Abstract
It is now 35 years since the first publication of the Cognitive Theory of Depression by Aaron Beck in 1962. It was surprising to read that there has been no systematic review of the evidence base or summary of the status of the cognitive theory of depression since 1967. Certainly, the many facets of the cognitive theory of depression have been available in various books up until now, but there has not been a singular review available.
In this era of evidence-based medicine, psychotherapies in general have been increasingly placed under scrutiny as to their efficacy and scientific foundations. Consequently, this book is a timely and erudite discussion of the scientific foundations of cognitive therapy for one of the major causes of disability in our society.
This is an academic work and therefore, as a whole, is not suitable for those wishing to gain a basic understanding of cognitive theory. It is very useful for academics and clinicians wishing to expand their knowledge of the current status of the literature. It reviews the strengths and weaknesses of the theory and gives a critical analysis of the criticisms that have been raised. These criticisms have mainly been focused upon the fact that the cognitive theory of depression is not scientific, but is based upon a series of clinical observations. Various critics have also felt that, as a theory, it is too imprecise, cumbersome and inaccurate. These criticisms are dealt with in an impartial and valuable manner. The authors have aimed to provide a comprehensive and critical evaluation of the literature around the theory. Having Aaron Beck as an author adds considerable weight to this review and his involvement provided an increased insight for me to various aspects of the theory.
The first chapter provides an excellent brief summary of the current state of knowledge regarding depression. It includes a comprehensive review of the major diagnostic criteria and types of depression, a detailed review of the comorbidity associated with depression (particularly with anxiety), and looks at the controversy as to whether depression is a dimensional or categorical diagnosis. This chapter also discusses the causes and outcomes of major depression. This chapter is only 35 pages long but provides an excellent summary for clinicians wishing to update themselves with the current status of studies into depression or for registrars wishing to learn about major depressive disorders.
The second chapter is less clinically relevant, but provides some fascinating history of the origins of cognitive theory and therapy of depression.
The third chapter discusses the philosophical and theoretical basis of cognitive theory. The authors outline the 12 theoretical assumptions that underlie the cognitive model. This is particularly interesting as it clearly elucidates the basic understanding upon which the model rests. This helps to develop a stronger cognitive construct of the theory itself.
Chapter 4 provides a clear description of the cognitive theory of depression itself. The elucidation of the different types of schemas that have been proposed to correspond to different ‘functions or aspects of the biopsychosocial systems of the organism’ was particularly interesting. The chapter discusses the following types of schemas: (i) cognitive conceptual; (ii) physiological; (iii) affective; (iv) behavioural; (v) motivational; (vi) validation seeking.
It then progresses to discuss how the cognitive theory of depression has utilized the concept of a ‘mode.’ A ‘mode’ is defined as ‘a specific cluster of interrelated cognitive, conceptual, effective physiological, behavioural, and motivational schemas organised to deal with particular demands placed upon the organism.’ It is postulated that these modes provide an overarching integration of the underlying schemas. The information processing that occurs at the modal level is therefore far more complex while simultaneously automatic and effortless. However, once these modes are activated they dominate information processing. Multiple types of modes are described, including primal, constructive and minor modes and their relationship to emotion.
There then follows a discussion of the cognitive theory of personality and of the cognitive process. The section on the cognitive process details the operation of the brain's information processing system according to the cognitive theory. There is then a detailed discussion of how the self is represented in self-schemas and how these are involved in depression.
Overall, this is probably the most useful chapter of the book providing an erudite and clear summary of the present status of the cognitive theory of depression.
Chapters 5 to 10 provide a discussion of the scientific and empirical research regarding cognitive model of depression. The authors pose that the research is adequately rigorous and comprehensive to confirm the scientific status of the cognitive theory of depression. I would not recommend these chapters for general reading due to their detailed and academic nature. However, they provide an excellent resource for academics reviewing the scientific basis of the theory.
The authors also discuss a clinically relevant theory on the relapse and recurrence of depression using a diathesis-stress model. They detail the relevance of latent ‘depressogenic’ schemas and predepressive personality suborganization as risk factors for recurrence and relapse of depression. They also pose the argument that chronicity in depression will occur as long as the dysfunctional schemas persist. Overall, this is a very interesting concept of recurrent and chronic depression. Unfortunately, there is only a limited amount of support for this in the literature. This is an area that requires further investigation as it becomes clearer that response to antidepressant treatment is often partial, leaving the patients with residual disability. The importance of psychotherapy in improving social and occupational functioning and providing relief of recurrent or chronic depression is an important avenue of research. If this theory is validated then valuable evidence for the use of psychotherapy in treatment of chronic and recurrent depression will be obtained.
In summary, this is a very timely review of the cognitive theory and therapy of depression. The first four chapters, particularly chapter 4, are the most useful for the general reader. Chapters 5 to 10 consist of an academic review of the scientific basis of the theory and are therefore most useful to academics or experts in the area.