Question 1

What is the best way to prevent the recurrence of a depressive episode?

Steven Hollon · Accepted Answer

There are two established preventive methods. Cognitive therapy and perhaps the closely related behavioral activation cut risk for relapse by more than half (Hollon 2005; Dobson 2008). People who get better on antidepressant medications are well advised to stay on medications. That appears to be about as preventive as prior exposure to cognitive therapy (Cuijpers 2013).

Question 2

Why do some patients not benefit from CBT?

Steven Hollon · Accepted Answer

Not everyone will respond to every different treatment even if it is adequately implemented. DeRubeis and colleagues found that just under a third of patients with more severe depression would have done better on antidepressant medications than on CBT whereas just under a third of the patients in that trial would have shown the opposite pattern (DeRubeis 2014). What he and others are trying to develop precision treatment rules that can predict in advance who will do better on which treatment. Getting the optimal treatment to each patient can make mental health delivery more efficient even before we improve our treatments and being able to predict what treatment is best for a given patient will help us figure out how to make our treatments more effective.

Question 3

What is 'treatment resistant' depression?

Steven Hollon · Accepted Answer

That is an episode of depression that has not responded to two more adequate courses of treatment. Some depressions are harder to treat than others but there are several different types of psychotherapy and at least four major classes of antidepressants each with several different specific medications and several different types of somatic treatments (ECT may be the strongest) so there are lots of options to try.

Question 4

Does antidepressant medication induce neuronal growth in the hippocampus?

Steven Hollon · Accepted Answer

The evidence seems to indicate that it does. Antidepressant medications stimulate brain derived neurotrophic factor (BDNF) which seems to promote growth in synaptic connections and quite possibly neuronal growth in the hippocampus (Duman 1999; Duman & Monteggia, 2006 ). Whether that is unique to antidepressant medications or a more general phenomenon produced by any intervention (for example exercise) that relieves depression remains unclear.

Question 5

Under what circumstances should psychotherapists (not doctors) recommend to clients that they see their GP for anti-depressant medication?

Steven Hollon · Accepted Answer

It always fair game to suggest that someone talk with their physician about whether medications might be appropriate but if someone wanted to consideration medications I would encourage them to see a psychiatrist not a general practitioner. The number of patients treated with antidepressants has skyrocketed since the SSRIs were first introduced back in the early 1990's and the vast majority of prescriptions nowadays are written by general practitioners. Most psychiatrists know to dose to remission (becomes fully well). That means raising dosage until the patient either remits or reaches their maximally tolerated dose and if they do without remitting then augmenting or combining or switching medications. General practitioners medicate too many patients (only about half of the patients medicated show a "true drug" response over and above placebo) and under medicate the people who ought to be on medications and would do better if they were seeing a psychiatrist.

Question 6

I've had many clients present stating that they don't want CBT. It does seem that CBT has fallen out of favour with some therapists and clients. What do you think is going on here?

Steven Hollon · Accepted Answer

I suspect that folks are simply misinformed as to what it actually involves. Not everyone responds to CBT but it is at least as efficacious as any other type of intervention and has a long-term enduring effect that simply has not been established for other interventions (behavior activation may as well).

Question 7

When people present with depression that includes sleep disturbance, what do you target first - e.g., mood or sleep?

Steven Hollon · Accepted Answer

I work on both. Sleep typically responds fairly rapidly to simple sleep hygiene strategies (within a couple of days) whereas mood typically takes a couple of weeks to clear but I would start on both in the initial sessions. As sleep improves that usually helps to improve mood.

Question 8

How much does the therapeutic relationship matter in CBT?

Steven Hollon · Accepted Answer

The therapeutic relationship matters in CBT just as it does in all types of therapy but in a somewhat different way than in most other approaches. Robert DeRubeis at the University of Pennsylvania tracked therapist behaviors and the quality of the working alliance across the course of treatment and found that adherence to specific cognitive and behavioral skills in early sessions drove rapid symptom change that in turn drove the rated quality of the working alliance (Feeley DeRubeis, & Gelfand, 1999). In brief, help patients improve quickly and you enhance the quality of the working alliance. When working with clients we go right after symptom change as rapidly as possible (not faster than the client wants to go but as rapidly as they are willing to tolerate) in a matter-of-fact business-as-usual fashion. I will answer any question and make it clear that we cannot predict how things will turn out but that but that we do know how to find out and that is to run experiments (try new things) and see how it goes. At the same time we are very much aware that it is the client who has to deal with the anxiety that trying new things can arouse so we do not push but rather facilitate. The analogy I like to use is that doing therapy with someone is like going off to war; the therapeutic relationship develops while you are sharing a foxhole and fighting together. The other analogy that I like to use is that I work with a client the same way that I train a promising new therapist; my goal is not just to do the therapy with them but rather to teach them how to do the therapy for themselves. I think that is why cognitive therapy gets such good enduring results; cognitive therapy cuts risk for relapse by more than half relative to medications following treatment termination (Cuijpers et al., 2013).

Question 9

What are some of the research findings on the long term impact a) on the brain from long term (i.e. years+) treatment with SSRIs, and b) on the ability to successfully stop taking SSRIs after long term treatment?

Steven Hollon · Accepted Answer

We know less about the long-term effects than we would like. SSRIs are thought to be relatively safe and non-addictive but there are indications that they increase "all cause" mortality by 30% among people without heart conditions (they are slightly protective for the latter) (Maslej 2017) and may be difficult to discontinue without triggering a relapse (Hollon 2019).

Question 10

CBT may be misunderstood as regimented (almost calloused) in it's approach - both to clients and other professionals. How do you navigate conversations with clients who have had negative past experiences with this therapy?

Steven Hollon · Accepted Answer

I simply talk with them about their prior experience(s) with the approach. CBT does not have to be regimented and it certainly should never be calloused. When I work with someone I make it clear that I work for them and not that they work for me. What I want to know is what they are trying to get out of therapy and I do my best to deliver.

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