case study examples for depression

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

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Patient case navigator: major depressive disorder.

Introduction

Learning Objectives

• How to perform a structured psychiatric interview
• Standardized psychiatric rating scales appropriate for patients with depressive symptoms
• Common barriers to adequate treatment response
• How to assess and monitor patients for treatment side effects and adequate treatment response

Watch the video:

History and Examination

Medical History

Examination

History of Present Illness

Eric is a 60-year-old man who presents to his primary care nurse practitioner, Tina, with irritability, excessive sleeping, and a lack of interest in his usual hobbies, such as attending baseball games and going to the movies with his wife. He also has been spending much time at home alone, watching television, rather than spending time with his friends or wife, as he usually does. Eric recently retired from his job as a general contractor remodeling people’s kitchens and bathrooms. He enjoyed his job very much and felt a sense of pride in helping people make their homes more functional and attractive. However, his job was very physical, and at times stressful, so Eric felt it was time to retire and find something new with which to occupy his time.

Eric was diagnosed with hypothyroidism 5 years ago and has been on medication ever since. Annual lab tests indicate his thyroid levels have remained within the normal range for the past few years. He also has mild hypertension, which is well-controlled at an adequate dose.

Psychosocial History

Eric reports that he has several close friends and that he got along well with people at work. He denies a history of substance misuse and reports that he occasionally drinks a glass of wine with dinner. He does not smoke. Eric describes his marriage as “very good.” He is also close with his adult daughter and enjoys spending time with his 2 grandchildren.

At age 33, Eric experienced a period of depressed mood after losing his job. During that time, he had problems getting out of bed in the morning because he felt hopeless and sad, stopped socializing with friends, and lost about 4 lbs of body weight in 4 weeks without intentionally dieting. He sought treatment from his primary care physician, who referred him to a psychiatrist for medication and a psychologist for outpatient cognitive-behavioral therapy (CBT). Eric worked with his psychiatrist and tried 4 different selective serotonin reuptake inhibitors (SSRIs) before he ultimately found one that seemed to work for him. He and his psychiatrist decided together that he could stop taking the medication after 1 year because his mood had improved and stabilized. He saw his therapist once weekly for approximately 2.5 years and reports that CBT also helped improve his mood and functioning.

Family History

Eric reports that, throughout his life, his mother had “very low periods” when she seemed extremely sad and had trouble functioning. However, she never sought treatment for these episodes.

Eric’s physical examination indicates he is generally healthy for his age. His vital signs are all within the normal range, and the mental status examination indicates he is fully oriented and alert. Eric’s appearance is that of an older man. His affect is flat, and he has trouble making eye contact, often staring at the floor instead.

Patient Interview

Quiz #1: initial presentation and diagnosis, dsm-5 diagnostic criteria for mdd.

MDE Diagnostic Criteria

Safety Plan

Major Depressive Episode (MDE)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of function

C. The episode is not attributable to the physiological effects of a substance or another medical condition

Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

• It is important to thoroughly review each of these 9 symptoms with your patients when assessing them for MDD.
• Clinical rating scales can help identify which patients require more in-depth screening for depression.

Quiz #2: DSM-5 Diagnostic Criteria for MDD

Scales for mdd.

PHQ-9 Scale Scoring

QIDS Scale Scoring

Patient Health Questionnaire-9 (PHQ-9)

This scale was developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues with an educational grant from Pfizer inc. No permission required.

Scoring Criteria

Kroenke K, Spitzer RL. Psychiatric Annals. 2002;32:509-521.

The Quick Inventory of Depressive Symptomatology (QIDS)

• The QIDS is a 16-item, multiple-choice questionnaire in which depressive symptoms are rated on a 0-3 scale according to severity
• Items are derived from the 9 diagnostic criteria for major depressive disorder used in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), including sadness, loss of interest or pleasure, poor concentration or decision-making, self-outlook, suicidal ideation, lack of energy, sleep disturbance, appetite change, and psychomotor agitation
• Although the QIDS was initially developed based on DSM-IV criteria, the scale is also compatible with the DSM-5. The core criteria for MDD are consistent across these editions

Rush AJ, et al. Biol Psychiatry. 2003;54(5):573-583.

Bernstein IH, et al. Int J Methods Psychiatr Res. 2009;18(2):138-146.

Quiz #3: Scales for MDD

Treatment initiation and monitoring.

APA Guidelines

Eric's PHQ-9 Score

Treatment Options

American Psychiatric Association (APA) Guidelines for Treatment of MDD

1-2 weeks: Improvement from pharmacologic therapy can be seen as early as 1-2 weeks after starting treatment

2-4 weeks: Some patients may achieve improvement in 2-4 weeks

4-6 weeks: Short-term efficacy trials show antidepressant therapy appears to require 4-6 weeks to achieve maximum therapeutic effects

4-8 weeks: The APA recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment *Adequate dose and duration Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

*Adequate dose and duration

Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

Quiz #4: Treatment Initiation and Monitoring

Assessing for treatment challenges.

Treatment Challenges

Eric's Updated PHQ-9 Score

Possible Challenges to Antidepressant Therapy

• Suboptimal efficacy due to the wrong dose, inadequate length of time on the medication, or the person's individual biology not being responsive to the medication
• Unpleasant side effects of antidepressants can occur, such as weight gain, insomnia, and sexual dysfunction
• Nonadherence to the antidepressant
• As a reminder, the American Psychiatric Association (APA) recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment

Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

MDD Diagnosis

Clinical Probes

Treatment Assessment

Monitoring Considerations

Factors to Consider When Making a MDD Diagnosis

• Take a thorough patient history
• Previous or current depressive episodes
• Previous or current manic or hypomanic episodes
• Family history of MDD, bipolar disorder
• Medical comorbidities
• Consider a broad differential diagnosis

Clinical Queries That Aid in Diagnosing Major Depressive Episodes

1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association; 2013. 2. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

APA Practice Guidelines on Treatment Assessment

• Wait 4 to 8 weeks to assess treatment response to antidepressants
• In patients without adequate response, clinicians can consider changing or augmenting with a second medication
• Changes to treatment plans, such as augmenting with a second-generation antipsychotic medication, are reasonable if a patient does not have adequate improvement in 6 weeks
• Consistently follow-up with patients to assess treatment effects, adverse medication effects, and risk of self-harm

APA Practice Guidelines note that the frequency of monitoring should be based on:

• Symptom severity (including suicidal ideation)
• Co-occurring disorders (including general medical conditions)
• Treatment adherence
• Availability of social supports
• Frequency and severity of side effects with medication

Tina Matthews-Hayes is a paid consultant for Abbvie Medical Affairs and was compensated for her time.

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.​

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. American Psychiatric Association; 2013. ​
• Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci . 2006;8(2):227-239.​
• Bobo WV. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc . 2017;92(10):1532-1551.​
• Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med . 2001;16:606-613.​
• Smarr KL, Keefer AL. Measures of depression and depressive symptoms. Arthritis Care Res . 2011;63(S11):S454-S466. doi:10.1002/acr.20556​
• Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573-583.​
• Brown ES, Murray M, Carmody TJ, et al. The Quick Inventory of Depressive Symptomatology–Self-report: a psychometric evaluation in patients with asthma and major depressive disorder. Ann Allergy Asthma Immunol. 2008;100(5):433-438. doi:10.1016/S1081-1206(10)60467-X​
• Liu R, Wang F, Liu S, et al. Reliability and validity of the Quick Inventory of Depressive Symptomatology-Self-Report Scale in older adults with depressive symptoms. Front Psychiatry . 2021;12:686711. doi:10.3389/fpsyt.2021.686711 ​
• Bernstein IH, Rush AJ, Suppes T, et al. A psychometric evaluation of the clinician-rated Quick Inventory of Depressive Symptomatology (QIDS-C16) in patients with bipolar disorder. Int J Methods Psychiatr Res . 2009;18(2):138-146. doi:10.1002/mpr.2855​
• Bernstein IH, Rush AJ, Trivedi MH, et al. Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents. Int J Methods Psychiatr Res. 2010;19(4):185-194. doi:10.1002/mpr.321 ​
• Kroenke K. Enhancing the clinical utility of depression screening. CMAJ . 2012;184(3):281-282.doi:10.1503/cmaj.112004 ​
• Levinstein MR, Samuels BA. Mechanisms underlying the antidepressant response and treatment resistance. Front Behav Neurosci . 2014;8:208. doi:10.3389/fnbeh.2014.00208​
• Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. 2015;115(1):183-201. doi:10.1093/bmb/ldv03​

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider.

Reach out to your family or friends for help if you have thoughts of harming yourself or others, or call the National Suicide Prevention Helpline for information at 800-273-8255.

ABBV-US-00976-MC, V1.0 Approved 12/2023 AbbVie Medical Affairs

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• Key learning aims

Background to the case study

Key practice points, data availability statement, author contributions, financial support, conflicts of interest, ethical standards, cbt for difficult-to-treat depression: single complex case.

Published online by Cambridge University Press:  11 August 2022

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients are difficult to treat: they are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk, and are prone to drop out, non-response or relapse. CBT based on a self-regulation model (SR-CBT) has been developed for this client group which incorporates aspects of first, second and third wave therapies. The model and treatment components are described in a concurrent article (Barton et al ., 2022). The aims of this study were: (1) to illustrate the application of high dose SR-CBT in a difficult-to-treat case, including treatment decisions, therapy process and outcomes, and (2) to highlight the similarities and differences between SR-CBT and standard CBT models. A single case quasi-experimental design was used with a depressed client who was an active participant in treatment decisions, data collection and interpretation. The client had highly recurrent depression with atypical features and had received several psychological therapies prior to receiving SR-CBT, including standard CBT. The client responded well to SR-CBT over a 10-month acute phase: compared with baseline, her moods were less severe and less reactive to setbacks and challenges. Over a 15-month maintenance phase, with approximately monthly booster sessions, the client maintained these gains and further stabilized her mood. High dose SR-CBT was effective in treating depression in a client who had not received lasting benefit from standard CBT and other therapies. An extended maintenance phase had a stabilizing effect and the client did not relapse. Further empirical studies are underway to replicate these results.

