While there are currently multiple empirically supported behavioral treatments for depression and alcoholism as individual disorders, knowledge about effective integrated treatment options is far from complete. Carroll [8] and others [27,28] acknowledge that there have been few well-specified behavioral therapies with an integrated approach (versus parallel) to treating symptoms of both disorders. Integrated treatment models are those in Carroll [8] reviewed the most common evaluated types of behavioral therapies for cooccurring disorders and included cognitive behavioral therapy (CBT), motivational interviewing (MI), and contingency management (CM). Cognitive behavioral therapy (CBT) and coping skills strategies have been shown to be effective across a wide range of substance use and psychiatric disorders, including alcohol dependence and depression [30-32], but controlled trials for co-occurring alcoholism and depression are limited, both in supply and design. In a qualitative review, Hides and colleagues [33] concluded that while CBT is more efficacious than no treatment control conditions, there is limited evidence to suggest that CBT is better suited for treating co-occurring depression and substance use compared to other psychotherapeutic interventions. In part, they site poor heterogeneity between existing studies as a key reason why the evidence is inconclusive.

Conversely, a more recent quantitative review of the literature highlights the effectiveness of CBT to reduce depressive symptoms and alcohol use [34]. In one study a moderate effect on alcohol use and/or depressive symptoms with Cognitive Behavior Therapy- Depression (CBT-D) was demonstrated, but included only patients with elevated depression (Beck Depression Inventory ≥ 10), not diagnosed depressive disorders [14]. Another study found that adding CBT-D for alcoholics with significant depressive symptoms was more effective on mood and alcohol use measures than standard treatment alone within an individual, but not a group treatment modality [35]. However, it is possible that treatment effects were due to the added therapist contact in the individual condition.

More systematic investigations have also been conducted in recent years. One randomized clinical trial compared the effectiveness of computer versus therapist delivered CBT with MI components [36]. All patients had comorbid depression with substance misuse, a substantial portion of which was alcohol misuse, and each received a single session of integrated CBT/MI before being randomized to a no treatment control condition, or nine sessions of CBT/MI delivered by a psychotherapist or a computer. As hypothesized, treatment conditions were associated with significant reductions in alcohol use and symptoms of depression, with long-term intervention having a greater impact. A similar RCT performed by Baker and colleagues [37] sought to determine the effectiveness of CBT/MI that is singlefocused or integrated. Results found integrated treatment to be associated with greater improvement in alcohol use as well as depressive symptoms when compared to single-focus interventions. Similar support has been found in adolescent samples, which highlight treatment gains even at two years post-treatment [38].

Although there is good empirical support for the effectiveness of MI in substance use disorders and related behavioral domains [39-41], well-controlled evaluations of MI as a stand-alone treatment or MI adapted for co-occurring disorders are rare, and demonstrate

improvements in treatment engagement/retention, motivation, and satisfaction, but not improvements in mood or decreased substance use [42-44]. In one small sample study (*N* = 5), MI was integrated with CBT for bipolar patients with comorbid substance use [45]. Modest reductions in both mood symptoms and substance use were observed.

Co-Occurring Chronic Depression and Alcohol Dependence: A Novel Treatment Approach 243

interpersonal trauma (e.g., physical/sexual abuse) or low grade, but continuous stream of psychological insults (e.g., punishment/rejection of some form); both lead to a preoperational form of thinking about one's social world. This derailment is particularly characterized by a lack of causal awareness and egocentrism in the depressive patient. This often results in a presentation of poor functioning and/or low motivation for change [51].

Additionally, a lack of awareness for their interpersonal impact and poor interpersonal problem-solving skills is prevalent [51,52,54,55]. CBASP takes a person-by-environment perspective in modifying depressive symptoms by raising a patient's awareness about their interpersonal impact on others [51,56,57]. This is done by highlighting the interpersonal interaction as it occurs in the therapeutic setting. Recognizing one's own stimulus value in the interpersonal context allows the chronic depressive to amend how he or she presents and copes with stressful interpersonal situations. CBASP holds that the interpersonal fear that drives avoidance, the central theme in many interpersonal failures, must be counterconditioned. This is done by aiding the patient in discriminating their experience with the therapist, from those experiences with harmful significant others to create a sense of felt

interpersonal safety that can then be generalized outside of the therapy setting [57].

their behavior.

Another major component of CBASP is Situational Analysis (SA). SA is an interpersonal problem-solving tool that is used in-session to help a patient actively re-experience an interpersonal encounter [51,56,57]. The goal of SA is to elicit the original cognitions and emotions during the target situation. This involves having the client first isolate an event, describe it in exclusively behavioral terms, and identify the situational outcome. The goal of this exercise is to help the client identify alternative ways of behaving and thinking that would lead to more desirable consequences. New ways of behaving interpersonally are often met with obtaining desirable outcomes, reinforcing effective problem-solving skills, and allowing the patient to perceive his or her contingent relationship with the environment. Through these means the patient may acquire "perceived functionality" – that is, the patient's ability to recognize and begin to change the interpersonal consequences of

CBASP has demonstrated effectiveness in treating chronic depression, and is more effective than antidepressant monotherapy in individuals with early trauma or adversity [7,58-60]. Moreover, both the therapeutic relationship and the ability of the patient to learn SA effectively have been shown to independently contribute to a reduction in depressive symptoms [61]. Additionally, there is some evidence to support the notion that CBASP may be efficacious for individuals who do not respond to a trial of antidepressant medications initially [62]. CBASP has also been shown to outperform interpersonal psychotherapy in treating chronic depression [63], suggesting it may offer more when treating co-occurring chronic depression and alcoholism. Strong support for CBASP has been tempered by recent results [64], which found that neither CBASP nor Supportive psychotherapy was more effective than medication alone for chronically depressed treatment resistant patients. The lack of positive findings in that study were hypothesized to be related to the small number of CBASP sessions (mean = 12.5 sessions) and the effect of an aspect of the study design

Contingency Management (CM) has demonstrated more robust findings when used in depressed cocaine addicted populations [46,47]. In a pilot study which employed an integrated CM approach, opioid dependent patients experienced decreases in depressive symptoms, but decreases in usage were not significant. However, it has not been implemented with CDAD individuals and CM is not always logistically or financially feasible.

In addition to those interventions highlighted by Carroll [8], mindfulness training (MT) and behavioral activation have seen more limited attention in the treatment of co-occurring disorders. Brewer and colleagues [21] reviewed the evidence for a shared mechanism in depression and substance abuse that might allow MT to reduce substance use and improve psychiatric symptoms. Another treatment study focused on inner-city substance users with mild to moderate depression and found that a modified version of behavioral activation was successful at reducing depressive symptoms of patients during residential substance abuse treatment [48]. Interpersonal psychotherapy has also seen moderate support in the reduction of depressive symptoms, but less so for days abstinent from alcohol with the converse being the case for brief supportive therapy [49]. Another study comparing integrated CBT with twelve-step facilitation (TSF) found both to be effective, with TSF producing slightly better improvements in depression and abstinence [50]. The aforementioned findings appear to support the hypothesis that an integrated therapy possessing components of motivational enhancement, cognitive and behavioral therapy, as well as management of reinforcements, would be most ideal when targeting co-occurring depression and alcoholism.

## **5. CBASP for chronically depressed alcohol dependent individuals**

Despite the aforementioned similarities found among individuals dealing with chronic depression and alcohol dependence, investigation of more synthesized treatment approaches has occurred in a limited fashion. "Third wave" cognitive behavioral therapies represent one underexplored subset of treatment approaches. Specifically, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) [51, 52] has demonstrated effectiveness in treating chronic depression, demonstrating effects equal to antidepressant medications as well as enhancing the effects of pharmacotherapy [6,7]. CBASP has yet to be studied in a large trial with persons with co-occurring alcohol dependence and chronic depression. However, in a case report from clinical practice, CBASP has been effective in reducing symptoms of chronic depression and significantly reducing alcohol intake to healthy drinking levels in CDAD individuals [53]. CBASP is particularly proficient for use with the early onset variety of unipolar mood disorders. Its etiological premise is that chronic depression arises as a result of a developmental history characterized by significant interpersonal trauma (e.g., physical/sexual abuse) or low grade, but continuous stream of psychological insults (e.g., punishment/rejection of some form); both lead to a preoperational form of thinking about one's social world. This derailment is particularly characterized by a lack of causal awareness and egocentrism in the depressive patient. This often results in a presentation of poor functioning and/or low motivation for change [51].

242 Psychiatric Disorders – New Frontiers in Affective Disorders

feasible.

depression and alcoholism.

improvements in treatment engagement/retention, motivation, and satisfaction, but not improvements in mood or decreased substance use [42-44]. In one small sample study (*N* = 5), MI was integrated with CBT for bipolar patients with comorbid substance use [45].

Contingency Management (CM) has demonstrated more robust findings when used in depressed cocaine addicted populations [46,47]. In a pilot study which employed an integrated CM approach, opioid dependent patients experienced decreases in depressive symptoms, but decreases in usage were not significant. However, it has not been implemented with CDAD individuals and CM is not always logistically or financially

In addition to those interventions highlighted by Carroll [8], mindfulness training (MT) and behavioral activation have seen more limited attention in the treatment of co-occurring disorders. Brewer and colleagues [21] reviewed the evidence for a shared mechanism in depression and substance abuse that might allow MT to reduce substance use and improve psychiatric symptoms. Another treatment study focused on inner-city substance users with mild to moderate depression and found that a modified version of behavioral activation was successful at reducing depressive symptoms of patients during residential substance abuse treatment [48]. Interpersonal psychotherapy has also seen moderate support in the reduction of depressive symptoms, but less so for days abstinent from alcohol with the converse being the case for brief supportive therapy [49]. Another study comparing integrated CBT with twelve-step facilitation (TSF) found both to be effective, with TSF producing slightly better improvements in depression and abstinence [50]. The aforementioned findings appear to support the hypothesis that an integrated therapy possessing components of motivational enhancement, cognitive and behavioral therapy, as well as management of reinforcements, would be most ideal when targeting co-occurring

**5. CBASP for chronically depressed alcohol dependent individuals**

Despite the aforementioned similarities found among individuals dealing with chronic depression and alcohol dependence, investigation of more synthesized treatment approaches has occurred in a limited fashion. "Third wave" cognitive behavioral therapies represent one underexplored subset of treatment approaches. Specifically, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) [51, 52] has demonstrated effectiveness in treating chronic depression, demonstrating effects equal to antidepressant medications as well as enhancing the effects of pharmacotherapy [6,7]. CBASP has yet to be studied in a large trial with persons with co-occurring alcohol dependence and chronic depression. However, in a case report from clinical practice, CBASP has been effective in reducing symptoms of chronic depression and significantly reducing alcohol intake to healthy drinking levels in CDAD individuals [53]. CBASP is particularly proficient for use with the early onset variety of unipolar mood disorders. Its etiological premise is that chronic depression arises as a result of a developmental history characterized by significant

Modest reductions in both mood symptoms and substance use were observed.

