SEVERELY DEPRESSED IN-PATIENTS 11

T:Maybe you could do an exercise for next time specifically about this attitude: ‘If I work up to my full potential, I will be liked and rewarded. If I am not, either I’m no good or people are being unfair.’

Assignment What are the advantages and disadvantages of holding such a belief?

In later sessions, the inconsistencies in the belief were also examined: how does one work to one’s full potential? How does one know when one has reached one’s full potential? Are there other ways of being liked? Do different individuals have different criteria for liking and disliking, for deciding what’s good and what’s not good? Fairness is desirable, but is it reasonable to expect it at all times? Can people do something which you think is unfair, but that they would not think is unfair, because they are using different criteria? As can be seen from the next section and Figure 1.1, this patient did not have high dysfunctional attitudes, as measured by the Dysfunctional Attitude Scale (DAS, Weissman 1979). This was reflected in what transpired during treatment. Her basic dysfunctional attitudes were circumscribed and apparent from the very beginning of therapy. Dealing with the automatic thoughts weakened the strength of the schemata so that their modification proceeded quickly and smoothly.

Outcome

The patient was discharged from the ward after eight weeks in hospital and twenty-six sessions of CT. She still had intermittent depressed mood, some diurnal variation, and early morning wakening. She continued to attend as an out-patient twice a week at the outset, then once a week for a further fifteen appointments. Apart from consolidating what had already been covered in previous sessions, a new problem arose. This was trying to reach a decision about early retirement or staying on for a further two years. This was discussed in terms of the advantages and disadvantages of each alternative and rehearsing in imagination what her life-style would be if she continued working or stopped working. We also did a series of role plays and role reversals to rehearse assertive behaviour in her interviews with her employers.

In fact, early retirement was accepted on advantageous terms. Anne was able to increase her leisure activities and enjoy things that she had not had time to do while working. She has remained well since discharge three years ago.

Ratings

The scores obtained on various rating scales over the eight weeks of in-patient treatment are shown in Figure 1.1.

The Hamilton Rating Scale for Depression (HRSD, Hamilton 1960), seventeen-item version, was administered weekly by the consultant in charge who was not, in any way, involved in the treatment. The score at admission was 27, which is considered severe, and came down steadily to a non-depressed level (score 6), just before discharge. The increase in HRSD score at week five coincided with a disappointment for the patient. She had been on pass the day before and had gone to a concert. She had to leave the concert hall after half an hour, because the music appeared too loud and noisy, although it was

12 COGNITIVE THERAPY IN CLINICAL PRACTICE

Figure 1.1 Ratings over the course of in-patient treatment

her favourite music. Her head felt ‘like bursting’ and she felt sick. Her thoughts were ‘I’m not able to cope with this. It was silly to come’ and ‘I can’t see myself getting better’.

Self-rating questionnaires were administered three times, at the beginning of treatment, and in the fourth and seventh weeks. The Beck Depression Inventory (BDI, Beck et al. 1961), a measure of self-rated depression, showed a decrease in score in parallel with the HRSD, consecutive scores being 22 (moderate), 13, and 9 (not depressed). The State-Trait Anxiety Inventory, State version (STAI-S, Spielberger et al. 1970), also showed a decrease from 57 to 34 and 36 consecutively. Blackburn et al. (1986) reported a mean score of 56.7 in a group of depressed patients and a mean score of 37 for recovered depressed patients. The two cognitive scales, the Dysfunctional Attitude Scale (DAS, Weissman 1979) and the Automatic Thoughts Questionnaire (ATQ, Hollon and Kendall 1980), on the other hand, indicated low scores at baseline relative to depressed patients. The mean scores of 147.7 on the DAS and 82.5 on the ATQ reported by Blackburn et al. (1986) for their depressed group are typical of scores reported in other studies. The corresponding scores for this patient were 122 on the DAS and 64 on the ATQ. This DAS score is more typical of the normal controls (M=114.4, SD 24.3) in the Blackburn et al. (1986) study. It is, therefore, not surprising that there was little change in DAS score from admission to discharge (122, 119, 115). The ATQ baseline score was elevated at baseline relative to normals (M=34.9, SD 13.4) and decreased to the normal levels of 44 and 43 at mid-point and end-point respectively. The low DAS score may be typical of patients with severe psychotic depression, with long periods of remission and normal coping between episodes of illness, as was the case for this patient. This hunch is open to empirical verification.

Discussion

This case study illustrates the applicability of CT to depressed in-patients. The therapy had a successful outcome, although the patient received no concurrent medication. There was also no group therapy or set occupational therapy. However, there is little doubt that the ward milieu was beneficial, as the patient began to improve soon after admission before the start of any treatment. Since this was not a controlled study, it is not possible to differentiate the effect of the ward milieu from the specific effect of the therapy. It must also be noted that this case is not typical of in-patient treatment, because, in my experience, most in-patients who receive CT are also on antidepressant medication. It was, however, decided to describe a case which was treated with CT alone to demonstrate the feasibility of this approach in a severely depressed in-patient. The combination of CT with ECT is probably not advisable, as the disruptive effect of ECT on memory would interfere with the continuity of successive sessions.

This case study has also demonstrated that, although the specific methodology of cognitive therapy is similar for in-patients and out-patients, there are important differences in the style of delivery of the treatment. The sessions are more frequent, there are more sessions, but the pacing of each session is slower. Other differences involve the need to keep other members of the ward staff fully informed of progress in therapy, for the therapist to gather information about the behaviour of the patient on the ward from the rest of the staff and to try and keep the approach of different members of staff as consistent as possible.

SEVERELY DEPRESSED IN-PATIENTS 13

In many instances, CT, alone or in combination with other treatments, is not suitable for severely depressed in-patients. Although it is difficult to specify objectively the conditions which would determine the unsuitability of certain patients, it is possible to give impressionistic guidelines derived from experience:

1.Patients with an extensive delusional system, often including delusions of guilt, poverty, and hypochondriasis, do not appear to respond to CT.

2.Patients who present with no insight, that is, who do not think that they are depressed or ill, or who attribute their illness to physical causes, do not benefit from a psychological approach.

3.Patients who are too severely affected to be able to establish a rapport with the therapist or who are unwilling or unable to collaborate in a problem-solving approach are not suitable.

4.In a previous study (Blackburn et al. 1981), we found that out-patients with chronic depressions of many years’ duration, on the whole, do not respond to CT alone or in combination with medication. Fennell and Teasdale (1982) reported very modest results in a report of CT with five treatment-resistant patients who had been continuously depressed for 18 months, 3, 7, 8, and 16 years respectively, with only short remission periods. However, it is possible that a combined treatment approach, over a much longer period, may be the most valuable approach for this notoriously difficult group of patients. More controlled research is urgently needed in this area.

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