(1) To find out similarities and differences between self-regulation CBT and other CBT models;

(2) To discover how self-regulation CBT treatment components are delivered in a bespoke way, based on the needs of the individual case;

(3) To consider the advantages of using single case methods in routine clinical practice, particularly with difficult-to-treat cases.

CBT based on a self-regulation model (SR-CBT) is a cognitive behavioural therapy for difficult-to-treat depression (McAllister-Willams et al ., Reference McAllister-Williams, Arango, Blier, Demyttenaere, Falkai, Gorwood, Hopwood, Javed, Kasper, Malhi, Soares, Vieta, Young, Papadopoulos and Rush 2020 ; Rush et al ., Reference Rush, Sackeim, Conway, Bunker, Hollon, Demyttenaere, Young, Aaronson, Dibué, Thase and McAllister-Williams 2022 ). The model and treatment components are described in a concurrent article (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ) and readers are encouraged to read that article for more details about the theoretical framework and how the treatment components are derived from it. The aim of this article is to illustrate the application of SR-CBT in a difficult-to-treat case of depression, in particular how the treatment components were organized and delivered, and how these influenced the process and outcome of therapy. SR-CBT has 10 treatment components and a key part of the approach is individualizing therapy based on the case formulation. Individualizing means varying the sequence, combination and dose of the treatment components, based on client need – it does not mean drifting from the therapist actions prescribed in the components.

The client in question was an active participant in the research process. She suffered from highly recurrent depression, with atypical mood fluctuations, and had received several treatments over the previous 13 years, including anti-depressant medication, computer-assisted CBT, counselling, psychodynamic psychotherapy, group-based mindfulness-based CBT, individual CBT, and intermittent care from a community mental health team and crisis team. She had received temporary but not lasting benefit from these interventions, gaining support, psychoeducation and coping skills, but not lasting remission from depression. She concurred that her depression was difficult to treat, acknowledging that there had been difficulties for both her and her previous therapists. Following assessment at the Centre for Specialist Psychological Therapies, the client was given the choice between a further course of standard CBT and a course of SR-CBT. She was given information, had an opportunity to ask questions and chose SR-CBT, explaining that the previous CBT been helpful but not lasting, and she would prefer to try a novel treatment.

At the time of the assessment, the client had been keeping a daily mood diary over the previous 16 months (514 days), during which time she had received a course of standard CBT (15 sessions), anti-depressant medication (ADM) and support from a community mental health team (CMHT). The daily diary created an opportunity for a baseline phase against which the SR-CBT could be compared and tested. The opportunity for a quasi-experiment was only recognized at this point, so the case study was limited to the mood measure that the client had been using in her previous care. The sequence of SR-CBT delivered after CBT, ADM and CMHT was not randomized or open to experimental control. Nevertheless, this case study is a good example of naturalistic practice-based evidence, with a high level of collaboration and participation from the service user. She recognized the value of continuing to complete the mood diary as a way of comparing SR-CBT with previous treatments, and was supportive of her treatment being summarized in this article, taking an active role in ensuring confidentiality within the write-up (several personal details are anonymized). She declined the opportunity to be a co-author but provided feedback on drafts and was satisfied with how the therapy had been summarized and discussed. The first author (S.B.) was the therapist, and he received monthly supervision throughout from the second author (P.A.).

Demographics and mental health history

Evelyn (psydonym) was a 52-year-old married woman with two grown-up daughters from a previous marriage. She first presented to mental health services aged 39, diagnosed with recurrent depressive disorder. She reported occasional episodes of depression as an adolescent that became more frequent and problematic in her late 20s and 30s. Evelyn’s marriage broke down when she was 42 and this precipitated an intense experience of personal failure, a severe depressive episode and a serious suicide attempt. In the subsequent 10 years, Evelyn experienced intermittent severe depressive episodes within the same phasic pattern. During periods of milder depression, Evelyn could be energized and engaged in her work as managing director of a company. These phases fell short of the threshold for hypomania: bipolar II disorder was not diagnosed, but psychiatric evaluation suggested an atypical phasic pattern of alternating mild, moderate and severely depressed moods with a high level of unpredictability from one day to the next.

Treatment phases

Up to 30 sessions is the usual dose of SR-CBT for clients with difficult-to-treat depression, and Evelyn received 27 sessions of SR-CBT over a 10-month acute phase (306 days). Her pre-treatment Patient Health Questionnaire score was 19 (PHQ-9; Kroenke et al ., Reference Kroenke, Spitzer and Williams 2001 ) indicating moderate depression symptoms, and her GAD-7 score was 5, confirming depression as the primary problem (Spitzer et al ., Reference Spitzer, Kroenke, Williams and Löwe 2006 ). Evelyn’s moods were subject to a lot of fluctuations and this pattern is depicted in a graph of her daily mood ratings (Fig.  1 ). The ratings were made on the following 11-point scale, with higher numbers representing milder depression: 7–10, OK mood; 5–6, very depressed; 4, suicidal wishes; 0–3, actively suicidal.

Figure 1. Evelyn’s daily mood ratings across treatment phases.

Evelyn was at heightened risk of relapse due to adverse childhood experiences, early onset depression, multiple previous episodes and unstable remission (Bockting et al ., Reference Bockting, Hollon, Jarrett, Kuyken and Dobson 2015 ). For this reason, she was offered a maintenance phase of monthly booster sessions after the acute phase was completed, with the goal of maintaining progress and staying well (Jarrett et al ., Reference Jarrett, Kraft, Doyle, Foster, Eaves and Silver 2001 ). This was initially expected to last 6 months, but it was extended to 15 months (15 sessions, 463 days) to accommodate Evelyn’s learning process and heightened risk. Evelyn continued to take anti-depressant medication and have intermittent CMHT support during both phases of SR-CBT.

Treatment process

Emphasis was placed on the self-regulation skills that Evelyn most needed to develop, based on her case formulation. To provide an overview of when and how the components were delivered, the acute and maintenance phases have been combined in the following summary. The number of sessions in which each component formed a significant part are presented in a cumulative plot in Fig.  2 . Sessions usually combined more than one treatment component (mean = 2.77 per session). The way each component was delivered, and the number of sessions in which they formed a part, are described below.

Figure 2. SR-CBT treatment components: cumulative number of sessions in which each component was delivered.

Alliance building (10/42 sessions)

An effective working alliance was established with Evelyn over the first five sessions. She was trusting and respectful and the personal alliance formed easily. The task alliance, reflected in alignment on target problems, goals and therapy tasks, was more challenging to develop, and there were three barriers (Barton et al ., Reference Barton, Armstrong, Wicks, Freeman and Meyer 2017 ; Cameron et al ., Reference Cameron, Rodgers and Dagnan 2018 ). Firstly, Evelyn was ambivalent about receiving further CBT and unsure whether it would differ from her previous therapy. Her initial motivation came from a sense of obligation to her husband, who encouraged her to try new therapies. Evelyn was not optimistic that SR-CBT would produce benefits that were different or greater than previous therapies. Secondly, Evelyn’s mood disorder was highly persistent with several recurrent major episodes and an atypical pattern of mood fluctuations. Even if she responded to SR-CBT, she would have heightened risk of relapse (Wojnarowski et al ., Reference Wojnarowski, Firth, Finegan and Delgadillo 2019 ). Thirdly, Evelyn had suffered adverse childhood experiences in her birth family for which she felt partly responsible. She felt uncomfortable discussing herself, and was particularly reluctant to discuss early experiences in case she was perceived to be blaming her parents.

The therapist’s response was to guide discovery about each of these issues, making them explicit and investing time to reach an aligned position. The therapist sought to differentiate SR-CBT from standard CBT, encouraging Evelyn to find out if it was similar or different by committing to a small number of sessions initially. This increased Evelyn’s agency to engage in the therapy, without the therapist taking too much responsibility for change. The therapist also emphasized the need for two phases of treatment, the first to improve Evelyn’s mood and the second to sustain those changes. The risk of relapse was acknowledged at the outset, with a pro-active approach emphasizing that staying well depended on applying self-regulation skills that could be learned during treatment. Finally, the therapist acknowledged that a strong relationship was needed to discuss painful childhood experiences, and Evelyn did not need to decide at the start of therapy whether she wanted to do this later. These conversations had an alliance-strengthening effect, sufficient to proceed with the other treatment components. Throughout treatment, the therapist had to be robust in maintaining the task alliance to keep the therapy sufficiently change-focused.

Treatment rationale (14/42 sessions)

The treatment rationale in SR-CBT is to reflect on mood fluctuations, differentiating depressed and less-depressed moods and using this to leverage change. Depressed moods help to formulate how depression is maintained; less-depressed moods help to find a path out of depression. Evelyn readily accepted that there were a lot of fluctuations in her moods. She found it particularly frustrating, and bewildering, that her moods could plummet from mild to severe in a short space of time with no apparent trigger. She accepted the logic that less-depressed moods could help to find a path out of depression, but in practice she would default to discussing depression, trying to find out what had triggered it so that she could avoid those triggers. Avoiding triggers was one of the strategies she had learned in previous treatments. In Evelyn’s case, this strategy was maintaining behavioural avoidance and rumination (e.g. ‘why do these keep happening?’). She gradually accepted that she could not always discover what the triggers were, and also came to realize that avoiding triggers was not the best strategy, because they were difficult to predict and attempting to do so maintained an avoidant orientation: trying to dodge undetermined hazards, rather than influencing situations in a preferred direction (Quigley et al ., Reference Quigley, Wen and Dobson 2017 ).

Over the first five sessions, Evelyn was socialized to key features of the self-regulation model. The model proposes that depression is perpetuated by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life-goals. The repeated interaction of these processes maintains depression like a traffic gridlock (Barton and Armstrong, Reference Barton and Armstrong 2019 ; Teasdale and Barnard, Reference Teasdale and Barnard 1993 ). Figure  3 presents Evelyn’s formulation which was built up over several sessions.

Figure 3. Evelyn’s case formulation.