Additionally, a lack of awareness for their interpersonal impact and poor interpersonal problem-solving skills is prevalent [51,52,54,55]. CBASP takes a person-by-environment perspective in modifying depressive symptoms by raising a patient's awareness about their interpersonal impact on others [51,56,57]. This is done by highlighting the interpersonal interaction as it occurs in the therapeutic setting. Recognizing one's own stimulus value in the interpersonal context allows the chronic depressive to amend how he or she presents and copes with stressful interpersonal situations. CBASP holds that the interpersonal fear that drives avoidance, the central theme in many interpersonal failures, must be counterconditioned. This is done by aiding the patient in discriminating their experience with the therapist, from those experiences with harmful significant others to create a sense of felt interpersonal safety that can then be generalized outside of the therapy setting [57].

Another major component of CBASP is Situational Analysis (SA). SA is an interpersonal problem-solving tool that is used in-session to help a patient actively re-experience an interpersonal encounter [51,56,57]. The goal of SA is to elicit the original cognitions and emotions during the target situation. This involves having the client first isolate an event, describe it in exclusively behavioral terms, and identify the situational outcome. The goal of this exercise is to help the client identify alternative ways of behaving and thinking that would lead to more desirable consequences. New ways of behaving interpersonally are often met with obtaining desirable outcomes, reinforcing effective problem-solving skills, and allowing the patient to perceive his or her contingent relationship with the environment. Through these means the patient may acquire "perceived functionality" – that is, the patient's ability to recognize and begin to change the interpersonal consequences of their behavior.

CBASP has demonstrated effectiveness in treating chronic depression, and is more effective than antidepressant monotherapy in individuals with early trauma or adversity [7,58-60]. Moreover, both the therapeutic relationship and the ability of the patient to learn SA effectively have been shown to independently contribute to a reduction in depressive symptoms [61]. Additionally, there is some evidence to support the notion that CBASP may be efficacious for individuals who do not respond to a trial of antidepressant medications initially [62]. CBASP has also been shown to outperform interpersonal psychotherapy in treating chronic depression [63], suggesting it may offer more when treating co-occurring chronic depression and alcoholism. Strong support for CBASP has been tempered by recent results [64], which found that neither CBASP nor Supportive psychotherapy was more effective than medication alone for chronically depressed treatment resistant patients. The lack of positive findings in that study were hypothesized to be related to the small number of CBASP sessions (mean = 12.5 sessions) and the effect of an aspect of the study design which focused on pharmacological switching and augmentation that may have had a negative impact on patients' interests in and expectations of, psychotherapy [65]. CBASP has been used to treat chronically depressed pregnant smokers and was found to be more effective than standard treatment at increasing abstinence and decreasing depressive symptoms six months post treatment. CBASP was more effective in women with higher levels of baseline depressive symptoms [66]. CBASP has also proven useful in a small sample study demonstrating that increases in positive affect and a decrease in depressive symptoms are associated with greater likelihood of prolonged abstinence from cigarette smoking [67].

Co-Occurring Chronic Depression and Alcohol Dependence: A Novel Treatment Approach 245

Importantly, CBASP provides an empirical method to facilitate and measure exactly what and how much is being learned during the course of therapy [57]. Both felt emotional safety in the therapeutic dyad and learned acquisition of perceived functionality are hypothesized to be related to the outcome of treatment and, over time, to the maintenance of the therapeutic gains. These skills can be measured in multiple correlated ways, including evaluation of learning in session via achievement of therapeutic interpersonal tasks, performance on psychological tests of prediction of interpersonal response, and fMRI assessment of the neurobiological correlates of perceived functionality that have been

In sum, treatment for CDAD individuals must be targeted or personalized for the underlying interpersonal issues and skill deficits of the individual in order to be most effective. CBASP is a behavioral treatment which can be adapted to comprehensively address these issues and deficits to successfully treat both alcohol dependence and chronic

**7. Current research with CBASP to treat co-occurring chronic depression**

We have developed an enhanced integrative CBASP for use in reducing both depressive symptoms and alcohol intake in CDAD patients. The augmented CBASP includes all the aspects of traditional CBASP and adds coping skills training for reducing alcohol intake. One of the most important components of successfully conducting CBASP with this population is helping the patient discover the causal connections between their mood symptoms and drinking behavior and ultimately change the functional linkages between their depression and drinking. The drinking behavior is conceptualized as a maladaptive coping strategy that is often an outcome of interpersonal situations for this patient population. Drinking behavior is also conceived of as avoidance behavior, which interferes with learning and practicing effective interpersonal problem solving and coping. Further augmentations include additional assessment and monitoring of stage of change and motivation levels for both depressive symptoms and alcohol use. During the middle phase of treatment and in session after the Coping Survey Questionnaire (Situational Analysis) has been remediated, alcohol reduction coping skills are identified and taught in the same manner that traditional CBT is conducted. Significant adaptations for use with this population involve setting and assessing alcohol consumption goals in addition to depressive symptoms and quality of life/level of functioning goals for treatment. A harm reduction approach, similar to that utilized in CBT for alcohol dependence, is used to address alcohol consumption. Thus, patients do not need to be abstinent when in treatment and do not necessarily have to set abstinence as their goal, although it is preferred. The overall approach to symptom change is compatible with the CBASP essence of treatment, which allows the patient to establish how the therapy session will

A twenty-session pilot study examining the use of our augmented CBASP for persons with co-occurring chronic depression and alcohol dependence is currently underway at the

identified in chronic depressives [68].

depression simultaneously.

**and alcohol dependence**

proceed and enables the patient to do the work of change.

## **6. Rationale for and adaptations of CBASP for CDAD individuals**

Those entering substance abuse treatment programs with co-occurring disorders report using multiple drugs, having more recent admissions to psychiatric and medical facilities, and experiencing more severe medical, social, and family problems compared to those diagnosed solely with a substance use disorder [23]. These characteristics are unique in nature, suggesting the need for specialized treatment addressing depression and alcoholism simultaneously. The Substance Abuse and Mental Health Services Administration (SAMSA) in the USA [26] has come to similar conclusions in their recommendations for Center for Substance Abuse Treatment (CSAT) treatment improvement protocols with co-occurring disorders, suggesting individualized, integrated dual primary diagnosis-specific treatment interventions matched to diagnoses, phase of recovery, stage of change, and severity. Interestingly, no studies have evaluated the use of a behavioral treatment approach that can address these specific mood and addiction symptoms that characterize the CDAD individual.

CBASP is a behavioral treatment that addresses the unique characteristics of chronically depressed individuals, most of which are highly relevant for alcohol dependent individuals as well.  Thus, CBASP appears to be a plausible behavioral approach for use with CDAD individuals who may report traumatic developmental histories, manifest impoverished interpersonal relations, interactions and coping skills, and demonstrate additional chronic under-functioning [59,61,67]. Because of its structured but individualized and collaborative design, emphasis on teaching effective coping strategies, and employment of motivational, cognitive, behavioral, and interpersonal techniques, CBASP is uniquely suited for use in treating alcoholism in the context of chronic depression [7,67].

The major goals of CBASP are (a) to enable patients to feel increased emotional safety, thus allowing them to more fully approach and engage in treatment and reduce avoidance behavior, including drinking; and (b) to allow patients to recognize how they contribute to their own interpersonal psychopathology (perceived functionality) and begin to learn how to negotiate interpersonal situations successfully and without the use of alcohol. Importantly, CBASP provides an empirical method to facilitate and measure exactly what and how much is being learned during the course of therapy [57]. Both felt emotional safety in the therapeutic dyad and learned acquisition of perceived functionality are hypothesized to be related to the outcome of treatment and, over time, to the maintenance of the therapeutic gains. These skills can be measured in multiple correlated ways, including evaluation of learning in session via achievement of therapeutic interpersonal tasks, performance on psychological tests of prediction of interpersonal response, and fMRI assessment of the neurobiological correlates of perceived functionality that have been identified in chronic depressives [68].

244 Psychiatric Disorders – New Frontiers in Affective Disorders

smoking [67].

individual.

which focused on pharmacological switching and augmentation that may have had a negative impact on patients' interests in and expectations of, psychotherapy [65]. CBASP has been used to treat chronically depressed pregnant smokers and was found to be more effective than standard treatment at increasing abstinence and decreasing depressive symptoms six months post treatment. CBASP was more effective in women with higher levels of baseline depressive symptoms [66]. CBASP has also proven useful in a small sample study demonstrating that increases in positive affect and a decrease in depressive symptoms are associated with greater likelihood of prolonged abstinence from cigarette

**6. Rationale for and adaptations of CBASP for CDAD individuals**

Those entering substance abuse treatment programs with co-occurring disorders report using multiple drugs, having more recent admissions to psychiatric and medical facilities, and experiencing more severe medical, social, and family problems compared to those diagnosed solely with a substance use disorder [23]. These characteristics are unique in nature, suggesting the need for specialized treatment addressing depression and alcoholism simultaneously. The Substance Abuse and Mental Health Services Administration (SAMSA) in the USA [26] has come to similar conclusions in their recommendations for Center for Substance Abuse Treatment (CSAT) treatment improvement protocols with co-occurring disorders, suggesting individualized, integrated dual primary diagnosis-specific treatment interventions matched to diagnoses, phase of recovery, stage of change, and severity. Interestingly, no studies have evaluated the use of a behavioral treatment approach that can address these specific mood and addiction symptoms that characterize the CDAD

CBASP is a behavioral treatment that addresses the unique characteristics of chronically depressed individuals, most of which are highly relevant for alcohol dependent individuals as well.  Thus, CBASP appears to be a plausible behavioral approach for use with CDAD individuals who may report traumatic developmental histories, manifest impoverished interpersonal relations, interactions and coping skills, and demonstrate additional chronic under-functioning [59,61,67]. Because of its structured but individualized and collaborative design, emphasis on teaching effective coping strategies, and employment of motivational, cognitive, behavioral, and interpersonal techniques, CBASP is uniquely suited for use in

The major goals of CBASP are (a) to enable patients to feel increased emotional safety, thus allowing them to more fully approach and engage in treatment and reduce avoidance behavior, including drinking; and (b) to allow patients to recognize how they contribute to their own interpersonal psychopathology (perceived functionality) and begin to learn how to negotiate interpersonal situations successfully and without the use of alcohol.

treating alcoholism in the context of chronic depression [7,67].

In sum, treatment for CDAD individuals must be targeted or personalized for the underlying interpersonal issues and skill deficits of the individual in order to be most effective. CBASP is a behavioral treatment which can be adapted to comprehensively address these issues and deficits to successfully treat both alcohol dependence and chronic depression simultaneously.

