Cognitive approach to depression

It has long been recognized that people who feel depressed tend to think depressed thoughts. It is commonly assumed that a depressed mood somehow leads to cognitive symptoms. Cognitive theories of depression aim to explain why some people are more vulnerable to depression when confronted with negative events, whereas others suffer only mild short-term distress. Seen from the cognitive approach, the interpretation people give to their life experiences influences their vulnerability to depression, meaning that depressed cognition, cognitive distortions, and irrational beliefs produce the disturbances of mood characteristic of depression.

The American psychiatrist Aaron Beck is seen as the founder of cognitive therapy. He argues that depression is rooted in what he called a patient's "automatic thoughts"- that is, negative self-schemas organized around themes of failure inadequacy, loss, and worthlessness. All these personalized thoughts are triggered by particular stimuli that lead to emotional responses and they are seen as potential vulnerabilities for the onset of depression.

Beck's theory of depression has three components:

The Negative cognitive triad: depressed patients have negative views of the self, the world, and the future.
They have negative schemas triggered by negative life events (dysfunctional beliefs).
They engage in cognitive biases - also referred to as "irrational thinking."

Beck argues that negative schemas can develop because of family problems, social rejection by peers, poor school experiences or by having depressed members of the family or close social circle. These schema are activated in depressed people whenever they are in a situation which in any way resembles the situations in which the schema were created. Beck describes three typical schema that are characteristic of depressed people: an ineptness schema - that is, I always fail; a self-blame schema - that is, it is my fault for anything that doesn't work out; a negative self-evaluation schema - that is, I am worthless.

Beck also argues that there are several patterns of faulty thinking or cognitive biases that are typical in depressed patients. These patterns are explained in the chart below.

Beck's Six Types of Faulty Thinking

Arbitrary inference: drawing conclusions based on little or no evidence. For example, when Mary does not immediately receive a text back from her boyfriend, she concludes that he is cheating on her.

Dichotomous thinking: An all-or-nothing approach to viewing the world. For example, you either love me or you hate me. I either have to be the best, or I am a failure.

Exaggeration: Also called magnification. Overestimating the significance of negative events. For example, when a teacher gives you constructive feedback on an essay and you conclude that "he thinks I am a terrible writer!"

Overgeneralization: Applying a single incident to all similar incidents. For example, when you have an argument with a friend and you think that this means that none of your friends supports or cares about you.

Personalization: Assuming that others' behaviour is done with the intention to hurt or humiliate you. For example, a friend throws a dinner party but you were not invited. You then assume that you were intentionally not invited so that he could hurt your feelings.

Selective abstraction: Drawing conclusions by focusing on a single part of a whole. For example, focusing on the fact that you earned a low grade on one of your quizzes this semester, without focusing on the fact that overall you have an "A" (or "7") in the class.

In addition to Beck’s extensive notes on his patients over the course of his career, there are also several studies that support the theory that cognitive biases are linked to depression. Alloy et al. (1999) wanted to see if one’s thinking patterns could be used to predict the onset of depression. In order to do this, they carried out a longitudinal study in which they followed a randomly selected sample of young Americans for six years. As this was a prospective study, their thinking style was tested at the very beginning of the study. They were placed in either the “positive cognitive group” (low risk) or “the negative cognitive group” (high risk) based on a number of tests such as the Cognitive Style Questionnaire. After six years, the researchers found that only 1 percent of those in the positive thinking group had developed depression compared to 17 percent in the negative thinking group. The results indicate that there may be a link between negative cognitive style and the development of depression.

In another study, Joiner et al (1996) gave a questionnaire to university students before mid-term exams. Those who had negative thoughts before the exam and who ended up doing poorly showed an increase in depressive symptoms. However, those that did well, did not. This shows that patterns of cognition alone are not enough to lead to depression, but they must also be in response to environmental stimuli.

Overall, it is not clear if depression is caused by negative thinking patterns or if these patterns are merely the consequence of having depression. If a negative cognitive style causes depression then replacing negative cognitions with positive thinking patterns could improve the patient’s condition. This is exactly what CBT (cognitive-behavioural therapy) tries to do.

The role of rumination in depression

Dysfunctional beliefs and self-schemas may not be the only cognitive factors that lead to depression. Nolen-Hoeksema has found that women are more likely to amplify depression by ruminating about their feelings and their possible causes - that is, they think a lot about how they feel and try to understand the reasons they feel the way they do. In one study, Nolen-Hoeksema (2000) found that both men and women who ruminate more following the loss of loved ones are more likely to become depressed and to suffer longer and more severe depression than those who ruminate less. According to the researcher, rumination appears to more consistently predict the onset of depression rather than the duration, but rumination in combination with negative cognitive styles can predict the duration of depressive symptoms.

Recent brain research seems to support Nolen-Hoeksema’s theory. Farb et al (2011) showed 16 formerly depressed patients sad and neutral movie clips and tracked their brain activity using an fMRI. They compared this to 16 healthy controls. All participants filled out questionnaires measuring their adaptive as well as maladaptive cognitive modes in the face of emotional challenges. They also measured the severity of depression in the patients. The researchers calculated correlations between emotional reactivity (neural responses to sad vs. neutral film) in patients after the scanning and subsequent relapse status over an 18 month follow-up period. The prediction was that activity in the medial prefrontal cortex predicted relapse. The results supported the hypothesis: ten of the 16 patients had relapsed into depression during the 18-month follow-up period.

Faced with sadness, the relapsing patients showed more activity in a frontal region of the brain, known as the medial prefrontal gyrus. These responses were also linked to higher rumination: the tendency to think obsessively about negative events and occurrences. The healthy participants showed activity in the visual cortex.

This study suggests that there are important differences in how formerly depressed people respond to emotional challenges that predict future well-being. Ruminating in order to analyze and interpret sadness may actually be an unhealthy reaction that can perpetuate the chronic cycle of depression. The researchers themselves argue that the study is limited in its ability to conclusively determine the neural predictors of depressive relapse due to a small sample size and a limited number of scans. It is important that the findings be replicated in order to determine their reliability. If more evidence is found that this pattern of thinking leads to depression, prevention strategies can be developed. Modern research on mindfulness has shown that refocusing one’s attention may be an important way to fight depression.

ATL: Inquiry

According to the APA, mindfulness is based on paying attention to one's experience in the present moment. It involves observing thoughts and emotions from moment to moment without judging or becoming caught up in them. During a practice session, when the mind wanders, the meditator ideally takes note of where it goes, and calmly returns to the moment at hand, perhaps focusing on breath, bodily sensations or a simple yoga move.

What is the evidence that mindfulness is a “promising treatment for depression?” Why would this make sense from both a cognitive and a biological point of view?

Evaluation of cognition explanations of depression

Strengths

Longitudinal, prospective research has been used to support the role of cognitive factors in depression.
There is some biological support for the theory of rumination.
Practical application of the theories has led to successful treatments that have improved some people’s lives.
To some extent, the theory of rumination helps to explain gender differences in the prevalence of depression.

Limitations

Correlational research means that causation cannot be established and bidirectional ambiguity cannot be resolved. It is unclear whether the thinking patterns are the cause or the result of depression.
The Treatment Aetiology Fallacy – that is, the mistaken notion that the success of a treatment reveals the cause of the disorder.