Evelyn’s self-identity was narrowly invested in taking responsibility for others through her work as a managing director. This was a positive self-representation in the sense that it provided self-definition, value and purpose. Evelyn ascribed importance to doing her job well and was highly invested in that goal. This does not mean that she had consistently positive beliefs about doing a good job; in fact, these fluctuated a great deal. She experienced phases of work going reasonably well when she reported her mood to be ‘OK’, but small setbacks at work (real or perceived) had a disproportionate effect on her mood. She could switch rapidly into a self-loathing, unmotivated, withdrawn, ruminative state, pre-occupied with memories of letting others down and uninterested in planning for the future. When Evelyn’s depression was milder, she would engage in work tasks with some interest and a felt-sense of obligation, sometimes over-working, joining in with others and experiencing some job satisfaction. She recognized that her attention was more externally focused on these occasions, and she was more able to think clearly and make decisions.

The treatment rationale was revisited regularly throughout therapy, particularly when Evelyn suffered setbacks and became despondent about change. When this happened, the therapist would re-focus attention on less-depressed moods and encourage Evelyn to keep influencing her motivation, actions and cognition. To effect change, sufficient emphasis has to be placed on less-depressed experiences, and to achieve this the treatment rationale usually has to be revisited regularly.

Approach motivation (18/42 sessions)

Approach motivation is often delivered in combination with active engagement (see below). The aim is to stimulate approach impulses which are usually attenuated during depression with reduced positive anticipation, lower reward expectancies and weakened interest in desired outcomes (Sherdell et al ., Reference Sherdell, Waugh and Gotlib 2012 ). When reflecting on Evelyn’s less-depressed moods, the therapist questioned her motivational impulses and intentions; for example, when she felt some satisfaction after a particular work meeting. This increased the explicitness of Evelyn’s desires to support the staff that worked in her company, to whom she felt very responsible. Rather than focusing on responsibility beliefs, the therapist asked what Evelyn would like to happen in her organization, and how she would like key staff to develop. These desires were elaborated in a lot of detail and they helped to generate reasons for action; for example, to influence work culture and strategic direction.

Another example was bringing attention to what Evelyn needed when she felt negative emotions; for example, upset, guilt, sadness or anger. Her tendency was to suppress negative emotions because they would often activate depressing thoughts and provoke rumination. She had not considered emotions as signalling needs, for example, the need for self-soothing, forgiveness, support, grieving, communication, fairness, etc. Evelyn was not accustomed to reflecting on her needs and desires in this way, initially appraising it as selfish. This was unfamiliar and uncomfortable for her – even dystonic at times – and took a long time to make sense and sit more comfortably. Attending to needs and desires is self-compassionate: it signals the value of responding to one’s suffering and attempting to alleviate it, and of taking desires seriously and wanting to realize them. Repeated attention to Evelyn’s needs and desires helped to generate reasons for action and, over an extended period, reasons to act gradually became impulses for action.

Active engagement (21/42 sessions)

The goal of active engagement is to increase clients’ interaction with tasks and other people, with engagement targeted in situations where the client tends to disengage, withdraw and/or avoid (Ottenbreit et al ., Reference Ottenbreit, Dobson and Quigley 2014 ). There is a big emphasis on experimentation, with clients encouraged to try out new ways of interacting, including how they relate to themselves. The focus is on setting goals to influence preferred outcomes and aligning those goals with needs and desires. Consequently, the output of approach motivation is often used to plan experiments within active engagement.

In Evelyn’s therapy, 50% of the sessions involved planning a behavioural experiment to be conducted before the next session, and this would often relate to a work commitment that Evelyn’s secretary had booked in, or a personal engagement that her husband had arranged for them. It was normal for Evelyn to be dreading these and feel like withdrawing from them. From session 6 onwards, the repeating therapeutic pattern was exploring prospectively what Evelyn would like to happen in those situations. Time was taken to plan how she wanted to approach the situation, emphasizing how she would interact and communicate with others, to try to influence what she would like to happen. She would also consider which mindset she needed to be in before, during and after the situation, in particular where to place her attention and how to keep preferences in mind. Sessions would end with Evelyn stating her preferred outcomes, not her predictions, and the experiment was to find out if and how she could influence those preferences. A de-brief was planned for the next session.

Examples include feeling despondent about not having sufficient administrative support in her office, even though she was the managing director of the company. When feeling depressed, it did not occur to Evelyn that she had the authority and influence to hire more staff, imagining that this would be blocked by red tape that was out of her control. The therapist dis-attended to Evelyn’s negative predictions and kept attention on what she would like to happen in this situation. With some reluctance and difficulty, Evelyn slowly worked back from the desired outcome and, over a number of weeks, the staffing was increased. Another example was dreading a visit to see her elderly parents, feeling like cancelling on the pretence of ill-health. The therapist enquired about the best and worst memories of visiting her parents, and this helped Evelyn to identify what she was most dreading: feeling trapped in their home, unable to leave (see self-organization section). By staying focused on what she would like to happen (e.g. having her own space, going out when she wanted), Evelyn developed a plan to stay in a local hotel and let her parents know in advance that she was increasing physical exercise. These possibilities had not previously occurred to Evelyn, and overall they contributed to a more tolerable family visit.

Evelyn struggled with active engagement for several months, preferring to talk about negative experiences that had occurred in the previous week, and was sometimes frustrated that the therapist did not pay much attention to her negative predictions. The personal alliance was sufficiently strong to withhold this, so the therapist kept the task alliance as the priority (i.e. change-focus). After 6 months of slow learning, a threshold was reached and Evelyn started to internalize the active engagement process that she had applied across several experiments. When she paid attention to her preferred outcomes, and formed an intention to bring them about, she was usually able to influence them in some way, even if it was not in the way she had expected.

Mental freedom (19/42 sessions)

The aim of mental freedom is to develop a good self-mind relationship with reflective capacity, attentional skills and productive questioning. The first step is to increase awareness of the difference between rumination and reflection and this occurred in the first six sessions when the treatment rationale and initial formulation was developed. Evelyn accepted that rumination was unhelpful but she did not always recognize when it was happening (Watkins and Roberts, Reference Watkins and Roberts 2020 ). When her mood lifted, she was usually able to reflect back on her experiences and recognize that rumination had occurred. It took several months for Evelyn to become aware of rumination when it was happening in the moment, and then she felt minimal control over it. As her reflective capacity increased, Evelyn developed more attentional skills. This grew out of the recognition that she tended to be self-focused in depressed moods and more externally focused in less-depressed moods. External focus of attention became a regular part of active engagement. This gradually gave her a tool to use when feeling more depressed, choosing to place her attention externally, when she remembered to do so. This was not sufficient to prevent all depression and rumination, but it had a beneficial effect and was the beginning of Evelyn learning how to influence her cognition during depressed moods.

The intervention that had greatest impact was recognizing the unhelpfulness of the questions she asked herself when feeling depressed, such as: ‘what’s the point?’, ‘why bother?’, ‘why can’t I be normal like everyone else?’, etc. These thoughts indicated how distressed, frustrated and angry Evelyn could become with herself. When her mood was less depressed, Evelyn brought these questions to mind in cognitive experiments within therapy sessions: the presence of the questions depressed her mood, brought negative thoughts to mind and led to unhelpful answers. Evelyn recognized their unhelpfulness, but didn’t know how to think differently, especially when feeling depressed. With the therapist’s guidance, she was able to experiment with different types of question such as ‘how can I help myself right now?’, ‘what do I need to do next?’, ‘who can I talk to?’. Evelyn recognized that these were more helpful, concrete and practical questions, giving her ideas for action, and that this was a better way to respond when feeling down. She started monitoring her questions at work, particularly when feeling burdened or guilty, and there was a gradual shift from less to more helpful questioning (e.g. ‘why do I keep messing up?’ became ‘did I make a mistake?’). The challenge was helping Evelyn to access reflective thinking when she most needed it, when her mood was 6/10 or less. Initially she was only able to apply these skills when her mood was 7/10 or greater, and this became one of the key aims of relapse prevention and staying well.

Self-organization (5/42), goal organization (2/42) and memory integration (2/42 sessions)

In the self-regulation model, vulnerability to depression results from the under-development of positive self-representations and their associated self-regulatory capacities, rather than the presence negative beliefs. The main aim of self-organization is to strengthen, diversify and re-structure positive self-representations. The main aim of memory integration is to elaborate positive recollections to increase their memorability and accessibility, when possible making explicit links to positive self-representations. The main aim of goal-organization is to structure life-goals so they are approach-based, concrete, imaginable and span a range of self-representations.

The main hypothesis about Evelyn’s vulnerability to depression was that her early family experiences limited the development of positive self-representations and associated life skills. When growing up, Evelyn endured several years of marital discord, conflict and miscommunication, with her parents unaware of its psychological impact on her. As time passed, Evelyn felt increasingly responsible for her family’s unhappiness, unable to solve her parents’ difficulties. She internalized a lot of unhappy memories and often felt helpless, unable to escape or improve the family situation. Her parents’ dissatisfaction with each other captured much of their attention, and Evelyn’s need for emotional support, encouragement and soothing was often overlooked.

This was compensated, to some degree, by her intelligence and aptitude at school where she was responsible, hard-working and successful, but her capacity to encourage herself and self-soothe was not consistently supported at home. On the contrary, the family atmosphere was characterized by criticism and harshness, which came to reflect Evelyn’s relationship with herself. Being responsible, intelligent and hard-working led to a successful path through school, university and her subsequent career, but her positive self-representations were few in number, narrowly invested in feeling responsible to others, particularly in her role as a managing director. This brought her a lot of career success and some periods of euthymic mood, but she had limited resilience to buffer negative interpersonal experiences when, as she perceived it, she made mistakes or let others down. As we have already observed, when her self-identity as a responsible managing director was disrupted Evelyn could switch rapidly into self-attack, self-blame and self-loathing.

Focusing on personal qualities was very challenging for Evelyn because she was very uncomfortable receiving positive feedback; it jarred as if it had no place within her. Throughout therapy, the therapist would comment on Evelyn’s good humour, compassion, intelligence and work expertise, in an attempt to strengthen her acceptance of these qualities, but this was limited by Evelyn’s reluctance to participate in this type of change. It is possible that Evelyn would have benefited from greater therapeutic focus on her memories, self-identity and life-goals, but throughout therapy she remained uncomfortable discussing herself, her early life in particular, and this limited the depth of self re-organization that was possible.