## **7. Current research with CBASP to treat co-occurring chronic depression and alcohol dependence**

We have developed an enhanced integrative CBASP for use in reducing both depressive symptoms and alcohol intake in CDAD patients. The augmented CBASP includes all the aspects of traditional CBASP and adds coping skills training for reducing alcohol intake. One of the most important components of successfully conducting CBASP with this population is helping the patient discover the causal connections between their mood symptoms and drinking behavior and ultimately change the functional linkages between their depression and drinking. The drinking behavior is conceptualized as a maladaptive coping strategy that is often an outcome of interpersonal situations for this patient population. Drinking behavior is also conceived of as avoidance behavior, which interferes with learning and practicing effective interpersonal problem solving and coping. Further augmentations include additional assessment and monitoring of stage of change and motivation levels for both depressive symptoms and alcohol use. During the middle phase of treatment and in session after the Coping Survey Questionnaire (Situational Analysis) has been remediated, alcohol reduction coping skills are identified and taught in the same manner that traditional CBT is conducted. Significant adaptations for use with this population involve setting and assessing alcohol consumption goals in addition to depressive symptoms and quality of life/level of functioning goals for treatment. A harm reduction approach, similar to that utilized in CBT for alcohol dependence, is used to address alcohol consumption. Thus, patients do not need to be abstinent when in treatment and do not necessarily have to set abstinence as their goal, although it is preferred. The overall approach to symptom change is compatible with the CBASP essence of treatment, which allows the patient to establish how the therapy session will proceed and enables the patient to do the work of change.

A twenty-session pilot study examining the use of our augmented CBASP for persons with co-occurring chronic depression and alcohol dependence is currently underway at the University of Virginia School of Medicine in the Department of Psychiatry and Neurobehavioral Sciences in Charlottesville, Virginia. Sessions were individually administered weekly for one hour by two trained Ph.D. level clinical psychologists with extensive experience in addictions treatment and depression. Sessions were audio taped to be rated for adherence, and follow up data regarding alcohol intake and depressive symptoms collected at one month and three months post termination. Preliminary results from this small study indicate that this patient population exists and is willing to seek and participate in such extensive and intensive treatment. Below are brief descriptions of the course of treatment for two participants in our current study.

Co-Occurring Chronic Depression and Alcohol Dependence: A Novel Treatment Approach 247

Participant 02, "Paul" is a 45-year-old, Caucasian male who is divorced and lives alone. He works part-time as a food vendor and also receives monthly social security disability benefits. At intake, he was diagnosed with Major Depressive Disorder, Recurrent and Alcohol Dependence. Paul reported an extensive drug and alcohol use history, further noting how his substance use helped him to avoid negative emotions and interpersonal problems. At intake, stage of change data indicated that he was planning to reduce both his alcohol intake and symptoms of depression. His stated goals for treatment were to learn how to better manage his mood so that he no longer used alcohol to cope with depression (he reported no drug use for the past five years), and to drink at a reduced level because he enjoys drinking alcohol. As shown in Figure 1, at session 1, he was drinking 48 drinks per week and his score on the Hamilton Depression Rating Scale was 16. In his final session, Paul was drinking 15 drinks per week and his score on the Hamilton Depression Rating Scale was 3. As can be seen in Figure 1, he continued to practice Situational Analysis using the Coping Survey Questionnaire on a weekly basis and began to gain an understanding of the importance of communicating to others to achieve socially desirable outcomes. This was especially true with regard to expressing negative affect to others. Paul's transference hypothesis was "If I express negative affect, emotions, or feelings to my therapist, then he will be angry or upset with me, and reject me." This fear of interpersonal rejection was addressed in treatment using the Interpersonal Discrimination Exercise. Despite the participant's difficulty discriminating between feedback from the therapist and feedback from significant others when he expressed negative affect, he reported an increased sense of self-confidence to assert himself with the therapist and others. In addition, Paul stated that whereas he was more concerned with others' reactions to his assertiveness in the past, across the final weeks of treatment he was more concerned with obtaining socially desirable

CBASP has been successfully augmented and implemented with a new and challenging patient population in much need of effective treatment options. Although neither patient set abstinence as their drinking goal, instead opting to cut back or reduce their alcohol intake to a less risky level, they made progress on these goals and remained engaged in treatment. Both patients reduced their depressive symptoms dramatically over the course of twenty weeks. More importantly, both patients were able to gain insight into the negative impact of their transference hypotheses and avoidance behaviors upon their mood and drinking behavior, and begin to implement causal thinking to approach and solve interpersonal problems. Indeed, preliminary investigations of this pilot study data suggest that treatment is most effective when tailored or personalized to the underlying interpersonal issues and

Preliminary results from the research examining CBASP for CDAD outpatients in individual therapy are presented in Figures 1, 2, and 3 below, but should be interpreted with caution due to the very small sample size (*N* = 2). However, the results are promising, as both participants showed reductions in their drinking measured via the Timeline Followback Calendar [69] and depressive symptoms measured via the Hamilton Rating Scale for Depression [70], as the number of completed Coping Survey Questionnaires increased.

outcomes than with what others' reactions were to him.

skill deficits of the patient as presented in the Transference Hypothesis.

Participant 01, "Denise" is a 54-year-old, Caucasian female who is divorced and lives alone. She works full-time as a nurse. At intake, she was diagnosed with Dysthymia, early onset, Major Depressive Disorder, recurrent, in partial remission, and Alcohol Dependence. She reported that she had been on vacation for three weeks prior to intake and that her symptoms of depression and alcohol use had reduced as a result. Denise noted that interpersonal stress at work and with family members was a primary trigger for her depression. She recognized that she drank to avoid her negative emotions and interpersonal problems. At intake, stage of change data indicated that Denise had already begun to reduce her alcohol intake and that she was ready to reduce her symptoms of depression. Her stated goals for treatment were to learn how to manage her mood so that she no longer used alcohol to cope with depression, and to drink at a reduced level because she enjoys the taste of alcohol. As shown in Figure 1, at session 1, she was drinking 28 drinks per week and her score on the Hamilton Depression Rating Scale was 14. In her final session, she was drinking 17 drinks per week and her score on the Hamilton Depression Rating Scale was 3. In session 10, Denise began effectively using Situational Analysis to solve interpersonal problems. As can be seen in Figure 1, she continued to practice Situational Analysis using the coping survey questionnaire on a weekly basis. By session 16, she reported that she no longer needed to drink to manage her mood. She noted, "For the first time in my life, I am finally taking control of situations and facing my demons." Much of her ability to take control of situations in her life involved learning through Situational Analysis to set boundaries with others. Setting boundaries with others was difficult for her due to fear of interpersonal rejection. Her difficulty setting boundaries often caused her to feel taken advantage of by others which led to depression and subsequent drinking behavior. Her fear of interpersonal rejection was also related to fear of making mistakes. Denise's transference hypothesis was "If I make a mistake with my therapist, I will disappoint her and she will think I am not good enough." This fear of interpersonal rejection was addressed in treatment using the Interpersonal Discrimination Exercise, and by session 7 the participant was able to discriminate between the feedback from the therapist and feedback from significant others when she made a mistake. As such, she reported an increased sense of safety and she demonstrated an increased ability to assert herself with the therapist. Across the final weeks of treatment Denise's learning generalized and she was regularly setting appropriate boundaries with significant others in her life. At termination, the participant stated that she no longer felt fear or guilt about expressing her limits to others and setting boundaries.

Participant 02, "Paul" is a 45-year-old, Caucasian male who is divorced and lives alone. He works part-time as a food vendor and also receives monthly social security disability benefits. At intake, he was diagnosed with Major Depressive Disorder, Recurrent and Alcohol Dependence. Paul reported an extensive drug and alcohol use history, further noting how his substance use helped him to avoid negative emotions and interpersonal problems. At intake, stage of change data indicated that he was planning to reduce both his alcohol intake and symptoms of depression. His stated goals for treatment were to learn how to better manage his mood so that he no longer used alcohol to cope with depression (he reported no drug use for the past five years), and to drink at a reduced level because he enjoys drinking alcohol. As shown in Figure 1, at session 1, he was drinking 48 drinks per week and his score on the Hamilton Depression Rating Scale was 16. In his final session, Paul was drinking 15 drinks per week and his score on the Hamilton Depression Rating Scale was 3. As can be seen in Figure 1, he continued to practice Situational Analysis using the Coping Survey Questionnaire on a weekly basis and began to gain an understanding of the importance of communicating to others to achieve socially desirable outcomes. This was especially true with regard to expressing negative affect to others. Paul's transference hypothesis was "If I express negative affect, emotions, or feelings to my therapist, then he will be angry or upset with me, and reject me." This fear of interpersonal rejection was addressed in treatment using the Interpersonal Discrimination Exercise. Despite the participant's difficulty discriminating between feedback from the therapist and feedback from significant others when he expressed negative affect, he reported an increased sense of self-confidence to assert himself with the therapist and others. In addition, Paul stated that whereas he was more concerned with others' reactions to his assertiveness in the past, across the final weeks of treatment he was more concerned with obtaining socially desirable outcomes than with what others' reactions were to him.

246 Psychiatric Disorders – New Frontiers in Affective Disorders

course of treatment for two participants in our current study.

University of Virginia School of Medicine in the Department of Psychiatry and Neurobehavioral Sciences in Charlottesville, Virginia. Sessions were individually administered weekly for one hour by two trained Ph.D. level clinical psychologists with extensive experience in addictions treatment and depression. Sessions were audio taped to be rated for adherence, and follow up data regarding alcohol intake and depressive symptoms collected at one month and three months post termination. Preliminary results from this small study indicate that this patient population exists and is willing to seek and participate in such extensive and intensive treatment. Below are brief descriptions of the

Participant 01, "Denise" is a 54-year-old, Caucasian female who is divorced and lives alone. She works full-time as a nurse. At intake, she was diagnosed with Dysthymia, early onset, Major Depressive Disorder, recurrent, in partial remission, and Alcohol Dependence. She reported that she had been on vacation for three weeks prior to intake and that her symptoms of depression and alcohol use had reduced as a result. Denise noted that interpersonal stress at work and with family members was a primary trigger for her depression. She recognized that she drank to avoid her negative emotions and interpersonal problems. At intake, stage of change data indicated that Denise had already begun to reduce her alcohol intake and that she was ready to reduce her symptoms of depression. Her stated goals for treatment were to learn how to manage her mood so that she no longer used alcohol to cope with depression, and to drink at a reduced level because she enjoys the taste of alcohol. As shown in Figure 1, at session 1, she was drinking 28 drinks per week and her score on the Hamilton Depression Rating Scale was 14. In her final session, she was drinking 17 drinks per week and her score on the Hamilton Depression Rating Scale was 3. In session 10, Denise began effectively using Situational Analysis to solve interpersonal problems. As can be seen in Figure 1, she continued to practice Situational Analysis using the coping survey questionnaire on a weekly basis. By session 16, she reported that she no longer needed to drink to manage her mood. She noted, "For the first time in my life, I am finally taking control of situations and facing my demons." Much of her ability to take control of situations in her life involved learning through Situational Analysis to set boundaries with others. Setting boundaries with others was difficult for her due to fear of interpersonal rejection. Her difficulty setting boundaries often caused her to feel taken advantage of by others which led to depression and subsequent drinking behavior. Her fear of interpersonal rejection was also related to fear of making mistakes. Denise's transference hypothesis was "If I make a mistake with my therapist, I will disappoint her and she will think I am not good enough." This fear of interpersonal rejection was addressed in treatment using the Interpersonal Discrimination Exercise, and by session 7 the participant was able to discriminate between the feedback from the therapist and feedback from significant others when she made a mistake. As such, she reported an increased sense of safety and she demonstrated an increased ability to assert herself with the therapist. Across the final weeks of treatment Denise's learning generalized and she was regularly setting appropriate boundaries with significant others in her life. At termination, the participant stated that she no longer felt fear or guilt about expressing her limits to others and setting boundaries.

