A Review of Literature Regarding Cognitive Behavior Therapy and Depression in Women
Molly W. Lineberger
Wake Forest University
Major depressive disorder is a common mental disorder. In the United States, the twelve-month prevalence of major depressive disorder is approximately 7% overall, and women are 1.5 to 3 times more likely than males to be affected (American Psychiatric Association, 2013). Depression in women is often associated with pregnancy and child bearing. There are a variety of accepted treatments for depression including antidepressant medications and psychotherapy (Siddique, Chung, Brown, & Miranda, 2012). Cognitive Behavior Therapy (CBT) focuses on examining the thoughts and feelings that influence behaviors. CBT is considered an effective treatment for a number of disorders, including major depressive disorder (Butler, Chapman, Forman, & Beck, 2006). This paper will provide an overview of the literature regarding the effectiveness of CBT in treating depression in women.
A Review of Literature Regarding Cognitive Behavior Therapy and Depression in Women
Major depression is a serious and pervasive mood disorder, causing persistent feelings of hopelessness, guilt, sadness, or worthlessness. According to The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), the essential feature of a major depressive episode is that it lasts at least two weeks, and it may present with physical symptoms such as body aches, irritability, or sleeplessness. Authors of that manual also relate that fatigue, weight loss or weight gain, memory problems, and difficulty concentrating or making decisions are further symptoms of the disorder and that thoughts of death and suicide and suicide attempts are common.
Although depression is roughly twice as prevalent in women as in men, before puberty girls and boys are equally likely to experience depression (Depression fact sheet, n.d.). The higher incidence in women after puberty may be related to lifelong changes in women’s hormone levels - menstrual cycle changes, pregnancy, miscarriage, postpartum period, perimenopause, and menopause may all cause a woman to develop depression (Depression fact sheet, n.d.). Authors of the fact sheet go on to say that other causes of depression in women can include, but are not limited to, genetic predisposition, poverty, and stressful work and family situations – such as caring for the young children or the loss of a child, as through miscarriage.
Impairment from depression can be mild to severe (American Psychiatric Association, 2013). Patients, care-providers, and third party payers need continuing guidance as to the type and cost of effective treatments for depression (Siddique, Chung, Brown, & Miranda, 2012). CBT is a considered an effective treatment for major depression in both men and women (Butler et al., 2006). CBT is often more affordable than some other types of therapy because it is usually a short-term treatment (Cherry, 2013). This literature review looks at CBT intervention for treating the disorder in women because of the prevalence of depression in women, and because CBT can be modified to meet the needs of women in various life situations – such as during pregnancy or after childbirth (O’Mahen et al., 2012). In a classical design, CBT is administered over 16 sessions, however in practice, therapy can consist of a variable number of sessions (Austin et al., 2008).
Research to seek peer review and scientifically-based information related to CBT and major depression in women began with a search for key terms, “depression,” “women,” and “CBT.” Two data bases, PsychINFO and PubMed, were explored through the Wake Forest University Z. Smith Reynolds Library website. The search was limited to articles published from 2003 through 2013. PsychINFO was the better database for finding information for this literature review, and an initial search resulted in 119 hits for peer reviewed articles. The PubMed search with the same key terms and parameters resulted in 8 hits. Not all articles found were appropriate for this review. After skimming abstracts, 25 articles were selected for closer inspection, and the search ultimately produced eight randomized controlled trials, a quasi-experimental study, and two surveys (one quantitative, one qualitative) for inclusion in this review.
Review of the literature revealed several common themes regarding CBT and the treatment of major depression in women. While three of the studies involved low-income, minority women, the majority involved women with perinatal depression, miscarriage, or infertility, and three studies dealt with delivery of CBT by internet.
Treating Depression in Low Income Women
Three randomized controlled studies pointed to the efficacy of group CBT with low-income women. A pilot study by Cramer, Salisbury, Conrad, Eldred, & Araya (2011) assessed the feasibility of a randomized controlled trial of group CBT–based intervention for depressed women in primary care. Women 30 to 55 years of age who lived in two disadvantaged urban areas were recruited and randomly assigned to either a control group (usual care) or to intervention based on a manual and using CBT. The CBT group met for 12 weeks. Problem-solving approaches sought to empower the women by increasing self-management skills. Patients were assessed at baseline, 3, and 6 months after starting the group. The small size - 45 in the CBT group at 6 month follow-up and 19 in the control group - was a limitation. The authors of the study reported that results were mixed in that no differences were found between the two arms in a questionnaire on social support or another on dysfunctional thoughts, but qualitative findings showed improvement in social support and in negative and balanced thinking. The authors held that the results of the study pointed to the feasibility of a larger trial and to the viability of brief, group CBT. This study by Cramer et al. (2011) indicated that such group CBT may be efficacious and cost effective for women with depression.