Risk reduction (4/42 sessions)

The aim of risk reduction is to reduce suicide risk when it is increased. Clients’ motives are explored in detail by asking about the intended and unintended consequences of suicidal actions. When feeling suicidal, clients’ attention often narrows around a specific need, for example, to be re-united with a loved one, to escape, to experience relief or put an end to a particular feeling. Evelyn’s mood rating did not enter the suicidal range (4/10 or less) during the course of SR-CBT, but there were occasions when she was bothered by suicidal thoughts, and on those occasions the therapy helped her to explore the goal of suicide: what did Evelyn imagine suicide would achieve? In Evelyn’s case, she believed it could result in ‘an end to hellish feelings’ and ‘not having to be me anymore’. This was tempered by potential unintended consequences, including pain, injury, illness and her husband being devastated. Evelyn recognized an inner battle between these pros and cons that she had lived with over several years.

The therapy tried to broaden Evelyn’s attention onto other life-goals and reasons for living, including seeing her company grow, supporting the development of key colleagues and enjoying holidays with her husband (Linehan et al ., Reference Linehan, Goodstein, Nielsen and Chiles 1983 ). Most importantly, it tried to identify non-lethal ways to respond to her felt-need to avoid ‘hellish’ emotions and escape herself. The main strategy was to encourage Evelyn to switch from avoidance to approach. Rather than avoid these feelings, she was encouraged to influence them so they occurred less frequently and respond to them differently when they were present. Rather than escape herself, she was encouraged to submit to a deeper acceptance of her personal qualities. Some of this therapeutic work was acutely uncomfortable for Evelyn, but it appeared to contribute to her increased safety over the course of the treatment.

Staying well (19/42 sessions)

Towards the end of the acute phase, four sessions of staying well were provided, aiming to consolidate the skills Evelyn had learned during therapy and apply them more independently (Jarrett et al ., Reference Jarrett, Kraft, Doyle, Foster, Eaves and Silver 2001 ). There remained an unpredictability in Evelyn’s moods that was frustrating and difficult for her to accept, and when her mood was more depressed (i.e. 6/10 or less) it was very difficult for her to remember and apply skills she had learned. It became apparent that this was a significant struggle for Evelyn, and this was what prompted the offer of maintenance therapy. This was initially expected to be monthly for 6 months, but it was extended to 15 months, reflecting the size of the task. There were two main aims: (a) to make Evelyn’s self-regulation skills more explicit and memorable; and (b) to help her access the skills when they were most needed, during depressed moods (i.e. 6/10 or less). Evelyn’s understanding of what she needed to do to stay well gradually became more explicit, and her skills became more automatic, but this was very slow learning that relied on multiple repetitions to become accessible during depressed moods.

Treatment outcomes

By the end of the acute SR-CBT phase, Evelyn’s PHQ-9 score had reduced from 19 to 2. This is a reliable change of more than 6 points that is also below the threshold for clinical caseness (McMillan et al ., Reference McMillan, Gilbody and Richards 2010 ). However, a pre–post comparison only takes account of two time-points and cannot capture the dynamics of mood patterns or changes within them. The daily mood ratings provided a richer description of those dynamics and also allowed comparisons between phases. The main questions were: (a) whether moods in the acute phase of SR-CBT were less depressed and more stable, compared with baseline; and (b) whether changes in mood during acute phase SR-CBT were sustained in the maintenance phase. Visual analysis of Fig.  1 confirms that there was a lot of variability within each phase, consistent with Evelyn’s formulation. A cyclical pattern was apparent, both within and across phases, with apparently milder depression and more stable mood during the SR-CBT phases (baseline median = 7; acute SR-CBT median = 8; maintenance SR-CBT median = 8). Evelyn’s risk was also less during SR-CBT: she scored 4 or less (indicating suicidal wishes) on 24/514 days during the baseline phase (4.6%) and 0/769 days during SR-CBT (0%).

Differences between phases were tested statistically using non-overlap methods (Morley, Reference Morley 2017 ; Parker and Vannest, Reference Parker, Vannest, Kratochwill and Levin 2014 ; Parker et al ., Reference Parker, Vannest, Davis and Sauber 2011 ). There was no significant trend within the baseline phase when Evelyn received standard CBT, ADM and CMHT (Tau-U=–0.028, Z=–0.963, p =0.336). The same underlying mood pattern was recurring without a significant trend towards better or worse mood, and this is reflected in the flat trend line in the baseline phase in Fig.  1 . There was therefore no need to control for baseline trend in the comparison with acute phase SR-CBT, which revealed a statistically significant improvement in mood, consistent with Fig.  1 (Tau-U=0.257, Z=6.167, p <0.001). Compared with baseline, Evelyn’s moods were significantly milder during acute SR-CBT, but there was also a significant decreasing trend during the acute phase which, without further intervention, could have led to relapse (Tau-U=–0.151, Z=–3.934, p <0.001). This is depicted in the sloping trend line in the acute phase in Fig.  1 . With this trend statistically controlled, there was a significant difference between acute phase SR-CBT and maintenance phase SR-CBT, favouring the maintenance phase (Tau-U=–0.093, Z=–2.192, p =0.028). Evelyn’s mood was more stable in the maintenance phase, with no significant trend for worsening or further improvement (Tau-U=–0.035, Z=–1.114, p =0.265). This is reflected in the flat trend line in the maintenance phase in Fig.  1 .

This single case demonstrates how SR-CBT is organized and delivered across a course of therapy. Because Evelyn kept a mood diary over an extended period, comparisons could be made between treatment phases. The case demonstrates the aim of SR-CBT: to provide effective therapy for difficult-to-treat clients who have received standard CBT in the past but where it has not had a beneficial or lasting effect (Barton and Armstrong, Reference Barton and Armstrong 2019 ). The pattern of results is consistent with the model’s claims, that SR-CBT can provide an effective alternative when standard CBT has not been sufficiently potent (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ). There are alternative explanations for the changes observed during SR-CBT, for example, that positive life events or other treatments were responsible for the effects. However, Evelyn attributed the changes to SR-CBT; there were no major positive life events during the 25 months of her treatment; she continued to take anti-depressant medication and receive CMHT support, but there were no substantial changes in medication and, due to her improvement, CMHT input was less than before.

Assuming that the changes are at least partly attributable to SR-CBT, this case does not provide evidence that SR-CBT is more effective than standard CBT; it does not address that question. The case is illustrative and not a comparative test: it is one case, without randomization or replication. A scientific comparison of cognitive therapy vs behavioural activation vs SR-CBT would need to balance the order in which they were received, since Evelyn’s gains during SR-CBT could be partly attributable to the preparatory effects of previous therapy. It would also need to match treatment doses and use a broader range of measures: 42 sessions is significantly greater than 15 sessions, which was the dose of the standard CBT she received in the baseline phase. Nevertheless, what can be claimed is that, in this particular case, high dose SR-CBT coincided with positive changes in mood that did not occur during standard CBT at a normal dose, and these changes were sustained over a 15-month maintenance phase. The enduring effect of SR-CBT in this case echoes the lasting benefits reported in an earlier version of this treatment (Barton et al ., Reference Barton, Armstrong, Freeston and Twaddle 2008 ).

Although a single case is limited without replication, single case methods have the potential to address issues in the field that are normally approached through randomized controlled trials and meta-analysis. For example, the bespoke combination of treatment components is open to empirical scrutiny to find out how much variance occurs across cases, and whether the same or different ingredients are associated with better outcomes. If it is the same ingredients, SR-CBT could become more protocolized in the future; if it is different ingredients, there is a case for continued individualization with this client group. Repeated measure designs also have the potential to detect trends that are not usually measured in RCTs, the best example in this study being the decreasing trend in the acute SR-CBT phase, even though this phase had significantly milder depression than the baseline. If this pattern was replicated in other cases, it could be a way of detecting empirically which cases are at greater risk of relapse through their response to acute phase treatment.

Two further questions need to be addressed. Firstly, how similar or different is SR-CBT compared with standard CBT? Therapists use core CBT skills to provide SR-CBT and it certainly has overlaps with other CBT treatments, for example, mental freedom shares features with rumination-focused CBT (Watkins and Roberts, Reference Watkins and Roberts 2020 ), and active engagement shares features with behavioural activation (Martell et al ., Reference Martell, Addis and Jacobsen 2001 ; Martell et al ., Reference Martell, Dimidjian and Herman-Dunn 2010 ) and activity scheduling in cognitive therapy (Beck et al ., Reference Beck, Rush, Shaw and Emery 1979 ). Readers are encouraged to access the concurrent article that explores these similarities and differences in more detail (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ).

Secondly, are the effects of SR-CBT attributable to high dose treatment rather than specific treatment components? This possibility cannot be ruled out, but the change pattern depicted in Fig.  1 suggests a specific response to SR-CBT, rather than a simple dose effect. However, this question needs to be addressed through replication in further studies, and the health economics of high dose treatment also need consideration. Arguably, an effective high dose treatment for difficult-to-treat cases would save resources in the long term, given the healthcare costs incurred by treatment-resistant depression (Johnston et al ., Reference Johnston, Powell, Anderson, Szabo and Cline 2019 ). For some clients, fast learning is not possible and slow learning across a high intensity treatment may be more cost-effective than subsequent multiple brief episodes of care. For example, slower change is inevitable when working with non-verbal aspects of trauma, and this may be one of the reasons why treatment responses in chronic depression are superior for doses of 30 sessions or greater (Brewin et al ., Reference Brewin, Reynolds and Tata 1999 ; Cuijpers et al ., Reference Cuijpers, van Straten, Schuurmans, van Oppen, Hollon and Andersson 2009 ). With respect to the current case, consider the costs incurred by Evelyn’s treatment in the 13 years prior to receiving SR-CBT, and the potential savings in the years ahead, if her treatment gains are sustained. The efficacy of SR-CBT and its health economics are now undergoing further empirical tests.

(a) When possible, increase the treatment dose compared with standard CBT.

(b) Pay more attention to building the working alliance by overcoming alliance barriers.

(c) Pay more attention to less-depressed moods as a way of finding a path out of depression.

(d) Conduct behavioural experiments that seek to influence clients’ preferences, rather than disconfirm their negative predictions.

(2) Therapists should consider using individualized measures, such as daily mood ratings, alongside standard measures as a way of observing trends and patterns of change.

Copies of the single case dataset are available from the first author on request.