CBASP has been successfully augmented and implemented with a new and challenging patient population in much need of effective treatment options. Although neither patient set abstinence as their drinking goal, instead opting to cut back or reduce their alcohol intake to a less risky level, they made progress on these goals and remained engaged in treatment. Both patients reduced their depressive symptoms dramatically over the course of twenty weeks. More importantly, both patients were able to gain insight into the negative impact of their transference hypotheses and avoidance behaviors upon their mood and drinking behavior, and begin to implement causal thinking to approach and solve interpersonal problems. Indeed, preliminary investigations of this pilot study data suggest that treatment is most effective when tailored or personalized to the underlying interpersonal issues and skill deficits of the patient as presented in the Transference Hypothesis.

Preliminary results from the research examining CBASP for CDAD outpatients in individual therapy are presented in Figures 1, 2, and 3 below, but should be interpreted with caution due to the very small sample size (*N* = 2). However, the results are promising, as both participants showed reductions in their drinking measured via the Timeline Followback Calendar [69] and depressive symptoms measured via the Hamilton Rating Scale for Depression [70], as the number of completed Coping Survey Questionnaires increased.

Additional completed study participants are necessary to confirm these preliminary findings and additional data collection is underway.

Co-Occurring Chronic Depression and Alcohol Dependence: A Novel Treatment Approach 249

**Figure 2.** Number of Coping Survey Questionnaires completed, Hamilton Rating Scale for Depression scores, and drinks per week by session for Participant 02. Session 0 refers to the participant's scores at

baseline.

**Figure 1.** Number of Coping Survey Questionnaires completed, Hamilton Rating Scale for Depression scores, and drinks per week by session for Participant 01. Session 0 refers to the participant's scores at baseline.

findings and additional data collection is underway.

Additional completed study participants are necessary to confirm these preliminary

**Figure 1.** Number of Coping Survey Questionnaires completed, Hamilton Rating Scale for Depression scores, and drinks per week by session for Participant 01. Session 0 refers to the participant's scores at

baseline.

**Figure 2.** Number of Coping Survey Questionnaires completed, Hamilton Rating Scale for Depression scores, and drinks per week by session for Participant 02. Session 0 refers to the participant's scores at baseline.

Co-Occurring Chronic Depression and Alcohol Dependence: A Novel Treatment Approach 251

J. Kim Penberthy, Christopher J. Gioia, Andrea Konig and Stephanie A. Cockrell

*Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine,*

*Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, United States*

We would like to thank Dr. James P. McCullough, Jr., the developer of CBASP and Dr. Penberthy's primary mentor, for his guidance and advice on this project. He has been a tireless advocate for those suffering from chronic depression and we are pleased to expand

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the application of CBASP to the chronically depressed alcohol dependent population.

**Author details**

Aaron M. Martin

**8. References**

14.

**Acknowledgement**

*Charlottesville, Virginia, United States*

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**Figure 3.** Differences between 90 days pretreatment (blue) and last 90 days in treatment (green) on four drinking variables for the study participants.

## **Author details**

250 Psychiatric Disorders – New Frontiers in Affective Disorders

**Figure 3.** Differences between 90 days pretreatment (blue) and last 90 days in treatment (green) on four

drinking variables for the study participants.

J. Kim Penberthy, Christopher J. Gioia, Andrea Konig and Stephanie A. Cockrell *Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, United States*

### Aaron M. Martin

*Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, United States*

## **Acknowledgement**

We would like to thank Dr. James P. McCullough, Jr., the developer of CBASP and Dr. Penberthy's primary mentor, for his guidance and advice on this project. He has been a tireless advocate for those suffering from chronic depression and we are pleased to expand the application of CBASP to the chronically depressed alcohol dependent population.

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**Chapter 11**

© 2013 Favorite and Vance, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Favorite and Vance, licensee InTech. This is a paper distributed under the terms of the Creative Commons

**Psychosocial Intervention for**

**Co-Existing MDD and PTSD**

Additional information is available at the end of the chapter

antidepressant medication and psychosocial interventions [9].

This chapter will focus on the relationship between chronic depression and posttraumatic stress disorder (PTSD). This relationship has become increasingly critical to our understanding of the etiology of early onset chronic depression. For the patient presenting with early onset chronic depression we typically find a developmental profile of maltreatment in the form of emotional abuse or neglect, physical abuse or neglect, and sexual abuse [1]. In addition, interpersonal maltreatment is not the only childhood experience occurring within the context of family and caregiver relationships. Children are also subject to a range of losses, sociopolitical stressors, and environmental disasters that can have a dramatic negative impact on their view of self,

It is generally accepted that early onset depression has a traumatic substrate that is rooted in a child's developmental history [3, 4, 5]. The derailment of a secure attachment and requisite cognitive-affective development produces negative self-other attributions and an enhanced fear response toward unfamiliar or threatening environmental stimuli. Behaviorally, this is manifested in a predominantly avoidant coping strategy, which, in turn, increases the strength of the fear structure [6]. Chronic depressive trajectories stemming from late onset or adult trauma have received less attention in the literature and yet present with frequency among veterans. For instance, a large proportion of veterans diagnosed with PTSD also carry a diagnosis of depression [7,8]. This population has a high treatment refractory rate for both

PTSD and Major Depressive Disorder co-occur at high rates. Gerrity et al [10] found that 86% of depressed VA patients (N=398) reported a history of trauma and severity of PTSD

Todd K. Favorite and Todd Vance

http://dx.doi.org/10.5772/51297

**1. Introduction**

other and their world [2].

**2. Problem statement**

**Rates of co-morbidity**

**Chapter 11**

## **Psychosocial Intervention for Co-Existing MDD and PTSD**

Todd K. Favorite and Todd Vance

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51297

## **1. Introduction**

256 Psychiatric Disorders – New Frontiers in Affective Disorders

211.

S173-S182.

Psychiatry 1960;23 56-62.

[67] Blalock JA, Fouladi RT, Cinciripini PM, Markowitz JC, Klein DN, Rothbaum BO, et al. Cognitive and Behavioral Mediators of Combined Pharmacotherapy and Psychotherapy of Chronic Depression. Cognitive Therapy & Research 2008;32(2) 197-

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> This chapter will focus on the relationship between chronic depression and posttraumatic stress disorder (PTSD). This relationship has become increasingly critical to our understanding of the etiology of early onset chronic depression. For the patient presenting with early onset chronic depression we typically find a developmental profile of maltreatment in the form of emotional abuse or neglect, physical abuse or neglect, and sexual abuse [1]. In addition, interpersonal maltreatment is not the only childhood experience occurring within the context of family and caregiver relationships. Children are also subject to a range of losses, sociopolitical stressors, and environmental disasters that can have a dramatic negative impact on their view of self, other and their world [2].

> It is generally accepted that early onset depression has a traumatic substrate that is rooted in a child's developmental history [3, 4, 5]. The derailment of a secure attachment and requisite cognitive-affective development produces negative self-other attributions and an enhanced fear response toward unfamiliar or threatening environmental stimuli. Behaviorally, this is manifested in a predominantly avoidant coping strategy, which, in turn, increases the strength of the fear structure [6]. Chronic depressive trajectories stemming from late onset or adult trauma have received less attention in the literature and yet present with frequency among veterans. For instance, a large proportion of veterans diagnosed with PTSD also carry a diagnosis of depression [7,8]. This population has a high treatment refractory rate for both antidepressant medication and psychosocial interventions [9].

## **2. Problem statement**

## **Rates of co-morbidity**

PTSD and Major Depressive Disorder co-occur at high rates. Gerrity et al [10] found that 86% of depressed VA patients (N=398) reported a history of trauma and severity of PTSD

symptoms was strongly associated with severity of depressive symptoms. Rates of reported Co-Morbid PTSD and Major Depression vary, but are generally quite high. For example, in a multi-site study (N=677), Campbell et al [11] reported 36% of patients met criteria for PTSD and Major Depression. In a large epidemiological study (N=5877), Kessler et al [12] found that 48% of those studied reported co-occurring PTSD and Major Depression.

Psychosocial Intervention for Co-Existing MDD and PTSD 259

avoidant behavioral patterns make trauma focused treatment problematical. On the other hand, treatment directed only at depressive symptoms may by derailed by the expression of trauma symptoms that serve to undermine the patient's sense of safety and trust within the therapeutic relationship, and negatively impact treatment adherence. What is clinically evident is that when these disorders co-occur, patients report greater symptom distress, and treatment interventions are often highly problematic or refractory [11]. Although first line psychosocial treatments such as, Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) for trauma disorders describe a remission of depressive symptoms when PTSD symptoms are actively addressed, it is argued that some chronically depressed patients find it difficult to engage in exposure therapies that directly activate trauma memories and require adherence to between session imaginal and in vivo exposures. This problem is represented in a 40% drop-out rate for veterans with PTSD who receive only trauma-based treatment, It many of whom had co-occurring

Various authors [19,20,21] have conceptualized "complex PTSD" in which the affected person is exposed to repeated traumas over a number of years. In persons with complex PTSD other problems often develop, including substance use disorders, Major Depression, and Axis II diagnoses. However, in persons with complex PTSD, these co-occurring disorders may present in different ways compared to a patient who presents with any of

A history of Major Depression may predispose one to developing PTSD. As Brady et al noted [22], Major Depression can result from exposure to a trauma and previous Major Depression is a risk factor for developing PTSD. Some researchers have found that early, toxic environmental milieus are correlated with the development of chronic depression [1,3], such as emotional maltreatment (active or passive); physical abuse or neglect; and sexual

An early, abusive environment may lead to the phenomenon of learned helplessness, which primes the person to develop Major Depression [26]. If that same person is then thrust into an environment in which a discreet traumatic event occurs, the person's learned

The clinician should consider both PTSD and Major Depressive Disorder during the initial. In fact, Kessler et al [12] advised considering all traumas, not only the most serious trauma during assessment. When assessing for co-occurring recurrent Major Depression and PTSD, the clinician must assess the patient's history in a way that allows developmental insults to be revealed. Often the patient's early environment was characterized by

disorders, including MDD [18].

these disorders alone [20].