A similar finding, with stronger quantitative results, was demonstrated in a randomized controlled trial by Tandon, Perry, Mendelson, Kemp, & Leis (2011) to test the efficacy of a 6–week, group CBT intervention in preventing the onset of perinatal depression in low- income home visiting clients. Participants were poor, black, urban women who were either pregnant or who had a child under 6 months old and who were already part of a home visitation program. Thirty-two were randomized into a group that used a manual-guided, 6-week, group CBT – based intervention aimed at preventing perinatal depression. Twenty-nine women were in the control group that received standard home visits and perinatal depression information. Results of the study found that 84% of the participants in the CBT group intervention showed improvements in depressive symptoms compared with 41% of the control group. The study did not conduct follow-up testing beyond 3 months post intervention, and authors suggested that this be done in future studies. They suggested a larger trial to replicate the findings of this promising study, and said that their findings do support the evidence that group CBT can reduce depression in low-income, ethnically-diverse, perinatal women. Tandon et al. (2011) found that in the home visiting context, the women already had a trusting relationship with the organization conducting the study, and reported that child-care, transportation, and a meal were provided around each group CBT session.
In third study, Siddique, Chung, Brown, & Miranda (2012) compared the effectiveness of medication to CBT in a year-long, randomized controlled study of low income, young, minority women with depression. This year-long study consisted of 267 urban women (44% black, 50% Latina, 6% white) with an average age of 29 years. They were randomized to CBT, antidepressants, or to referral to community mental health services. The 90 women in the CBT group received manual-guided therapy from trained CBT providers in 8 weekly group or individual sessions (if group therapy times were not suitable). The 89 women in the community referral group received information about community services. The 88 women in the pharmacology group received paroxetine for 6 months. Authors said that the study did not offer medication after 6 months, but that women could seek medication elsewhere. Results showed that young, low-income women with moderate depression are likely to improve on either medication or CBT (Siddique et al., 2012). Authors said that there were not significant differences among those who received only group CBT and those who had some individual sessions. For participants with mild to moderate symptoms, there were better outcomes for those taking medication at 6 months and no difference between the 2 treatments at 12 months. However, for those with severe depression, CBT was superior to medication at 1 year. Siddique et al. (2012) pointed out that the worsening symptoms among the group receiving medication may be attributed to the medication ending.
While mixed, the results of these three studies suggest that brief, group, manual-based CBT may be an effective intervention with economically disadvantaged, ethnically diverse women.
Treating Perinatal Depression
Four studies examined the use of CBT for women in the perinatal period, usually defined as the 5 months before and 1 month after childbirth (Definition of perinatal, n.d.). Many women who are depressed in pregnancy continue to be depressed postnatally (Burns et al., 2013). Depression can have adverse effects on both maternal and infant health (Alder, Fink, Bitzer, Hösli, & Holzgreve, 2007). A qualitative study by O’Mahen et al. (2012) to inform ways to modify CBT to better fit the perinatal period involved semi-structured interviews focusing on pregnancy and postpartum experience as related to mood, and perspectives on ideal treatment content. The 22 women interviewed for the study were over 18 years old and were not receiving treatment for mental health issues. Consistent thoughts and behaviors that emerged were grouped into three primary domains: the woman’s self, motherhood, and the interpersonal domain. Authors found that results of the study provided support for the use of CBT as a way to avoid or treat depression in the perinatal period. O’Mahen et al. (2012) maintained that CBT intervention during this period may be strengthened by an enhanced understanding of the culturally endorsed beliefs about the importance of maternal selflessness; the impact of pregnancy and a new infant on a woman’s identity and ability to engage in previously valued activities; and the importance of adding interventions aimed at improving social support. They pointed to the need for study and testing in the ways CBT can be modified to become more helpful during the perinatal period.