Acknowledgements

The authors would like to thank colleagues who provided feedback on drafts and contributed to the development of the treatment components: Nina Brauner, Beth Bromley, Elisabeth Felter, Dave Haggarty, Youngsuk Kim, Lucy Robinson and Karl Taylor.

Stephen Barton: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing – original draft (lead), Writing – review & editing (lead); Peter Armstrong: Conceptualization (supporting), Investigation (supporting), Supervision (lead); Stephen Holland: Conceptualization (supporting), Project administration (supporting), Writing – original draft (supporting), Writing – review & editing (supporting); Hayley Tyson-Adams: Conceptualization (supporting), Project administration (supporting), Writing – original draft (supporting), Writing – review & editing (supporting).

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors have no competing interests to declare.

The authors have abided by the ethical principles and code of conduct set out by the British Association of Behavioural and Cognitive Psychotherapies and British Psychological Society. The reported study is practice-based evidence and did not receive ethical approval in advance. In lieu of this, oversight was sought from CNTW Foundation Trust management which supported service-user involvement in collecting practice-based evidence. The service user was an active participant in the research process, read the manuscript and agreed to it going forward for publication.

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• Stephen B. Barton (a1) (a2) , Peter V. Armstrong (a1) , Stephen Holland (a1) and Hayley Tyson-Adams (a3)
• DOI: https://doi.org/10.1017/S1754470X22000319

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Case Study and Treatment Plan: Major Depressive Disorder and Alcohol Use

Info: 4892 words (20 pages) Nursing Case Study Published: 5th May 2020

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• Medical supervision for Alcohol Withdrawal (inpatient admission for detoxification)
• Residential rehabilitation
• Pharmacotherapy for post detoxification support and in an attempt to prevent relapse
• AOD counselling weekly for support
• AA Meetings weekly for peer support in relapse prevention
• Personal counselling
• Psychology sessions (ie Cognitive Behavioural Therapy (CBT))
• Taking medication as prescribed
• Attending weekly AOD counselling sessions
• Attending weekly AA meetings
• Attending regular counselling
• Attending psychology (CBT) sessions
• Able to indicate some positivity and hope for his future
• Regular attendance at gardens with support worker
• Regular conversations with family members and support people

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• Adams, P. J.(2007) Fragmented Intimacy: Addiction in a social world. Springer Science &Business Media
• American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3 rd ed.,rev.) Washington, DC
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington,VA, American Psychiatric Association (2013).
• Baker, A., & Velleman, R. (Eds.). (2007). Clinical handbook of co-existing mental health and drug and alcohol problems . Routledge.
• Brown, R. A., Evans, D. M., Miller, I. W., Burgess, E. S., & Mueller, T. I. (1997). Cognitive–behavioral treatment for depression in alcoholism. Journal of consulting and clinical psychology , 65 (5), 715.
• Brown, R. A., & Ramsey, S. E. (2000). Addressing comorbid depressive symptomatology in alcohol treatment. Professional Psychology: Research and Practice , 31 (4), 418.
• Durie, M. (1998). Whaiora: Maori health development. Oxford University Press
• Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B. Z., Keith, S.J., Judd, L. L., & Goodwin, F.K.(1990) Comorbidity of Mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. Journal of the American Medical Association, 264,2511-2518
• Turner, R., & Wehl, C. (1984). Treatment of unipolar depression in problem drinkers.   Advances in behavioural research and Therapy, 6, 115-125

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Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

This guideline has been stood down. All of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
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Brain scans identify 6 types of depression in new study

Depression can be sorted into six distinct types using brain scans, a revelation that could improve treatment for many suffering the debilitating mood disorder.

Researchers analyzed brain scans to identify six different biological types of depression , based on differences in patterns of brain activity, according to results published Monday in the journal Nature Medicine . Advertisement

These differences allowed researchers to single out the potentially best treatments for three of the depression types, results show.

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"In essence, it's a demonstration of a personalized medicine approach for mental health based on objective measures of brain function," Williams said in a Stanford news release. Advertisement

If these findings hold, people diagnosed with depression could one day undergo a brain scan to reveal the treatment that would best work for them.

About 30% of people with depression don't respond at all to either medication or talk therapy, and as many as two-thirds find that treatment isn't able to fully quell their depression.

That's in part because up to now there's been no good way to know which antidepressant or type of therapy would most benefit any particular patient, researchers said.

Drugs are prescribed through a trial-and-error method, so it can take months or years to land on one that works. In the meantime, the grinding process can make a person's depression even worse.

"The goal of our work is figuring out how we can get it right the first time," Williams said. "It's very frustrating to be in the field of depression and not have a better alternative to this one-size-fits-all approach."

For the study, researchers analyzed brain scans of 801 people diagnosed with depression or anxiety. The people were scanned at rest, and again when they were engaged in different tasks intended to stir up thoughts and emotions.

Researchers narrowed in on regions of the brain known to play a role in depression. Artificial intelligence helped them sort the activity in these regions into six distinct types of depression. Advertisement

In a further trial, 250 participants were randomly assigned to either talk therapy or one of three commonly used antidepressants. The results provided some indication that some therapies work better than others on certain types:

One type, characterized by overactivity in the cognitive regions of the brain, experienced the best response to the antidepressant venlafaxine (Effexor).

Another type, in which brains at rest had more activity between three regions associated with depression and problem-solving, responded better to talk therapy.

A third type, which involved lower levels of activity at rest in a brain region tied to attention, was less likely to respond to talk therapy.

The distinct biotypes of depression also correlated with differences in symptoms between participants, researchers found.

For example, those with overactive cognitive regions of the brain were more likely to be unable to feel pleasure, and also performed worse on tasks involving organization.

Researchers plan to expand the study to include more people, and to test more medicines and treatments in all six of the biotypes.

"To really move the field toward precision psychiatry, we need to identify treatments most likely to be effective for patients and get them on that treatment as soon as possible," said researcher Dr. Jun Ma , director of the Center for Health Behavior Research at the University of Illinois Chicago. Advertisement

"Having information on their brain function, in particular the validated signatures we evaluated in this study, would help inform more precise treatment and prescriptions for individuals," Ma added.

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The National Institute of Mental Health has more about depression .

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Cognitive group therapy for depressive students: The case study

Juhani tiuraniemi.

University of Turku, Department of Psychology, University of Turku, Finland

Jarno Korhola

The aims of this study were to assess whether a course of cognitive group therapy could help depressed students and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. “Johanna” was a patient in a group that was designed for depressive students who had difficulties with their studies. The assimilation of Johanna's problematic experience progressed as the meetings continued from level one (unpleasant thoughts) to level six (solving the problem). Johanna's problematic experience manifested itself as severe and excessive criticism towards herself and her study performance. As the group meetings progressed, Johanna found a new kind of tolerance that increased her determination and assertiveness regarding the studies. The dialogical structure of Johanna's problematic experience changed: she found hope and she was more assertive after the process. The results indicated that this kind of psycho-educational group therapy was an effective method for treating depression. The assimilation analysis offered a useful way of analysing the therapy process.

Introduction

Clinical depression is one of the most common mental disorders (Kessler, Berglund, Demler et al., 2003 ). Approximately 5–6% of Finns suffer from depression (Isometsä, 2001 ; Isometsä, Aro & Aro, 1997). Students suffering from depression often have difficulties in coping with their studies (Brackney & Karabenick, 1995 ; Kessler & Walters, 1998 ; Lyubomirsky, Kasri & Zehm, 2003 ), and a strong association has been found between depressive symptoms and stress (Mikolajczyk, Maxwell, Naydenova, Meier & Ansari, 2008 ). According to their own estimation, 53% of American college students had suffered from depression during their studies (Furr, Westefeld, McConnell & Jenkins, 2001 ). Over half of those who had experienced depression stated that problems related to studying were the most important depression-inducing factor. Therefore, there is a close connection between depression and studying difficulties.

According to Isometsä et al. ( 1997 ), of those who suffer from depression, 50% feel they need mental health services. Of depressed students, 17% seek help for their problems (Furr et al., 2001 ). Depression diminishes a person's ability to act through various mechanisms. Being depressed has a lowering effect on a student's sense of self-efficacy (Beck, 1976 ) and it lowers the expectations of doing well with one's studies (Brackney & Karabenick, 1995 ). A depressed student may feel that he/she will not complete his/her studies like everyone else. The fatigue, the powerlessness and the lack of concentration that accompany depression also reduce the student's ability to function.

Depression affects academic performance and ability to act through the students' motivation and their use of studying strategies (Brackney & Karabenick, 1995 ; Lyubomirsky et al., 2008). Often, depressed students are not able to plan their studies efficiently or observe their own work. They may have difficulties in sufficiently regulating their time-use, their study environment or the amount of work they pour into their tasks. Cognitive-behavioural therapy resulted in a significant improvement in perceived stress, depressive symptoms, reduced use of avoidance coping strategies, and more use of approach coping strategies among university students (Hamdan-Mansour, Puskar & Bandak, 2009 ).

Persons with depressive symptoms often seek validation for their own needs and actions from other people (Clark & Beck, 1999 ). In this manner, they strive to prove their worth, their competence or their likeableness. Those suffering from depression often have limited social skills (Segrin, 2000 ). This leaves a student in an adverse position, because there is an inseparable social side to student life.

Sometimes a depressive person is troubled by the aspiration to be extremely competent and efficient. Perfectionist tendencies involve high expectations of oneself, and an individual's self-respect is based on the perception of one's own efficiency and competence (Chang & Sanna, 2001 ; Cox & Enns, 2003 ). Perfectionists have difficulty working with others and find asking for help very difficult (Brackney & Karabenick, 1995 ). In a student, high expectations of competence may be manifested as, for example, a great amount of work done, good marks and dissatisfaction with a performance that did not reach the desired level and is not consistent with one's self-image.