**5. Application area**

abuse.

**4. Etiology of complex PTSD and chronic depression**

helplessness may then be reinforced by this trauma event.

**Implications for assessment and treatment**

According to DSM-IV-TR criteria, specific symptom overlap exists in Major Depression and PTSD [13]. In the DSM-IV-TR, anhedonia, sleep problems, and difficulty concentrating are specific symptoms that are included as criteria for both PTSD and a Major Depressive Episode. Depressed mood, a criterion for Major Depression, in some patients can present as restricted range of affect, a diagnostic criterion for PTSD. Irritability and anger, criteria for PTSD, also co-occur in depressed mood, specifically for children and adolescents. However, clinical experience indicates that anger is frequently present in chronically depressed patients, and this may be especially true in depressed men [14, 15].

PTSD is a chronic often disabling disorder that affects approximately 6.8% of the U.S. population with a lifetime prevalence of 3.6% for males, and 9.7% for females [12]. There is a complex interaction among neurobiological and psychosocial factors that involve the overactivation of the Hypothalamic-Pituitary-Adrenal (H-P-A) axis [16]. The Veterans Health Study [17] showed that 31% of the over 2,000 veterans sampled had experienced significant depressive symptoms with 54% of these depressed veterans evidencing one or more psychiatric co-morbidity, predominantly PTSD. Additionally, 88% had medical co-morbidities such as hypertension, heart disease, diabetes, and degenerative joint disease. The lifetime prevalence of Major Depressive Disorder in patient populations such as combat veterans who have a diagnosis of PTSD has been reported to be as high as 68% [18]. A community co-morbidity sample demonstrated that individuals who have PTSD are 3-5 times more likely to develop Major Depressive Disorder over their lifetime [19].

While the empirical literature has begun to outline the interaction of these two disorders, most of the treatment literature focuses on effective interventions with MDD or PTSD alone. This presents a gap in our understanding about how to clinically address the patients with co-morbid MDD/PTSD. Patients suffering from co-occurring Major Depression and PTSD also experience overlap in subjective symptoms. For example, problems with relationships, lack of intimacy, poor emotion regulation, social isolation, feelings of worthlessness, low self-esteem, helplessness and hopelessness, and cognitive and behavioral rigidity characterize both chronic depression and PTSD.

## **3. Clinical presentation of co-morbid MDD/PTSD**

The distinction that we are treating co-occurring and interactive disorders rather than two separate or sequential disorders makes a significant difference in our approach to treatment. On the one hand the clinician is faced with a singular treatment goal of working through a patient's trauma symptoms when their motivation is poor, and avoidant behavioral patterns make trauma focused treatment problematical. On the other hand, treatment directed only at depressive symptoms may by derailed by the expression of trauma symptoms that serve to undermine the patient's sense of safety and trust within the therapeutic relationship, and negatively impact treatment adherence. What is clinically evident is that when these disorders co-occur, patients report greater symptom distress, and treatment interventions are often highly problematic or refractory [11]. Although first line psychosocial treatments such as, Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) for trauma disorders describe a remission of depressive symptoms when PTSD symptoms are actively addressed, it is argued that some chronically depressed patients find it difficult to engage in exposure therapies that directly activate trauma memories and require adherence to between session imaginal and in vivo exposures. This problem is represented in a 40% drop-out rate for veterans with PTSD who receive only trauma-based treatment, It many of whom had co-occurring disorders, including MDD [18].

## **4. Etiology of complex PTSD and chronic depression**

Various authors [19,20,21] have conceptualized "complex PTSD" in which the affected person is exposed to repeated traumas over a number of years. In persons with complex PTSD other problems often develop, including substance use disorders, Major Depression, and Axis II diagnoses. However, in persons with complex PTSD, these co-occurring disorders may present in different ways compared to a patient who presents with any of these disorders alone [20].

A history of Major Depression may predispose one to developing PTSD. As Brady et al noted [22], Major Depression can result from exposure to a trauma and previous Major Depression is a risk factor for developing PTSD. Some researchers have found that early, toxic environmental milieus are correlated with the development of chronic depression [1,3], such as emotional maltreatment (active or passive); physical abuse or neglect; and sexual abuse.

An early, abusive environment may lead to the phenomenon of learned helplessness, which primes the person to develop Major Depression [26]. If that same person is then thrust into an environment in which a discreet traumatic event occurs, the person's learned helplessness may then be reinforced by this trauma event.

## **5. Application area**

258 Psychiatric Disorders – New Frontiers in Affective Disorders

Disorder over their lifetime [19].

characterize both chronic depression and PTSD.

**3. Clinical presentation of co-morbid MDD/PTSD**

Depression.

symptoms was strongly associated with severity of depressive symptoms. Rates of reported Co-Morbid PTSD and Major Depression vary, but are generally quite high. For example, in a multi-site study (N=677), Campbell et al [11] reported 36% of patients met criteria for PTSD and Major Depression. In a large epidemiological study (N=5877), Kessler et al [12] found that 48% of those studied reported co-occurring PTSD and Major

According to DSM-IV-TR criteria, specific symptom overlap exists in Major Depression and PTSD [13]. In the DSM-IV-TR, anhedonia, sleep problems, and difficulty concentrating are specific symptoms that are included as criteria for both PTSD and a Major Depressive Episode. Depressed mood, a criterion for Major Depression, in some patients can present as restricted range of affect, a diagnostic criterion for PTSD. Irritability and anger, criteria for PTSD, also co-occur in depressed mood, specifically for children and adolescents. However, clinical experience indicates that anger is frequently present in chronically depressed

PTSD is a chronic often disabling disorder that affects approximately 6.8% of the U.S. population with a lifetime prevalence of 3.6% for males, and 9.7% for females [12]. There is a complex interaction among neurobiological and psychosocial factors that involve the overactivation of the Hypothalamic-Pituitary-Adrenal (H-P-A) axis [16]. The Veterans Health Study [17] showed that 31% of the over 2,000 veterans sampled had experienced significant depressive symptoms with 54% of these depressed veterans evidencing one or more psychiatric co-morbidity, predominantly PTSD. Additionally, 88% had medical co-morbidities such as hypertension, heart disease, diabetes, and degenerative joint disease. The lifetime prevalence of Major Depressive Disorder in patient populations such as combat veterans who have a diagnosis of PTSD has been reported to be as high as 68% [18]. A community co-morbidity sample demonstrated that individuals who have PTSD are 3-5 times more likely to develop Major Depressive

While the empirical literature has begun to outline the interaction of these two disorders, most of the treatment literature focuses on effective interventions with MDD or PTSD alone. This presents a gap in our understanding about how to clinically address the patients with co-morbid MDD/PTSD. Patients suffering from co-occurring Major Depression and PTSD also experience overlap in subjective symptoms. For example, problems with relationships, lack of intimacy, poor emotion regulation, social isolation, feelings of worthlessness, low self-esteem, helplessness and hopelessness, and cognitive and behavioral rigidity

The distinction that we are treating co-occurring and interactive disorders rather than two separate or sequential disorders makes a significant difference in our approach to treatment. On the one hand the clinician is faced with a singular treatment goal of working through a patient's trauma symptoms when their motivation is poor, and

patients, and this may be especially true in depressed men [14, 15].

#### **Implications for assessment and treatment**

The clinician should consider both PTSD and Major Depressive Disorder during the initial. In fact, Kessler et al [12] advised considering all traumas, not only the most serious trauma during assessment. When assessing for co-occurring recurrent Major Depression and PTSD, the clinician must assess the patient's history in a way that allows developmental insults to be revealed. Often the patient's early environment was characterized by unpredictability, physical or emotional harm, or being thrust into a care-giving role. Chronic depression is correlated with these various types of trauma in the early, developmental environmental [1, 3]. The Significant Other History is used in CBASP to assess the nature and extent of early psychological insults [3].

Psychosocial Intervention for Co-Existing MDD and PTSD 261

alternative perspective taking and cognitive flexibility. Within this preoperational cognitive frame the individual fails to make perceptual connection between their behavior and the outcome of interpersonal events. Therefore they find it difficult to learn the consequences of particular behaviors that lead to negative outcomes. This lack of *perceived functionality* is hypothesized by McCullough [23] to be a precursor of learned helplessness and hopelessness that is characteristically exhibited by the chronically

McCullough's Cognitive-Behavioral Analysis System of Psychotherapy (CBASP) is the only empirically supported treatment developed specifically for chronic depression [3]. CBASP offers a type of therapy that addresses the relational aspect of chronic depression and PTSD. The therapist using CBASP becomes a safety signal to the patient, allowing the patient to feel safe and then to move toward extinguishing the previously learned response of interpersonal avoidance [23]. Because interpersonal avoidance characterizes the chronically depressed patient as well as the patient with chronic PTSD, treatment with CBASP may pave the way for the patient to feel safe enough to remain in therapy and address the traumas that are related to the unique symptoms of PTSD, such as re-experiencing

CBASP, as an integrative methodology, is fundamentally attuned to traumatic experiences in early development. Systematic exploration of interpersonal situations occurring in the patient's current interactions typically reveal patterns of interpretations and behaviors that reflect aspects of the individual's developmental experiences of maltreatment from caregivers, as well as significant traumatic events that have shaped their self-other perspectives. To the extent that interpretation of interpersonal situations and coping behaviors are maladaptive and rely primarily on avoidant coping strategies, it can be expected that these patterns will resurface in the therapeutic dyad. An initial task for the CBASP therapist is to collaboratively define the significant relationships in the patient's history and develop a casual conclusions stemming from these relationships that have had an adverse impact on the self-other, and world view. This process assists the therapist and the patient to arrive at a pivotal "*Transference Hypothesis*" that becomes the cornerstone for new interpersonal learning by means of the therapist's judicious use of CBASP techniques, such as *"Interpersonal Discrimination"* and *"Disciplined Personal Involvement,"* which are only mentioned here, but can be best understood by referencing

Based on our work with depressed patients who have co-existing PTSD, the use of the *Significant Other History* (SOH) to also record salient traumatic experiences, has provided therapeutic utility for assessment and intervention. Obtaining a record of the significant people in the patient's formative history as well as the linkage to specific traumatic experiences allows the therapist to respond directly to expression of trauma symptoms as

**7. Cognitive behavioral analysis system for psychotherapy**

depressed patients.

symptoms.

McCullough [3,23].

they surface in treatment.

Becoming a source of perceived safety is one of the first tasks of the clinician treating a patient with PTSD and chronic Major Depression. The principle of "safety first" has long been recognized for its importance in the treatment of PTSD [20]. What may be less widely recognized is that the same principle is operative with the chronically depressed patient. In order for learning to take place, the therapist must first become an inhibitor or "safety signal" for the patient [23]. Becoming a source of safety and helping the patient differentiate between the therapist and toxic others, and between past toxic environments and the therapeutic environment is critical in successful treatment of depressed persons who have experienced early trauma.

