISG it is .97. Test-retest trust quotient of the two testing phases (T1 and T2) is between .77 and .87.
Multidimensional Scale of Perceived Social Support is an instrument projected to mesure the way people perceive social support from three sources: family, friends and significant others. Internal consistency is .91 (12 items). Test-retest trust quotient of the two testing phases (T1 and T2) is between .67 and .80.
Kohn şi Macdonald [4] proposed Survey of Recent Life Experiences which they validated starting from 92 items. The internal consistency of the total score was .90 (41 items). Test-retest trust quotient of the two testing phases is between .66 and .78.
Current Thoughts Scale, as its name sugests, underlines the importance of current feelings. The internal consistency of the SGC total score was .84. Test-retest trust quotient of the two testing phases is between .64 and .81.
In time, Profile of Mood States was accepted as an efficient way of measuring psychological stress. The internal consistency ranges between .90 (negative emotions) and .88 (positive emotions). Test-retest trust quotient is between .31 and .56.

Results
Atfer the first 6-7 sessions we can see an increase of self esteem as a state in patients following CBT [t(11) = -2,684, p < .02], an improvement in the perception of support from others in general [t(11) = -2,368, p < .03] and fammily support in particular[t(11) = -2,534, p < .02]. In PT group there is an unexpectedly increase of friends support [t(12) = -2,226, p < .02].
Negative attributional style or depressogenic style is decreasing between T1 and T2 [t(11) = 4,568, p < .001] proving the efficiency of CBT (compared to PT) in improvement of cognitive symptoms of depression.
Yet, depressive attributional style in CBT3 is significantly decreasing compared to PT3 proving the efficiency of the cognitive level intervention. On the emotional level, the CBT and PT interventions are equally efficient, fact also sustained by the outcomes compared to C2. Therefore, CBT and PT can generate a decrease of negative emotions. Improvement of symptoms is obvious in CBT3 and PT3 compared to C sample.
We consider CBT superior to PT in producing changes on the level of cognitive symptoms, indicating a better posttreatment prognosis and a lower rate of relapses.
The significant statistic outcome for negative internal × group interaction showes that the two factors are not acting independentely but in a moderating relation. Both variables are statisticaly significant (group type and negative internal). That allows us to say that each factor is moderating the relation of the other with the dependent variable (the change of depression symptoms from T2 to T3).

Conclusions
This research paper subscribes to recent preoccupations for psycho-social implications of learned helplessness in explaining human behaviour (Beck, 1991;Seligman, Schulman, DeRubeis & Hollon, 1999). We analyse the cognitive modifications and symptoms decrease due to cognitive-behavioural therapy (CBT) and pharmacotherapy (PT) in depression. We evaluate the efficiency of CBT compared to PT in socio-cognitive and symptomathological changes as wel as the extent to which attributional changes in the first phase of CBT intervention are predictive for subsequent improvement of depression symptoms.
We showed that learned helplessness gives an efficient explanation for psychological depression and less for endogenuous depression; this statement is sustained also by implementation of the study where we modified maladaptive attributions and the control perspective of the patients.
Finally, we offer a comment about what to measure. In accordance with the hypothesis suggested, we propose that in future studies, in addition to measures such as the ASQ, the following constructs be examined as mediators: (a) the acquisition of problem solving and skills the patient can apply in response to events and (b) the frequency with which the patient applies those skills in daily encounters during the course of therapy.
This research underlines, at a practise level, the implications of helplessness quantitative research in clinical psychology, and psychotherapy.
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