There has been quite a lot of research on the effects of cognitive-behavioural group therapy as a treatment for depression. According to the extensive mapping by DeRubeis and Crits-Christoph ( 1998 ), treating depression with cognitive-behavioural group therapy is efficient and useful. Kush and Fleming ( 2000 ) have had similar results. In their therapy, they tried to teach the patients skills that diminish depression and anxiety. For example, they tried to develop the patients' problem-solving skills. Treating depression with cognitive-behavioural group therapy has proven efficient and useful (Bright, Baker & Neimeyer, 1999 ; DeRubeis & Crits-Christoph, 1998 ; Kush & Fleming, 2000 ; Kwon & Oei, 2003 ). Cognitive behavioural group therapy has led to reduction in the levels of depression, negative automatic thoughts, and students' dysfunctional attitudes (Hamamci, 2006 ). It has been proven that the symptoms of depression lessen during therapy.

Brackney and Karabenick ( 1995 ) stated that psychotherapy aimed at students suffering from depression should contain instruction on structuring one's studies and on life-control skills . The patients should also be taught means of mood-control to improve their concentration and they should be encouraged not to ruminate and wallow in their depression (Lam, Smith, Checkley, Rijsdijk & Sham, 2003 ). Certain group-members' individual factors can predict their benefit from group therapy: mild depression in the beginning of the group work, a feeling of being in control of the situation, the group's cohesiveness and the ability to function as a group (Hoberman, Lewinsohn & Tilson, 1988 ). According to Pace and Dixon ( 1993 ), short-lived cognitive therapy lessens the depressive symptoms and also helps the schemata related to a more positive self-image.

Greenberg ( 2002 ) has stated that the change happens by activating an unadaptive schema to which an adaptive feeling is then attached. For instance, an unadaptive schema created by loss can be changed by grieving, that is, by adding the feeling of grief to the schema. According to Guidano ( 1991 ), the superficial and deep level change-processes do not exclude each other; in fact, superficial changes may promote deep level changes. In the assimilation model (for example Stiles, 2002 ; Stiles et al., 1990 ; Stiles et al., 1991 ), the change occurs by the assimilation of problematic experiences into a particular schema or schema chart. This can be described in eight different stages.

The change has been described in stage theories. The transtheoretical model posits that health behaviour change involves progression through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997 ). Precontemplation is the stage wherein individuals are not aware of their problems, and they are resistant to change. In the contemplation stage, they are aware of their troubled behaviour but they are not committed to action. In the action stage, they change their behaviour and in the maintenance stage they try to prevent relapse. The assimilation model is more detailed and the description of cognitions and emotions is more specific. With the aid of the assimilation analysis, it is possible to delve into the cognitive and emotional changes that occur in the patient's problematic experiences and to evaluate the change process. The analysis is not just about the final result of the therapy: the problematic experience and the stages of changes the individual goes through are observed and assessed at different phases of therapy (Stiles et al., 1990 , 1991 ; Stiles & Osatuke, 2000 ).

A series of case studies has been executed using assimilation analysis (e.g. Brinegar, Salvi, Stiles, & Greenberg, 2006 ; Leiman & Stiles, 2001 ; Stiles et al., 2006 ). Assimilation analysis allows for focus on the focal points of the process. Using a case study has some advantages, e.g. the possibility to describe detailed process in psychotherapy, but there are some limitations. Behaviour can be described, not explained, and a case study cannot be representative of the general group or population. However, there is a need for process descriptions when we want to find a means to help depressive students who have problems in their studies. The evaluation of the case can also be susceptible to mistakes. For example, the researcher can see the change more positively or in the perception that other psychological phenomena can happen. In the evaluation, one must indeed be conscious of this , and be able to change a perspective for a subject so that mistakes in the evaluation do not take place (Montgomery & Willen, 1999 ).

This study depicts the change process of a student's psyche. The aims were to assess whether a course of cognitive group therapy could help depressed students with their problems affecting their studies and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. This study was carried out using assimilation analysis to try to interpret and understand the contents of the subject's problematic experiences and the change she underwent through the sessions.

Research methods

The basic materials of this study are Johanna's (the name has been changed) discussion contributions that were singled out from taped group sessions. Johanna is a university student suffering from depression.

The group consisted of six students suffering from depression and studying difficulties. Altogether, the group met 16 times and the sessions lasted two hours each. In its final form, the group was composed of five women and one man. One student stopped attending the course after four times. The members' ages varied from just over 20 to a little over 40 years of age. Five of the members were at the final stages of their studies, and one was at the beginning of them. Some students were receiving treatment elsewhere, but we had no exact information about other care or treatment. Those who were at the final stages of their studies had particular difficulties with their theses and their studies had been delayed. The research subjects were referred to take part in the course and in this research by the Turku branch of Finnish Students Health Service (FSHS).

In the beginning of the course, the goal was to activate the participants. At a later stage, more attention was paid to the feelings of helplessness and powerlessness and how these feelings affected the participants' studying performance. The contents of the group sessions and the themes covered in each of them are depicted in Table I . In the beginning of the course, students made exercises in problem-solving methods. The basic elements in cognitive therapy are behaviour techniques, methods for studying beliefs and thoughts and techniques for managing emotions and feelings. The students analysed the things that hinder their studies and goals. After that, they analysed their daily activities and planned new strategies for their actions and studies. They analysed the effect of thought and worked with their beliefs and thoughts. They made assertiveness exercises and learned new strategies for managing their emotions. At the end of the course, they evaluated what they had learned and what they have to do in the future.

Cognitive group therapy for depressive students: Course program and contents.

The criteria for participating in the course were: (1) depression (at least 13 points on the BDI-scale); and (2) constant absences from lectures or delay of studies. It was stipulated that suicide risk, bidirectional affective syndrome and acute crisis would prevent participation in the course. In addition, it was expected of the attendees that they possess enough concentration to carry out the assignments required by the course programme.

The preliminary interviews were conducted to assess who could benefit from this short-term, psycho-educative course. To have successful group therapy, preliminary interviews and the composition of the group have to be carried out with utmost care (Bernard et al., 2008 ). The group meetings were referred to as a course instead of group therapy, because its purpose was to be as non-labelling and as easily approachable as possible. The interviews and the composing of the group were conducted by the group leader.

The course consisted mainly of different assignments that the participants completed on their own time. At the sessions, the group leader led discussion about the assignments. The participants were given assignments such as mapping out their social network and thinking about problems that complicated their studies. The assignments were based on a book of exercises called Depressiokoulu (Depression School) by Koffert and Kuusi ( 2003 ). The depression school introduced in the book consists of ten lessons that were used in the course when planning the 16-session programme. The group leader's role was active and encouraging.

The therapist had six years of therapy education in cognitive therapy, and six years of education in family therapy. Furthermore, he had experience from working with the groups. The supervisor had qualifications of the trainer psychotherapist (cognitive therapy) and the work supervision was carried out during the group process.

The case discussed in this study was chosen on the criteria of informativeness and representativeness compared to other group members. Johanna (the name has been changed) was a university student suffering from depression. At the beginning of the course, Johanna was just under 30 years of age and living with her significant other. She was a student of natural sciences and her studies were at the stage where she was to write her thesis.

Johanna's studies had been stuck for 18 months. Carrying out the studies seemed utterly overpowering to her. She had found other things to do instead of studying, such as household chores. Johanna felt that she no longer had any ambition to study and in addition, her motivation to study her chosen field was running low. This was, at least in part, due to the lack of jobs in the field.

Johanna felt that she had fallen hopelessly behind from her fellow students. She avoided meeting her course mates and spoke to virtually no one about her studying difficulties. She said that she lacked concentration. Johanna felt she was lazy and inefficient. She described herself as bad and a failure, both as a student and as a person. She had worked during the summers and the work had gone well.

Depression represents a mode that has been named loss or deprivation mode (Clark & Beck, 1999 ). There were indications of each of the schemata included in the mode in Johanna. In Johanna's case, feelings of hopelessness and the loss of pleasurable feelings (motivational scheme) were particularly noticeable, in addition to passiveness and withdrawal (behavioural scheme). Johanna felt dispirited (affective scheme) and she had difficulty in coping with her studies (physiological scheme). The threat of loss (cognitive-conceptual scheme) was only suggestive, which in Johanna's case would have meant possibly giving up her studies entirely.

The subject's depression was assessed with the Beck Depression Inventory self-assessment form that had been translated into Finnish (Beck et al., 1961 ) that comprised of 21 items. In each item, there are 4–7 alternative statements that have been awarded points from 0 to 3. The items depict attitudes and symptoms related to depression and the severity of the depression from neutral to severe (0 = neutral, 1 = mild, 2 = relatively severe, 3 = severe). The full score of the BDI is 63. The clinical norms of the Inventory are: neutral or not depressed (0–9 points), mildly depressed (10–18), relatively severely depressed (19—29) and severely depressed (30 to 63) (Beck, Steer & Garbin, 1998). The form is a reliable and valid tool for assessing the severity of depression (Beck et al, 1988 ; Beck, Ward, Mendelson, Mock & Erbaugh, 1961). The indicator also gives information on changes in the severity of depression, so it is also a reliable aid when examining the effects of therapy (Beck et al., 1961 ).

The BDI-form was used to gather information in the middle of the course, both midways through it and at the end of it. The subjects were also given a form to fill out approximately two months after the group sessions had ended. In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe.

Assimilation analysis is a research methodological trend used for measuring the effects of psychotherapy. According to Stiles et al. ( 1990 , 1991 ), the client's troubling experiences assimilate into already existing knowledge structures in successful psychotherapy. In the course of the therapy, the client aims to give his/her experience new meanings and the experience integrates into a part of the client's schema structures. The assimilation model takes into account both emotional and cognitive change processes. To analyse the stages of assimilation, we can use the APES (Assimilation of Problematic Experiences Scale) developed by Stiles et al. ( 1990 , 1991 ). The stages of assimilation are demonstrated in Table II .

Summary of the stages of assimilation of problematic experiences scale (APES).

Assimilation can be examined as a continuum in which the assimilation of the problematic experience progresses with the progression of therapy. Assimilation progresses in stages and it is notable that the patient's assimilation process can be at any stage when the therapy begins (Stiles et al., 1990 , 1991 ). Assimilation does not progress rigidly and systematically; there can be regressions.

The closer the client is to understanding the problem, the more focal the problematic experience becomes in his/her consciousness (APES 4, Table I ). From this stage onward, the amount of conscious effort aimed at the problematic experience begins to decline. The neutral state of mind in the beginning of the assimilation process reflects a successful denial of the problem. As the client becomes increasingly aware of the problematic experience, the tone of the emotions becomes more negative. As the assimilation progresses, the anxiety will gradually lessen and the mood becomes more positive: the problem is understood and solved. When the problem is under control, emotions regarding it become neutral.