Regarding treatment of co-occurring chronic depression and PTSD, the question arises as to which disorder to treat first. Foa and Rothbaum [6] stated that in cases of severe depression, depression should be treated first, as severe depression is likely to limit a patient's ability to benefit from cognitive-behavioral therapy for PTSD. Others have argued that addressing the relational aspect of trauma is a key element of successful treatment for PTSD [20].

## **6. Theoretical considerations**

Learning theory posits that learning theory, the early abusive environment that often characterizes the developmental history of the chronically depressed patient establishes both Pavlovian and Skinnerian learning. Typically, the patient who has a history of abuse associates that abuse with specific persons and then generalizes his or her fear response to other persons, so that all or nearly all people elicit a Pavlovian fear response. Additionally, the patient with a history of early trauma demonstrates Skinnerian learning by avoiding people in order to decrease the fear response (negative reinforcement). While this strategy of interpersonal avoidance decreases anxiety, social isolation serves to maintain chronic depression [23].

For persons who have a history of trauma in the early environment, other traumatic events (e.g., combat, rape) reinforce previous learning. Specifically, subsequent traumas can heighten the fear response and further generalize interpersonal avoidance. Therefore, traumas from which distinct PTSD symptoms develop reinforce what was previously learned in the toxic early environment.

In addition, McCullough [3] also references Piaget's theory of cognitive development in his formulation of the chronic depressive patient as having a predominant reliance on preoperational or concrete thought processes, which are characterized by precasual, prelogical thinking that precludes the use of abstractions and interpersonal empathy. As such the chronic depressive patient is stuck in a pattern of avoidant behaviors that limit alternative perspective taking and cognitive flexibility. Within this preoperational cognitive frame the individual fails to make perceptual connection between their behavior and the outcome of interpersonal events. Therefore they find it difficult to learn the consequences of particular behaviors that lead to negative outcomes. This lack of *perceived functionality* is hypothesized by McCullough [23] to be a precursor of learned helplessness and hopelessness that is characteristically exhibited by the chronically depressed patients.

## **7. Cognitive behavioral analysis system for psychotherapy**

260 Psychiatric Disorders – New Frontiers in Affective Disorders

experienced early trauma.

treatment for PTSD [20].

depression [23].

**6. Theoretical considerations**

learned in the toxic early environment.

assess the nature and extent of early psychological insults [3].

unpredictability, physical or emotional harm, or being thrust into a care-giving role. Chronic depression is correlated with these various types of trauma in the early, developmental environmental [1, 3]. The Significant Other History is used in CBASP to

Becoming a source of perceived safety is one of the first tasks of the clinician treating a patient with PTSD and chronic Major Depression. The principle of "safety first" has long been recognized for its importance in the treatment of PTSD [20]. What may be less widely recognized is that the same principle is operative with the chronically depressed patient. In order for learning to take place, the therapist must first become an inhibitor or "safety signal" for the patient [23]. Becoming a source of safety and helping the patient differentiate between the therapist and toxic others, and between past toxic environments and the therapeutic environment is critical in successful treatment of depressed persons who have

Regarding treatment of co-occurring chronic depression and PTSD, the question arises as to which disorder to treat first. Foa and Rothbaum [6] stated that in cases of severe depression, depression should be treated first, as severe depression is likely to limit a patient's ability to benefit from cognitive-behavioral therapy for PTSD. Others have argued that addressing the relational aspect of trauma is a key element of successful

Learning theory posits that learning theory, the early abusive environment that often characterizes the developmental history of the chronically depressed patient establishes both Pavlovian and Skinnerian learning. Typically, the patient who has a history of abuse associates that abuse with specific persons and then generalizes his or her fear response to other persons, so that all or nearly all people elicit a Pavlovian fear response. Additionally, the patient with a history of early trauma demonstrates Skinnerian learning by avoiding people in order to decrease the fear response (negative reinforcement). While this strategy of interpersonal avoidance decreases anxiety, social isolation serves to maintain chronic

For persons who have a history of trauma in the early environment, other traumatic events (e.g., combat, rape) reinforce previous learning. Specifically, subsequent traumas can heighten the fear response and further generalize interpersonal avoidance. Therefore, traumas from which distinct PTSD symptoms develop reinforce what was previously

In addition, McCullough [3] also references Piaget's theory of cognitive development in his formulation of the chronic depressive patient as having a predominant reliance on preoperational or concrete thought processes, which are characterized by precasual, prelogical thinking that precludes the use of abstractions and interpersonal empathy. As such the chronic depressive patient is stuck in a pattern of avoidant behaviors that limit McCullough's Cognitive-Behavioral Analysis System of Psychotherapy (CBASP) is the only empirically supported treatment developed specifically for chronic depression [3]. CBASP offers a type of therapy that addresses the relational aspect of chronic depression and PTSD. The therapist using CBASP becomes a safety signal to the patient, allowing the patient to feel safe and then to move toward extinguishing the previously learned response of interpersonal avoidance [23]. Because interpersonal avoidance characterizes the chronically depressed patient as well as the patient with chronic PTSD, treatment with CBASP may pave the way for the patient to feel safe enough to remain in therapy and address the traumas that are related to the unique symptoms of PTSD, such as re-experiencing symptoms.

CBASP, as an integrative methodology, is fundamentally attuned to traumatic experiences in early development. Systematic exploration of interpersonal situations occurring in the patient's current interactions typically reveal patterns of interpretations and behaviors that reflect aspects of the individual's developmental experiences of maltreatment from caregivers, as well as significant traumatic events that have shaped their self-other perspectives. To the extent that interpretation of interpersonal situations and coping behaviors are maladaptive and rely primarily on avoidant coping strategies, it can be expected that these patterns will resurface in the therapeutic dyad. An initial task for the CBASP therapist is to collaboratively define the significant relationships in the patient's history and develop a casual conclusions stemming from these relationships that have had an adverse impact on the self-other, and world view. This process assists the therapist and the patient to arrive at a pivotal "*Transference Hypothesis*" that becomes the cornerstone for new interpersonal learning by means of the therapist's judicious use of CBASP techniques, such as *"Interpersonal Discrimination"* and *"Disciplined Personal Involvement,"* which are only mentioned here, but can be best understood by referencing McCullough [3,23].

Based on our work with depressed patients who have co-existing PTSD, the use of the *Significant Other History* (SOH) to also record salient traumatic experiences, has provided therapeutic utility for assessment and intervention. Obtaining a record of the significant people in the patient's formative history as well as the linkage to specific traumatic experiences allows the therapist to respond directly to expression of trauma symptoms as they surface in treatment.

## **8. Significant traumatic events**

Significant traumatic events (STE) are frequently parallel the patient's recounting of their experiences leading to the casual analysis stemming from their Significant Other History. In conducting the STE the therapist collaboratively explores the primary thematic domain within the following areas: *Safety, Trust, Control, Closeness, and Self-esteem*. These thematic domains come from research conducted by Resick, et al. [30] that demonstrated that these overlapping interpersonal themes account for the predominant sources of psychological distress for traumatized patients. These connect to both intrapsychic and interpersonal changes for patients with PTSD. This adaptation to the SOH can assist therapists in understanding the impact of the patient's trauma on their cognitive-affective attributions and relational environment. In other words, what does the patient do on a cognitive, emotional, and interpersonal level when this traumatic theme is re-experienced. This is often expressed during sessions in the form of trauma related symptoms, but may also reflect an interpersonal "pull" with the therapist that is maladaptive due to distorted interpretations of the interpersonal environment.

Psychosocial Intervention for Co-Existing MDD and PTSD 263

Participant's narrative responses on weekly Coping Questionnaires were analyzed using the Standard Cognitive Developmental Classification System (SCDCS) that was developed by Ivey [26] to score patient narratives across cognitive domains, and was used to ascertain

Note: Schematic shows CBASP procedures used to treat depression (left), as well as the parallel adaptations at each

Both the measure for depression (BDI-II*), t*(11)=6.28*, p*=.00 and for PTSD (PCL-C), *t*(11)=6.99*, p*=.01 evidenced a significant reduction at the end of treatment. The results can be seen in figure 2. There was a greater reduction in the mean BDI-II score than for PCL-C scores. Mean depression fell with mild depressive range. Mean scores on the PCL-C were higher overall and showed less reduction compared to the BDI-II. There was a significant reduction, however, even though mean PCL-C scores continued to show symptom

We were particularly interested in the Hypothesized change from concrete/preoperational cognitive processes to formal operational cognitive processes over the course of CBASP

shifts in participants' predominant cognitive orientation.

stage to accommodate PTSD symptoms (right).

**10. Results**

expression for PTSD.

**Figure 1.** Adaptations to CBASP for Co-existing PTSD and MDD

During the treatment process, the therapist working with the co-morbid patient needs to attend to both interpersonal *hotspots* as well as trauma *hotspot*s, which are typically addressed at the conclusion of the Situational Analysis. These modifications parallel and interact with the standard CBASP methods and require the therapist's mapping of trauma events along the depression timeline provided by the patient, and the addition of the Significant Trauma Event description and causal conclusion in reference to the Significant Other History. Additionally, these adaptations are reflected in the Interpersonal Discrimination Exercise (IDE) in which the patient is taught to differentiate internal arousal signals from environmental stimuli. These adaptations are reflected schematically in Figure 1.

## **9. Research course**

#### **Methods**

In a sample of 12 male veterans, aged 48-65, diagnosed with chronic depression and PTSD, CBASP was delivered as an individual psychotherapy over the course of 24 sessions. All sessions were conducted by three clinical psychologists trained in CBASP as well as the added interventions for PTSD symptoms. In each of the cases the veterans were on psychotropic medications and had dropped out of trauma focused psychotherapy at least once prior to engaging in CBASP. Veterans with psychosis, bipolar disorder and/or current substance abuse were excluded from the sample. The adaptations, outlined above were implemented to address co-existing PTSD symptoms and each of the therapist were trained in the application of these methods.

Pretreatment measures were administered to establish baseline scores on BDI-II and PCL-C. At the end of 24 sessions of CBASP the BDI-II and PCL-C were administered again and the scores were analyzed by a t-test to determine the level of change for each measure. Participant's narrative responses on weekly Coping Questionnaires were analyzed using the Standard Cognitive Developmental Classification System (SCDCS) that was developed by Ivey [26] to score patient narratives across cognitive domains, and was used to ascertain shifts in participants' predominant cognitive orientation.

Note: Schematic shows CBASP procedures used to treat depression (left), as well as the parallel adaptations at each stage to accommodate PTSD symptoms (right).