A study done a year later used findings from the O’Mahen et al. interviews. Burns et al. (2013) conducted a randomized controlled trial of individual CBT looking at treating depression by the end of pregnancy. Authors of the study used O’Mahen’s research in creating a CBT manual, specific to antenatal depression, used for 9 to 12 sessions with 18 depressed pregnant women. Eighteen other women who had also screened positively for depression were randomly assigned to continue with usual care only. Two CBT therapists delivered the intervention. Burns et al. (2013) maintained that one aspect of this intervention that was unusual was that therapy was offered to women in their own homes. At the 33 weeks post randomization assessment, 81.2% of the women in the intervention group did not have depression, compared with 36.4% of the usual care arm. Although the sample of the study was small, results point to the feasibility of using a CBT intervention modified for antenatal depression during the antenatal period (Burns et al., 2013).
An earlier trial found very different results. Austin et al. (2008) conducted a randomized controlled study involving group CBT intervention for the prevention of postnatal depression and anxiety. This study identified pregnant women with mild to moderate symptoms of depression and randomized 191 to the CBT intervention group and 86 to the control group. The CBT group intervention comprised 6 weekly 2-hour sessions of CBT focusing on prevention of stress, anxiety, and low mood in the context of pregnancy and caring for a new infant. The CBT intervention used in the study was in a manual format and led by a clinical psychologist. The control group was given a booklet with comprehensive information regarding topics such as triggers for pre and postnatal distress and strategies to prevent or manage such problems. The booklet also contained information on how to access local postnatal support services. Results (2 months post intervention, 4 months post intervention and 4 months postpartum) showed similar improvements for both groups in depressive and anxious symptoms. The CBT intervention was not found to be superior to the control intervention (Austin et al., 2008) That the control group booklet was equally effective as the group CBT intervention caused the authors to conclude that the booklet may have had more effect than was intended. Ideally, they said, a usual care control would have been the best design to test effectiveness of the CBT intervention.
A pilot study by Cho, Kwon, & Lee (2008) to examine the efficacy of CBT for preventing postpartum depression randomized 27 women screened for depression into a CBT intervention group and a control group. The intervention consisted of nine 1-hour, biweekly individual CBT manual-guided sessions focused on improving depressed mood and dysfunctional marital relationships in the context of pregnancy. The control group received 1 session regarding strategies to control depression. Results in the postpartum period indicated that participants that had received the CBT intervention had a lower self-reported rate of depression than the women in the control group. Largest differences between the two groups were in automatic thoughts and marital communication dissatisfaction (Cho, Kwon, & Lee, 2008). Authors of this study concluded that the success of the CBT intervention in preventing postpartum depression may have resulted from its delivery individually rather than in a group format. They suggested further study with a larger population and using structured clinical interviews as well as self-reports for the postpartum assessment.
Treating Depression in Infertile Women
A study by Faramarzi et al. (2008) found CBT to be superior to fluoxetine in reducing or resolving depression in infertile women. This randomized controlled clinical trial at an infertility clinic assigned 124 depressed women who had been trying to conceive for 2 years to 3 groups: 42 allocated to CBT; 42 allocated to fluoxetine; 40 allocated to control. Participants in the CBT group received group therapy in 2-hour weekly sessions over 10 weeks. Authors of the study reported that the CBT was especially adapted for infertile women, and that the first 3 sessions included a 30 minute explanation from a gynecologist about the cause of infertility for each patient. The fluoxetine group took the medication for 90 days. Results showed that depression decreased for both the CBT group and the fluoxetine group, with no notable change in the control group; resolution of depression in the groups was: fluoxetine 50%, CBT 79.3%, and the control group 10% (Faramarzi et al., 2008). Authors maintained that CBT was superior to fluoxetine in treating depression in infertile women. They said their version of CBT was a combination of different approaches, tailored to their group, and that this was one major reason for the success of the intervention.
Internet-Based CBT for Treatment of Depression in Women
Two studies investigated the efficacy of delivering CBT by internet. Internet and other computerized treatments show potential for treatment of depression (Andersson & Cuijpers, 2009). A randomized controlled trial by Kersting, Kroker, Schlicht, Baust, & Wagner (2011) looked at the effects of CBT internet-based therapy in mothers after the loss of a child during pregnancy. The authors maintained that loss of a child during pregnancy is a relatively common experience that is not openly discussed, hence psychosocial support is often lacking. This study involved 83 women who had lost a child during pregnancy due to miscarriage, termination of pregnancy due to fetal anomaly, or stillbirth. All were self-referrals. Participants were randomly allocated to either 5 weeks of internet therapy or a 5-week waiting condition. The CBT program comprised three phases – self-confrontation, cognitive restructuring and social sharing – of writing assignments, with written feedback from the therapist. Depression was assessed, along with posttraumatic stress, grief and general psychopathology, pretreatment, post treatment and at a 3-month follow-up. Results indicated significant improvements in the overall mental health and depression of the CBT group as compared with the control group (Kersting et al., 2011). The authors maintained that the on-line treatment has great practical significance, and pointed to the advantage that internet service offers because of its geographical and temporal independence particularly for women looking after young children. They also said that the internet option is important for women who feel reluctant to go to a clinic that offers psychological services.
