Depression. Aaron T. Beck, M.D.

Modification of Interpersonal Dysfunctions

       Behavioral Activation

       COGNITIVE TECHNIQUES

       Delineating the Major Maladaptive Patterns

       Neutralizing Automatic Thoughts

       Pinpointing Depressive Cognitions

       Identifying Idiosyncratic Content

       Recognizing Formal Characteristics of Cognitions

       Distinguishing “Ideas” from “Facts”

       Checking Observations

       Responding to Depressive Cognitions

       Weighing Alternative Explanations

       Validating Basic Premises

       Modifying Mood by Induced Fantasies

       Case Illustration

       Case Illustration: Relapse Prevention

       TREATING BIPOLAR DISORDER: DRUGS AND PSYCHOTHERAPY

       PREVENTION OF SUICIDE

       PREVENTION OF RELAPSE

       PSYCHOTHERAPY CHANGE PROCESSES

       16. Evaluating Depression Treatments: Randomized Controlled Trials

       Outcome and Follow-Up Data

       RANDOMIZED CLINICAL TRIALS

       ECOLOGICAL VALIDITY AND RANDOMIZED CLINICAL TRIALS

       RELAPSE PREVENTION

       Overall Conclusions

       Issues for Further Study

       Afterword

       The New Developmental Cognitive Model

       Cognitive Vulnerability

       Genetic Links to Cognitive Vulnerability

       Physiological Hyperreactivity

       Cognitive Neurobiology

       Appendix: Scoring Instructions for Negative Dreams

       Definition

       Scoring

       NEGATIVE REPRESENTATION OF THE SELF

       PHYSICAL DISCOMFORT AND INJURY

       THWARTING

       DEPRIVATION

       PHYSICAL ATTACK

       NONPHYSICAL ATTACK

       EXCLUDED, SUPERSEDED, OR ABANDONED

       LOST

       PUNISHMENT

       FAILURE

       Exclusions

       THREAT DREAMS

       References

       Name Index

       Subject Index

       Preface to the Second Edition

      The first edition of this book posed the question, “What has definitely been established regarding the nature, the causes, and the treatment of depression?” To answer it, Aaron Beck sifted through thousands of clinical and controlled studies and summarized representative research on the clinical, biological, psychological, and theoretical aspects of depression. Of greater significance, he described an original research program that, in retrospect, represented a breakthrough in understanding the cognitive components and treatment of depression.

      Like the first edition, this one presents an update and overview of what is currently known about clinical depression, including developments that have taken place since the book was originally published 40 years ago and, also like that earlier volume, offers a historical perspective. Moreover, in Chapter 16 we review the randomized controlled trials that have built upon and elaborated cognitive theory and research.

      What is new to the second edition? Definitions of the mood disorders have changed over the years, and new categories have been added. We now recognize major depression as the leading cause of disability worldwide, and it has received increased clinical and research attention. In the years since the book was first published additional types of bipolar disorder have been recognized, and research has been conducted on the relation between manic symptoms and life events. New drugs, such as the selective serotonin reuptake inhibitors, or SSRIs, have been developed. While comparable in efficacy (except in severe depression), they are chemically unrelated to tricyclic, heterocyclic, and other antidepressants discussed in the first edition, and they enjoy several advantages over those “first-generation” drugs. The newer medications can induce fewer adverse side effects and provide greater safety in case of overdose and improved tolerability and patient compliance. SSRIs may also be augmented with lithium, psychostimulants, and other agents.

      There are even now many unresolved problems in pharmacotherapy. Drug treatment of depression—even using the newer SSRIs—still results in unwanted side effects, such as the sexual dysfunction that affects 60 percent of patients. There are potential lethal interactions between SSRI and MAOI drugs. Other unintended effects include gastrointestinal disturbance, nausea, and somnolence. Electroconvulsive therapy (ECT) causes side effects as well, and alternatives are under review, including transcranial magnetic stimulation (TMS). We describe the results and conclusions of preliminary studies on this new treatment.

      Since this book first appeared we have made considerable progress in understanding the biological basis of depression. Steps have been taken in identifying the genetic basis of the mood disorders, including schizoaffective disorder. Research on changes in hippocampal neurons and amygdala enlargement appears promising. “Neurotrophic” (keeping cells alive) and “neurogenesis” (stimulating growth of new cells) theories abound and are being tested.

      Many of the biological aspects of depression still remain uncertain, though progress continues. One research area explores specific brain changes that correspond to the effective pharmacological and psychological treatments of depression. For example, studies have focused on differential effects in recovery for paroxetine (Paxil) therapy and cognitive therapy in modulating specific sites in limbic and cortical brain regions.

      Researchers have continued to identify the pathophysiological aspects of major depressive disorder, including alterations in various monoamine brain systems. Neuropeptides such as corticotropin-releasing hormone are under investigation, as are hormonal variables such as glucocorticoid secretion. Dexamethasone nonsuppression of plasma cortisol has been suggested as a marker, although the same effects have been induced experimentally by sleep deprivation and dietary fasting.

      Several studies have tested whether genetic markers can predict differential