**Figure 1.** Adaptations to CBASP for Co-existing PTSD and MDD

## **10. Results**

262 Psychiatric Disorders – New Frontiers in Affective Disorders

Significant traumatic events (STE) are frequently parallel the patient's recounting of their experiences leading to the casual analysis stemming from their Significant Other History. In conducting the STE the therapist collaboratively explores the primary thematic domain within the following areas: *Safety, Trust, Control, Closeness, and Self-esteem*. These thematic domains come from research conducted by Resick, et al. [30] that demonstrated that these overlapping interpersonal themes account for the predominant sources of psychological distress for traumatized patients. These connect to both intrapsychic and interpersonal changes for patients with PTSD. This adaptation to the SOH can assist therapists in understanding the impact of the patient's trauma on their cognitive-affective attributions and relational environment. In other words, what does the patient do on a cognitive, emotional, and interpersonal level when this traumatic theme is re-experienced. This is often expressed during sessions in the form of trauma related symptoms, but may also reflect an interpersonal "pull" with the therapist that is maladaptive due to distorted interpretations

During the treatment process, the therapist working with the co-morbid patient needs to attend to both interpersonal *hotspots* as well as trauma *hotspot*s, which are typically addressed at the conclusion of the Situational Analysis. These modifications parallel and interact with the standard CBASP methods and require the therapist's mapping of trauma events along the depression timeline provided by the patient, and the addition of the Significant Trauma Event description and causal conclusion in reference to the Significant Other History. Additionally, these adaptations are reflected in the Interpersonal Discrimination Exercise (IDE) in which the patient is taught to differentiate internal arousal signals from environmental stimuli. These adaptations are reflected schematically in Figure

In a sample of 12 male veterans, aged 48-65, diagnosed with chronic depression and PTSD, CBASP was delivered as an individual psychotherapy over the course of 24 sessions. All sessions were conducted by three clinical psychologists trained in CBASP as well as the added interventions for PTSD symptoms. In each of the cases the veterans were on psychotropic medications and had dropped out of trauma focused psychotherapy at least once prior to engaging in CBASP. Veterans with psychosis, bipolar disorder and/or current substance abuse were excluded from the sample. The adaptations, outlined above were implemented to address co-existing PTSD symptoms and each of the

Pretreatment measures were administered to establish baseline scores on BDI-II and PCL-C. At the end of 24 sessions of CBASP the BDI-II and PCL-C were administered again and the scores were analyzed by a t-test to determine the level of change for each measure.

therapist were trained in the application of these methods.

**8. Significant traumatic events**

of the interpersonal environment.

1.

**Methods**

**9. Research course**

Both the measure for depression (BDI-II*), t*(11)=6.28*, p*=.00 and for PTSD (PCL-C), *t*(11)=6.99*, p*=.01 evidenced a significant reduction at the end of treatment. The results can be seen in figure 2. There was a greater reduction in the mean BDI-II score than for PCL-C scores. Mean depression fell with mild depressive range. Mean scores on the PCL-C were higher overall and showed less reduction compared to the BDI-II. There was a significant reduction, however, even though mean PCL-C scores continued to show symptom expression for PTSD.

We were particularly interested in the Hypothesized change from concrete/preoperational cognitive processes to formal operational cognitive processes over the course of CBASP

treatment. As expected, there was no significant change in sensorimotor or dialectic/systemic cognitive orientations at the end of treatment. However, there was a significant reduction in the frequency ratings for preoperational cognitions*, t(*11)=8.20*,p=.00* . Additionally, there was a moderate increase in the production of formal operational cognitions at the end of CBASP treatment, *t(*11)=2.08, p=.06 . These findings can be seen in figure 3.

Psychosocial Intervention for Co-Existing MDD and PTSD 265

**11. Limitations and future research**

**12. Summary and conclusions**

treatments outcomes.

**Author details**

Todd K. Favorite

traumatic events and their current interpersonal life.

model.

This study was conducted as a preliminary investigation of the feasibility of adaptation to the CBASP method to accommodate co-morbid PTSD when working with chronically depressed patients. This was a small, homogenous sample of middle aged veterans who were not able to utilize first line trauma-focused treatments and our results may not generalize to other age, gender or cultural groups. Although there were significant results in terms of symptom reduction, the effect size is small. Future controlled research is needed on a larger, heterogeneous sample to see if these results can be replicated. It would be essential to compare co-morbid groups who receive CBASP and CBASP that has been adapted for co-existing PTSD/MDD to determine added benefits of the adapted

In this chapter, we proposed the use of an adapted CBASP model treatment of chronic depression with co existing posttraumatic stress disorder. Given the high rate of cooccurrance and significant symptomatic interaction we propose that with specific adaptations CBASP provides an active therapeutic environment that can accommodate the patient's traumatic memories and link them to interpersonal avoidance patterns that exacerbate depressive mood. The techniques of Situational Analysis and Interpersonal Discrimination Exercises assist the patient to make clearer distinctions between historical

The effectiveness of CBASP in the treatment of co-morbid PTSD and chronic MDD is being studied in veteran populations at several VA Healthcare Systems in the United States due to the significant number of treatment refractory cases that require maintenance mental health care. There are also a high ratio of young veterans returning from multiple deployments in Iraq and Afghanistan that are diagnosed with chronic forms of depression and PTSD [8]. The increased burden of delivery of effective mental health services is by no means isolated to veteran populations. Natural disasters, interpersonal violence, and increased familial stressors appear to be omnipresent over the past several years placing children and adults at risk for the chronic psychiatric conditions such as MDD and PTSD. Finding efficacious methods for early intervention and improving our service delivery system are becoming more important than ever. The potential benefits of a transdiagnostic perspective in the adaptation of CBASP to patients with chronic depressive co-morbidities, potentiates a reduction in the rate of refractory

*University of Michigan Dept. of Psychiatry, Ann Arbor VA Healthcare System, USA*

**Figure 2.** CBASP 24 individual sessions (N=12)

Note: Standard Cognitive Developmental Classification System (SCDCS)

**Figure 3.** CBASP - Cognitive-Affective Change 24 sessions (N=12)

## **11. Limitations and future research**

264 Psychiatric Disorders – New Frontiers in Affective Disorders

**Figure 2.** CBASP 24 individual sessions (N=12)

0

10

20

30

40

50

60

70

Note: Standard Cognitive Developmental Classification System (SCDCS) **Figure 3.** CBASP - Cognitive-Affective Change 24 sessions (N=12)

Dialectic Formal Concrete Sensorim

figure 3.

treatment. As expected, there was no significant change in sensorimotor or dialectic/systemic cognitive orientations at the end of treatment. However, there was a significant reduction in the frequency ratings for preoperational cognitions*, t(*11)=8.20*,p=.00* . Additionally, there was a moderate increase in the production of formal operational cognitions at the end of CBASP treatment, *t(*11)=2.08, p=.06 . These findings can be seen in

> BDI-II PCL-C

Pre SCDCS Post SCDCS

Pre Post

This study was conducted as a preliminary investigation of the feasibility of adaptation to the CBASP method to accommodate co-morbid PTSD when working with chronically depressed patients. This was a small, homogenous sample of middle aged veterans who were not able to utilize first line trauma-focused treatments and our results may not generalize to other age, gender or cultural groups. Although there were significant results in terms of symptom reduction, the effect size is small. Future controlled research is needed on a larger, heterogeneous sample to see if these results can be replicated. It would be essential to compare co-morbid groups who receive CBASP and CBASP that has been adapted for co-existing PTSD/MDD to determine added benefits of the adapted model.

## **12. Summary and conclusions**

In this chapter, we proposed the use of an adapted CBASP model treatment of chronic depression with co existing posttraumatic stress disorder. Given the high rate of cooccurrance and significant symptomatic interaction we propose that with specific adaptations CBASP provides an active therapeutic environment that can accommodate the patient's traumatic memories and link them to interpersonal avoidance patterns that exacerbate depressive mood. The techniques of Situational Analysis and Interpersonal Discrimination Exercises assist the patient to make clearer distinctions between historical traumatic events and their current interpersonal life.

The effectiveness of CBASP in the treatment of co-morbid PTSD and chronic MDD is being studied in veteran populations at several VA Healthcare Systems in the United States due to the significant number of treatment refractory cases that require maintenance mental health care. There are also a high ratio of young veterans returning from multiple deployments in Iraq and Afghanistan that are diagnosed with chronic forms of depression and PTSD [8]. The increased burden of delivery of effective mental health services is by no means isolated to veteran populations. Natural disasters, interpersonal violence, and increased familial stressors appear to be omnipresent over the past several years placing children and adults at risk for the chronic psychiatric conditions such as MDD and PTSD. Finding efficacious methods for early intervention and improving our service delivery system are becoming more important than ever. The potential benefits of a transdiagnostic perspective in the adaptation of CBASP to patients with chronic depressive co-morbidities, potentiates a reduction in the rate of refractory treatments outcomes.

## **Author details**

Todd K. Favorite *University of Michigan Dept. of Psychiatry, Ann Arbor VA Healthcare System, USA*

#### Todd Vance

*University of Virginia Dept. of Psychiatry, Salem VA Healthcare System, USA*

## **13. References**

[1] Cicchetti,D., & Barnett, D. (1991). Attachment organization in maltreatment preschoolers. *Developmental and Psychopathology*, 3, 397-411.

Psychosocial Intervention for Co-Existing MDD and PTSD 267

[12] Kessler, R.C, Sonnega, A., Bromet, E., Hughes, M., Nelson,C.B.(1995). Posttraumatic Stress Disorder in the National Comorbidity Survey, *Arch Gen Psychiatry.* 52(12):1048-

[13] American Psychiatric Association (2000) *Diagnostic and statistical manual of mental disorders, fourth edition, text revision.* Washington, DC, American Psychiatric

[14] Cochran, S.V., Rabinowitz, F.E. (2003) Gender-sensitive recommendations for assessment and treatment of depression in men. *Professional Psychology: Research and*

[15] Magovcevic, M., Addis, M.E. (2008) The masculine depression scale: Development and

[16] Yehuda, R., Giller, E.L., Southwick, S.M., Lowy, M.T., Mason, J.W. (1991). Hypothalamic-pituitary-adrenal dysfunction in posttraumatic stress disorder. *Biol*

[17] Rauch, S., Favorite, T., Giardino, N., Porcari, C., Martis, B., Liberzon, I. (2009). Relationship between anxiety, depression, and health satisfaction among veterans with

[18] Briere, J. (2002) Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J.E.B. Meyers, L. Berliner, J. Briere, C.T. Hendrix, T. Reid, & C. Jenny (Eds.) (2002) *The APSAC handbook on child maltreatment, 2nd*

[19] Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005a). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. *Archives of General Psychiatry, 62(6)*:

[21] Resick, P.A., Nishith, P., Griffin, M.G. (2003) How well does cognitive-behavioral therapy treat symptoms of complex PTSD?  *Journal of Clinical Psychiatry, 61*

[23] McCullough, J.P. Jr. (2008) The cognitive behavioral analysis system of psychotherapy:

[24] McCullough, J.P., Jr. (2006). Treating chronic depression with disciplined personal