A study by Openshaw, Pfister, Silverbaltt, & Moen (2011) involved internet-delivered CBT focused on depression treatment for middle-aged women residing in rural Utah. Therapy was provided via a system, called Technologically Assisted Psychotherapeutic Intervention (TAPI) that used internet power points, online measures of progress, online modules, and real time video conferencing. It allowed a clinician whose office was not located close enough to a client for suitable access to conduct virtual face to face therapy in real time. Women were recruited through an article addressing depression in the local newspaper. Inclusion criteria included residing in a rural Utah community and having mild to moderate or moderately severe depression score on a number of tests. Participants were provided ten 1-hour CBT therapy sessions through the medium of TAPI by trained counselors. Women would go to one of two regional campuses where the equipment was located in a private room of an office that resembled a faculty office. Data on the 16 patients were collected pre-therapy, 5th session, post therapy, and 3 and 6 months post therapy. Openshaw et al. (2011) reported results indicating significant changes in symptoms of depression for the majority of the women. Changes continued 3 and 6 months post-therapy, suggesting that women continued to use skills learned through the intervention, and to remain free of depressive symptoms.
A follow-up study consisted of a survey of these same women who had been provided CBT using teletherapy (Openshaw et al., 2012). Survey questions focused on 3 factors used to measure satisfaction with the therapy experience: clinician competence, privacy and confidentiality, and outcome. The survey showed that the women who received the manual-guided CBT for moderate or moderately severe symptoms of depression through TAPI were satisfied with their therapy experience. One study finding was that there was a modest decline in client perception of clinician empathy over time. The authors concluded that due to physical distance and use of the video camera for virtual face to face interactions, clinicians who use teletherapy need to be particularly sensitive to rigorously displaying behaviors that are consistent with trust and genuineness. They stressed the benefits of this delivery of CBT for depression through teletherapy to those unable to receive needed mental health services “due to barriers of availability, accessibility and acceptability” (Openshaw et al., 2012).
From the review of the literature, it is evident that CBT can be an effective treatment for major depression in women. Some studies did show, however, that CBT was not always a highly effective intervention. A main finding of this review is that CBT is effective when it and the delivery method is designed to meet the specific needs of the patient. The studies with results pointing to a strong CBT efficacy emphasized that point. The study by Tandon et al. (2011) in which intervention with low-income women was highly effective, was the one where other needs, such as transportation and child care, were met and a meal was served at each therapy session. In the study by Faramarzi et al. (2008) involving depression in infertile women in which CBT was superior to fluoxetine, the authors stressed that an important strength of that particular CBT intervention was the way in which it was tailored for infertile women. More qualitative studies, such as the one done by O’Mahen et al. (2012) for perinatal women, should be conducted to help modify CBT interventions to meet specific needs of women in various life situations.
Results of the study by Austin et al. (2008) indicated that an individual session reviewing a booklet discussing strategies for avoiding pre and postnatal depression was equally as effective as a 6-week course of 2-hour group intervention. Authors said the time patients and a therapist spent going over the booklet may have been an effective intervention in itself. A study should be designed based on that finding, because a one-time meeting with a patient would be more cost effective than a longer, multi-week intervention.
Another finding of this review is the promise that the internet holds for effective CBT delivery. Without restraints of time or geography, more individuals can effectively access CBT intervention. Athough the TAPI delivery system in studies by Openshaw et al. (2011) and Openshaw et al. (2012) was different from the internet delivery system in the study by Kersting et al. (2011), in which women who had lost a child during pregnancy accessed therapy from a home computer, both delivery methods afforded clients privacy and avoided the stigma associated with visiting a psychological services clinic. More studies of the efficacy of internet-delivered CBT should be conducted.
With the ever-increasing presence of stressors in the lives of women, CBT should continue to be considered an effective intervention for major depressive disorder. Studies to increase content value based on women’s life circumstances and to maximize the effects of delivery by internet would be worthwhile.
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