Data collection

The assimilation analysis can be carried out in many different ways (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). However, it is possible to separate four steps that one can follow to ease the process.

I Getting to know the data and listing

In this study, the basic data consisted of videotapes, consisting of approximately 30 h of footage. The analysis was begun by watching all the tapes through carefully (carried out by JK, the other author of this article). He noted the topics the subject addressed in the order they were discussed. The topics noted were attitudes or actions directed at a specific object. The topic could be, for instance, hopelessness in regards to writing the thesis and studying. The main purpose of this work stage is that the researcher acquaints himself with the data as much as possible.

II Recognizing and choosing the themes

The theme that will be examined can be a repeatedly expressed attitude or object (Stiles et al., 1991 ; Stiles & Osatuke, 2000 ). The research problem directs the choice of theme. The researcher can choose a theme that is (a) focal or important in the therapy, regarding which; (b) there has been remarkable progress, regarding which; (c) there has been little or no progress; or (d) some other interesting theme. It is best to describe the chosen theme's contents as clearly as possible, for example, by using certain key words.

In this study, the themes were chosen on the grounds that these topics seemed to emerge as focal and important for the subject. In this subject's case, her relationship with herself as a student was most prominent, because the subject brought this topic up constantly when she spoke up. The course dealt with many factors related to studying difficulties. Mainly because of that, the central themes, such as problematic experiences of the subject, were related to studying and difficulties therein.

III Separating parts related to the theme

At this stage, the parts of the material that deal with a certain theme or problematic experience are collected from the material (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). In practice, at this stage the footage was viewed again. By now, the material had already been quite well outlined since the subject's topics had been listed. At this stage, the subject's addresses were actually transcribed word for word.

IV Description of the assimilation process

At the final stage of the analysis, the assimilation is examined from a theoretical point of view. The examination is based on what happened to the problematic experience during therapy. In this study, the examination was performed by classifying the parts that dealt with the themes according to the theoretic stages of assimilation (APES).

Ethical considerations

Names and identification data were changed so that the person is not recognizable. The students were told that the sessions were videotaped for the purpose of the study and the data would be published in a scientific forum. After that, all information would be destroyed. The information was also given in the paper, and they signed on the dotted line.

We named Johanna's problematic experience as a difficult relationship with herself. In the beginning, this was unclear. Johanna's APES was 1/7: she preferred not to think about her problematic situation and her feelings were anxiety and anger. The connection between Johanna's feelings and the problematic experience was unclear. In the fourth session, the problematic experience was identified for the first time. In the seventh and eighth sessions, her understanding of her problematic experience increased. Her understanding fluctuated back and forth. At the end of the course, her attitude gradually became assimilated into her schemas: she found new perspectives on her academic problems. The connection between intervention and its results can be found by describing the therapy process and reporting the relevant utterances (McLeod, 2001 ). In the next section, we describe the process by showing some of Johanna's comments during different sessions (APES number shows the stage in assimilation model, Figure 1 ).

The results of APES analysis over the course of the 16 group sessions. The Y axis shows the stages in the assimilation model. The X axis shows the number of the sessions.

In the first session, Johanna expressed her hopelessness regarding her thesis. In her speech, there was also an emphasis on her sensitivity to criticism and to other people's advice. The connection between Johanna's feelings and the problematic experience was unclear (APES 1: unwanted thoughts):

Johanna: …I've been studying seven years or started these studies seven years ago. And the thesis I've been doing for a bit over a year [is] going nowhere. It's like that no one can say anything about it. I can't listen to any advice on it and the like. And no one close to me can say anything like now I'll get so down if I can't get it done. And then I really can't get it done.

In the second session, Johanna expressed that she was very critical of herself and of her progress in her studies (APES 1.5: unwanted thoughts and vague awareness):

Johanna: …Now I've totally been lazin' and stuff. Like I left my job last year so that I could work on that thesis. I haven't been working on it. I haven't been able. Then it becomes like kinda …that you can't like …like, you can't allow anything nice to yourself, you know. It's like I should be doin' it now that I got the time. Therapist: Let me clarify, you mean that when you feel you haven't done enough, then you can't like enjoy yourself or just do nothing.

During the third session, the group discussed the fact that it would be good to commend oneself every day for the things one has done. Johanna found it quite hard to give herself credit (APES 1.5: unwanted thoughts and vague awareness).

Therapist: How can you give credit? What could you tell yourself, for example, Johanna? Johanna: I dunno. Therapist: Try it. …Or think about it. Johanna: Well maybe like that you've been doin' stuff all day. That you haven't like ran outta steam in the middle. Therapist: Yeah. So you could say daily that you've done well.

In the fourth session, Johanna disclosed that she felt she lacked the self-discipline required to write the thesis. The problematic experience began to take shape (APES 2: vague awareness/emergence):

Therapist: Johanna, would you like to say something to this? Johanna: I dunno, I got like …that thesis; it's like mainly the self-discipline. …That I'd like have enough discipline to, like, take a hold of it. Cos sure I'd rather be somewhere else doin' somethin' fun.

The difficulty that Johanna experienced in giving herself credit came up again during the fourth session. She expressed the existence of a problematic experience quite directly (APES 3: problem statement/clarification):

Therapist: And Johanna, have you remembered (to give yourself credit)? Johanna: [Shakes her head] No. Therapist: You haven't? Johanna: It's somehow not. …It goes against my nature. I don't know how. …I can't. Therapist: That, that when you try, then you've done so much everyday stuff. Then you do a huge amount. It's like an employer not paying salary. So then … You get through so many, many difficult things.

In the seventh session, Johanna told the group that undone work dampened her spirits and paralyzed her from acting. Her understanding of the problematic experience was improved (APES 4: Understanding/insight):

Johanna: My last week was like, that I was sick on the weekend and early in the week … Therapist: When you got better, what was the biggest obstacle that you didn't touch those papers? Johanna: I dunno. Maybe it was a kinda feeling of incapability that just like took me with it. Therapist: Did you then have this feeling like everything's gone to waste or? Johanna: Yeah. Not when I was sick, then I just didn't have the energy. So that, I just let slide. But um then that … Then after it I'd just lost that whole week. It's like, it's gotta start with Monday or it won't start at all. I just got that feeling. Therapist: It's funny, that it's kinda like a sort of programming. But d'you think that this thought of everything going to waste paralyzed you? Johanna: Yeah, probably.

In the eighth session, Johanna groped for words as she tried to describe her new views on studying and writing her thesis that she had learned from the course. Here, Johanna's newly-found tolerance toward herself and her behaviour was apparent. Writing her thesis no longer seemed completely mandatory; instead, Johanna felt that she could do other things, even if she was not working on her thesis. She worked on her problematic experience further (APES 5: application/working through):

Johanna: …I got a lot of new views from others and stuff to think about. Therapist: Which new views did you get? Johanna: Well … The one about that um … you do little by little and then you can like rest. And like that when you don't give yourself permission to do. That it would be like important just so that you can stay in shape and then work again. Therapist: Wait, did I get this right, that when you something, you'd do it. But then on the other hand you'd give yourself permission to do other stuff and enjoy that too. Was that what you meant? Johanna: Wait a sec …I meant that like, if you're not doing the thesis, it's still okay to do something else.

In the ninth session, Johanna felt that giving herself positive feedback was quite difficult. She was, however, able to give herself some positive feedback, but negative thoughts and criticism took over her mind very easily. This depicted Johanna's severity on herself (APES 4.5: understanding and working through).

When the group had met ten times, Johanna had been able to become more active with her thesis. She still felt, however, that the more she focused on studying, the lower and the more desperate she felt. Criticism and severity could be heard in Johanna's speech (APES 3.5: problem statement and understanding).

In the eleventh session, Johanna said that she needed instruction on her thesis, but she was afraid of going to meet her instructor. Here, Johanna's feelings of hopelessness with her studies and her thesis became apparent. Alternatively, it seemed that she was ashamed that she had not achieved what she thought was enough (APES 4: understanding/insight):

Johanna: I'd really probably need like my own field's point of view at this stage and …I just somehow don't dare to go to the department. …I just don't dare go there. Therapist: What scares you? Johanna: I dunno. It just makes me feel like that, I'm a loser and I'm so totally lousy, and now it's been so long, and more time just keeps passing. It's like this endless circle … or kinda like, it's too late now.

Later in the same session, Johanna said that she felt she got support from the group. She worked on her experiences some more. The emotional tone was positive and optimistic (APES 5: application/working through):

Therapist: What do you hope from us (the group)? Johanna: Well, I hear all kinds of … well I hear stories here, survival stories. [Laughs.] Therapist: [Laughs.] This is a survivors' club. Johanna: Maybe that kinda gives hope, that maybe I'll be brave enough to go there [to the instructor], because now I've got it figured out what my next step is, that I should take to get forward.

In the twelfth session, Johanna reflected upon her determination to work on her thesis (APES 5: application/working through):

Therapist: …Now that you've been more active, what's helped you? Johanna: Well just that like you've decided once and for all that now you gotta do it. That I … well first of all, I went to see the professor right then, that week [Therapist: Yeah.] when we talked here. Therapist: Good, great. Yeah. And you didn't get eaten there. Johanna: Right. And now I have this like …or that kinda feeling that it's now or never. That otherwise it will just stay here, and I can't leave it now. It'd be even harder to start. Therapist: So does that mean that you've made yourself an action plan? Johanna: Well, a bit like that, yeah. That I don't have to have like a schedule [Therapist: On how you'll go on.] but just so that …. Johanna: Every day I should get something done. –

In the thirteenth session, Johanna brought up the fact that she could get studying done little by little. She had learned to have mercy on herself (APES 5.5: application/working through and problem solution):

Therapist: How about your studies this week? Johanna: Well. I studied stuff on Tuesday and Wednesday. Therapist: Great. Johanna: But then I've had these gap days. Therapist: Have you given yourself credit? Johanna: Well, I have tried or at least be happy even if I don't do a lot. Cos I get something …like reading stuff. Therapist: This sounds great. So what's your recipe now? Johanna: Like one day at a time. If it feels bad, then you can like …give it a rest, you know, and do something else.