[25] Monson, C.M., Schnurr, P.P., Resick, P.A., Friedman, M.J., Young-Xu, Y., & Stevens, S.P. (2006) Cognitive Processing Therapy for veterans with military-related Posttraumatic

A value-added strategy for chronic depression. *Psychiatric Times*, 25 (10),

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[2] Bonanno, G. A., Brewin, C. R., Kaniasty, K. & La Greca, A. M, (2010). Weighing the costs of disaster: Consequences, risks, and resilience in individuals, families, and

[3] McCullough, J.P. Jr. (2000) *Treatment for Chronic Depression: Cognitive Behavioral Analysis*

[4] Nemeroff, C.B., Heim, C.M., Thase, M.E., Klein, D.N., Rush, A.J., Schatzberg, A.F., Ninan, P.T., McCullough, J.P., Weiss, P., Dunner, D.L., Rothbaum, B.O., Kornstein, S.G., Keitner, G., & Keller, M.B. (2003). Differential responses to psychotherapy versus pharmacotherapy in the treatment of patients with chronic forms of major depression and childhood trauma. Proceedings of the National Academy of Sciences, 100, 14293-

[5] Wiersma, J.E., Van Schaik, DJF, van Oppen, P., McCullough, Jr., J.P, Schoever, R.A., Dekker, J.J. et al. (2008). Treatment of chronically depressed patients: A multisite randomized controlled trial testing the effectiveness of CBASP for chronic depressions

[6] Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-Behavioral

[7] Valenstein M, Austin K, Khanuja K, McCarthy JF, Owen RE, Blow FC (2004). Specialty Care for Veterans with Depression in the VHA: 2002 National Registry for Depression (NARDEP) Report. Serious Mental Illness Treatment Research and

[8] Hoge, C.W., Auchterlonie, J.L., Milliken, C.S.(2006). Mental health problems, use of mental health services, and attrition from military service after returning from

[9] Chermack, S.T., Zivin, K., Valenstein M., Ilgen ,M., Austin K.L., Wryobeck J., Blow, F.C. (2008). The Prevalence and Predictors of Mental Health Treatment Services in a

[10] Gerrity, M.S., Corson, K., & Dobscha, S.K. (2007) Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms. *Journal of General*

[11] Campbell, D.G., Felker, B.L., Liu, C., Yano, E.M., Kirchner, J.E., Chan, D., Rubenstein, L.V., & Chaney, E.F. (2007). Prevalence of depression-PTSD comorbidity: Implications for clinical practice guidelines and primary care-based interventions. *Journal of General*

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therapy for PTSD, New York: Guilford Press.

deployment to iraq or afghanistan. *JAMA*, 295, 9, 1023-1032.

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	- [26] Ivey, A.E., Rigazio-DiGilio, S.A. (1991). The standard cognitive-developmental classification system. In A.E. Ivey, *Developmental strategies for helpers: Individual, family and network interventions* (pp.301-306). Pacific Grove, CA: Brooks/Cole.

**Chapter 12**

© 2013 Favorite and Conrad, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Favorite and Conrad, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Group Intervention**

Todd K. Favorite and Kayla J. Conrad

http://dx.doi.org/10.5772/51226

**1. Introduction**

Additional information is available at the end of the chapter

**for Chronic Depression and PTSD**

In this chapter, we propose the use of the Cognitive Behavioral Analysis System for Psychotherapy as a group modality in the treatment of co-morbid chronic depression and posttraumatic stress disorder. CBASP has been found to be effective for the treatment of chronic depression and the functional impairments often associated with this disorder (i.e., pessimism, sense of failure, lack of satisfaction, guilt, sense of punishment, self-hate, selfaccusations, irritability, social withdrawal, indecisiveness, work inhibition, sleep disturbance, loss of appetite, weight loss, somatic preoccupation, and loss of libido, etc.). [1,2,3,4,5,6]. Although large studies such as Klien et al. [6,7,8] have focused on individual treatment for which it was developed, CBASP has been shown to be feasible as a group treatment in U.S., Canada, and in Germany. Clinical application of group CBASP in the U.S., thus far, has focused on combat veterans, who have been shown to be particularly vulnerable to Posttraumatic stress disorder (PTSD) and chronic depression [9]. We will outline the nature of these often chronic, co-existing symptoms and then present the

The rationale for developing a group protocol for CBASP is based on a number of variables. For example, group involvement for chronically depressed patient reduces social isolation which limits opportunities to experience social interaction and new learning. In addition, interactions among patients with similar symptoms and experiences may create opportunities for validation, belonging, and the generation of hope that may not be as strong in individual psychotherapy. Group interactions also provide an in-vivo learning environment that maximizes interpersonal exposure and enhances social skill development. We have found that peer modeling has a positive impact on attendance as well as increased compliance with assignments and in session participation. Finally, within the VA Healthcare

rationale. For group CBASP interventions with co-morbid population.

## **Group Intervention for Chronic Depression and PTSD**

Todd K. Favorite and Kayla J. Conrad

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51226

## **1. Introduction**

268 Psychiatric Disorders – New Frontiers in Affective Disorders

[26] Ivey, A.E., Rigazio-DiGilio, S.A. (1991). The standard cognitive-developmental classification system. In A.E. Ivey, *Developmental strategies for helpers: Individual, family*

*and network interventions* (pp.301-306). Pacific Grove, CA: Brooks/Cole.

In this chapter, we propose the use of the Cognitive Behavioral Analysis System for Psychotherapy as a group modality in the treatment of co-morbid chronic depression and posttraumatic stress disorder. CBASP has been found to be effective for the treatment of chronic depression and the functional impairments often associated with this disorder (i.e., pessimism, sense of failure, lack of satisfaction, guilt, sense of punishment, self-hate, selfaccusations, irritability, social withdrawal, indecisiveness, work inhibition, sleep disturbance, loss of appetite, weight loss, somatic preoccupation, and loss of libido, etc.). [1,2,3,4,5,6]. Although large studies such as Klien et al. [6,7,8] have focused on individual treatment for which it was developed, CBASP has been shown to be feasible as a group treatment in U.S., Canada, and in Germany. Clinical application of group CBASP in the U.S., thus far, has focused on combat veterans, who have been shown to be particularly vulnerable to Posttraumatic stress disorder (PTSD) and chronic depression [9]. We will outline the nature of these often chronic, co-existing symptoms and then present the rationale. For group CBASP interventions with co-morbid population.

The rationale for developing a group protocol for CBASP is based on a number of variables. For example, group involvement for chronically depressed patient reduces social isolation which limits opportunities to experience social interaction and new learning. In addition, interactions among patients with similar symptoms and experiences may create opportunities for validation, belonging, and the generation of hope that may not be as strong in individual psychotherapy. Group interactions also provide an in-vivo learning environment that maximizes interpersonal exposure and enhances social skill development. We have found that peer modeling has a positive impact on attendance as well as increased compliance with assignments and in session participation. Finally, within the VA Healthcare

© 2013 Favorite and Conrad, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Favorite and Conrad, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

System where we have treated combat veterans, the provision of. Group psychotherapy allows greater access to treatment for growing numbers of veterans seeking help.

Group Intervention for Chronic Depression and PTSD 271

The foundational derailment of secure attachments and normative cognitive-affective development produces negative self-other attributions and an enhanced fear response toward unfamiliar or threatening environmental stimuli. Behaviorally, this is manifested in a predominantly avoidant coping strategy, which, in turn, increases the strength of the fear structure [21]. Chronic depressive trajectories of late onset or adult traumatic events have received less attention in the literature and yet represent approximately 8% of the chronically depressed adult population. For instance, over 50% of military veterans diagnosed with PTSD carry a diagnosis of depression lasting for two or more years with no evidence of depressive disorder prior to their military duty [22,9]. This co-morbid PTSD/chronically depressed population has a high treatment refractory rate for both

PTSD is a chronic often disabling disorder that affects approximately 6.8% of the U.S. population with a lifetime prevalence of 3.6% for males, and 9.7% for females [18]. In the Veterans Health Study [22] it was shown that 31% of the over 2,000 veterans sampled, had experienced significant depressive symptoms with 54% of these depressed veterans evidencing one or more psychiatric co-morbidity, predominantly PTSD. Additionally, 88% had medical co-morbidities such as hypertension, heart disease, diabetes, and degenerative joint disease. The lifetime prevalence of Major Depressive Disorder in patient populations such as combat veterans who have a diagnosis of PTSD has been reported to be as high as 68%[24]. Large community sample co-morbidity research has demonstrated that individuals who have PTSD are 3-5 times more likely to develop Major Depressive Disorder over their lifetime [18]. There is a complex interaction among neurobiological and psychosocial factors that involve the overactivation of the hypothalamic-pituitary-adrenal axis [25]. While the empirical literature has begun to outline the interaction of these two disorders, most of the treatment literature focuses on effective interventions with either MDD or PTSD alone. This presents a gap in our understanding about how to treat patients with co-morbid chronic

That we are treating interacting disorders rather than two separate or sequential disorders complicates both treatment and the evidence base of the treatment modality, which is based on data from single diagnosis samples. Regarding the complexity of treatment, the clinician has, in the case of PTSD, the treatment goal of reducing patients' trauma symptoms when their motivation is poor and their coping strategies (i.e., avoidance, substance abuse, anger) are maladaptive and entrenched. When treatment for chronic depression is linked to that of PTSD, treatment can be compromised and derailed by the expression of trauma symptoms that may undermine the patient's sense of safety and trust

As clinicians working in the Veterans Administration HealthCare System, we have noted that when these disorders co-occur, patients report greater symptom distress, treatment interventions can become highly problematic, and/or patients become treatment refractory [23]. Although first-line PTSD treatments, such as Prolonged Exposure Therapy (PE) and

antidepressant medication and psychosocial interventions [23].

depression/PTSD.

and reduce treatment adherence.

The rationale for developing a group format for this established, evidence-based treatment for chronic depression stems, in part, from the need for greater access to treatment for increasingly numbers of veterans returning from combat with PTSD and MDD symptoms. Group methodologies have been shown to be very effective in working with homogeneous populations, both in terms of cultural characteristics and symptom presentation [10]. In fact, veterans share a distinct military culture and as such report a "bond" and increased sense of cohesion with the experiences of each other than they do with most civilians [11]. Utilizing this commonality to enhance a sense of social connection and support as well as counteract patterns of interpersonal avoidance may improve treatment outcomes for this frequently treatment resistant population.

In a meta-analysis of 48 group therapy studies of depression treatment, McDermut, Miller, Brown [12] found that patients treated in group modalities reported a significant reduction in depressive symptoms when compared to 85% of untreated patients. In studies exploring the benefits of culturally relevant intervention strategies, Ginder and Smith [13] found that when group interventions with homogeneous cultural groups, they were four times more effective than groups that were culturally nonspecific.

## **2. Problem statement**

## **2.1. Co-morbid MDD and PTSD**