In the fourteenth session, Johanna listed her short-term priorities. Her short-term aims reached the time-line of approximately six months. In addition to working on her thesis, Johanna mentioned recovering even further from her depression as a goal. In addition, the fact that Johanna was happier with herself was clear; this had increased during the group sessions (APES 5.5: application/working through and problem solution):

Therapist: How about Johanna? Johanna: Well I pretty much have the same things [as the others] that I've put down. I wanna have the thesis like up and running, so that it kinda takes care of itself or that like …I could see the end of it already. And that I'd move past the depression, that I'd be like rid of it already. I dunno. That I'd be happy with myself. Therapist: You have that too, to be happy with yourself. Johanna: Yeah. Or like, yeah. Therapist: Yeah. Do you feel that it's increased during this group, that being happier with yourself? Johanna: Yeah, probably.

The fifteenth and the sixteenth meetings of the course were held together as a single four-hour session. During this session, it came up that Johanna was less critical of herself. She said she could write her thesis gradually (APES 6: problem solution):

Therapist: What have you done lately when you said ‘I've done’? Johanna: And that um …I've been reading. Reading some of the stuff I got, some materials. And then I've just written straight to the computer. And that text doesn't matter at this stage that it's just like some text. Therapist: Yeah. Johanna: That I can like mould it later into what I want. That's just it, cos it's that starting up that's hard for me, that writing is kinda hard. I could really think about one sentence for half an hour. Then it's just gonna go nowhere. So I'll just write then, even if it's not perfect language yet. Therapist: It's probably good that you do it like that. Johanna: It's like I get something done. I get that kinda … Therapist: So is this a new method that you've developed, that you just write ahead? Johanna: Well, yeah. I think it kinda is. The whole time it just kinda gets more fluent and like um …the text [Therapist: Yeah.] and the like, the way it comes out. [Therapist: Yeah.] And It's probably the reading too that does it, the more familiar the thing is the easier it gets, of course and the easier it maybe is to write.

Johanna felt that her beliefs regarding her own actions had changed. She had found new perspective and relief for her problems from the group (APES 6: problem solution):

Therapist: But Johanna, is it kinda like, you've seen that these kinda things don't have to knock you down, that you've then changed your beliefs on your own actions? Johanna: Yeah. Or like. … That this [problems with the thesis and depression] isn't such a big monster anymore. Then when here you've had to and it's been okay to talk about it, then it's not. … It's like easier to take that thing. It's not so big anymore. That you can talk about it. You gotta bring it up once a week anyway, it gets smaller. I don't really know.

As the course went on Johanna was increasingly vocal about having mercy on herself and being happy with herself. She spoke about having received support from the group and was learning to commend herself. Little by little, she became less critical toward herself. She had more room in her inner world. Her tolerance toward herself had a positive impact on Johanna's ability as an actor. She began to work on her studies gradually and it also became easier for her to do other things besides studying.

Finding the ability to be merciful led, in Johanna's case, to increased determination and assertiveness regarding her studies. She wanted to finish her thesis and felt that the thesis was no longer “some monster.” In other words, Johanna got more motivation to continue her studies and to finish them. These new views formed another self-state in Johanna. Johanna's symptoms of depression eased and her ability to act improved.

In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe. Four months later, the score was 23 and two months after that, it was 19. At this point the course was finished. A follow-up measuring three months later showed the score was 12, which meant that Johanna was, according to the BDI-indicator, only mildly depressed. Johanna's BDI-score kept decreasing throughout the course, and also after it. She felt that her depression eased during the group meetings.

Johanna's problematic experience (APES) progressed as the meetings continued from level 1 (unpleasant thoughts) to level 6 (solving the problem) ( Figure 1 ). In the beginning, Johanna's problematic experience manifested itself as severe and excessive criticism toward herself and her study performance. The assimilation of Johanna's problematic experience was facilitated by learning different methods of depression control in the group.

Discussion and conclusions

During the course, Johanna directed her energy toward surviving depression, finishing the course and carrying out the assignments given in the group. If working helped in recovering from depression, we can assume that after the course, Johanna had even more resources to direct her actions at, for instance, her studies and particularly on writing her thesis.

Johanna expressed plenty of severe and excessive criticism aimed at herself during the course. According to Guidano's (1991) theory, “I” represents the experiencing and reacting side of the human mind and “self” represents the evaluating and observing side. In Johanna's case, “me” was very rigid and severe, even merciless. This side of her mind attributed that the lack of progress in her studies and other negative experiences were her own fault. Depressive, negative attribution style is a central method of self-regulation in depression (Beck, 1976 ; Beck, Rush, Shaw & Emery, 1979 ). In Johanna's case, the rigid and severe “me” produced negative, permanent inner attributes. These assessments were the source of the severity and harsh critique she directed at herself. By examining this according to Guidano's (1991) theory, Johanna became more lenient in the assessments “me” made of the actions of “I”. This was seen in Johanna's case as the depressive, negative attributions becoming less prevalent.

Of the schemata belonging to the loss or deprivation mode, the behavioural scheme, in particular, changed in Johanna's case during the course. Passiveness and withdrawal made way for her new determination and assertiveness toward her studies. The feelings of hopelessness seemed to go away, so the motivational scheme can also be said to have changed for the better. Alternatively, Johanna reported that her role as an actor regarding her studies remained rather passive throughout the course. The contents of the affective and physiological schemata also underwent a positive change. Johanna's melancholia eased and she gained strength to continue her studies.

The assimilation of Johanna's problematic experience was facilitated by her learning different methods of depression control in the group. Treatment aimed at depressed students would do well to teach structuring one's studies and methods of mood-control and life-control skills (Brackney & Karabenick, 1995 ; Lam et al., 2003 ). The approach of this course was specifically psycho-educative. Johanna felt that she had also received peer support from the group: she had heard how the other group members had managed to get their studies started.

One of the focal questions in this study was whether or not finishing the course helped in combating depression and studying difficulties. The results indicate that the subject's depressive symptoms eased and her role as a student became more active. In the group, mood-improving techniques were also taught. The depression-control skills taught were important.

When examining the change process, we can distinguish two kinds of change processes: superficial and deep changes (Guidano, 1991 ). The group members' troubling feelings were not discussed at great length in the group. This can be a sign that the achieved changes happened mainly on the superficial level of the psyche. Deep level change cannot take place without active work on the emotions related to the problematic experience (Greenberg, 2002 ; Greenberg & Paivio, 1997 ; Guidano, 1991 ). Thus, the achieved changes are not necessarily very permanent. In the follow-up meeting, the subject's BDI-score had continued to decline, although she was still, according to the BDI, mildly depressed.

In Johanna's case, the single most important factor that promoted change was sharing and examining the contents of the problematic experience with the therapist and the group. The group members took turns in examining their problematic experiences in the group and in this way, they supported each other. All members felt that peer support was important. The group leader taught mood-control skills that each group member exercised independently outside the group. Johanna reported that she had found learning how to schedule her time particularly useful.

Johanna's problematic experience became less restrictive through the course. This led to more lenience toward herself and more determination and assertiveness toward her studies.

The downside of working in a group was the fact that the attention of the therapist and of the whole group was divided among six people. At times, it seemed that none of the group members had the opportunity to express and work on their issues adequately in the session time frame. The therapist took an encouraging and supportive approach: he actively strove to pay attention to each group member and to include them all in the discussions. On several occasions, however, it seemed that the two-hour session was far too short a time for this group.

Some of the group members were receiving treatment elsewhere while they attended the course. Consequently, in this study we could not control, for instance, the effects of medication on the lessening of a person's depressive symptoms. In addition, some group members had a discussion contact with a mental health professional outside the group.

In assimilation analysis, determining the subject's APES stages was sometimes rather difficult. At this point, the summary of the stages of assimilation ( Table II ) was quite helpful. It was often so that a seemingly essential utterance by the subject was found, but determining the APES stage was difficult nonetheless. Eventually, seemingly correct stages were found for all excerpts. Finding the correct APES stages was aided by repeatedly reading the subject's utterance and assessing the excerpt according to the amount of cognitive processing and in light of the emotional content. However, the final text probably contains utterances that could have been rated otherwise. Thinking critically, the data achieved by assimilation analysis could be said to be, in all its detail, merely approximate and dependent on the researcher's interests. Alternatively, we should, of course, bear in mind that the APES stage given to a single utterance is not very significant in the scale of the entire change process.

In Johanna's case, the conceptualized problematic experience could have been, for instance, hopelessness regarding studying, and the effect of negative thoughts on studying or getting support from other people. In this case, the research problem directed the choice of themes. Furthermore, the problematic experiences had to be such that they could be conceptualized into suitable units.

The fact that the analysed data is mainly linguistic can be seen as a weakness of the assimilation analysis. This deficiency is a drawback with most qualitative research methods. The verbal descriptions of the subjects do not always accurately convey the relevant contents of the meanings or the emotions related to them. However, if the analysis is to be successful, it has to recognize the subtle nuances and feelings from the material. That is why we used videotapes: the chance to check the process in video deepens the researchers' understanding.

The very concept of a problematic experience can easily be challenged. In this study, the subject's problematic experiences were the themes that were discussed often and at length. However, other criteria could have been used to choose the problematic experience. The themes conceptualized as problematic experiences could also have been, for example, themes for which there was great progress or for which there was little or no progress at all. Alternatively, another interesting theme could have been chosen.

From an economical point of view, it must be mentioned that with a course such as this, a large number of people can be treated relatively quickly. Nowadays, there is pressure to treat depression as cost-effectively as possible (Bright at al., 1999). Group treatment is substantially less costly than individual treatment. The studied group had 16 gatherings, and sessions were two hours each. The group had six members from beginning to end. If they had each had an individual appointment 16 times, there would have been 96 meetings altogether.

One viewpoint is that coping with depression can be taught. One outlook could be introducing depression school as a part of general, basic health care, for instance at schools. The aim could be to teach mood-control skills to persons predisposed to depression, before they become ill. It would be reasonable for the sake of these people themselves, because it would save them from a great deal of human suffering. In addition, this practice would be sensible for society as well, because economically, it would be much less costly than long-term treatments and sick leaves. However, more research is needed to determine this.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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