Open Journal of Depression
2013. Vol.2, No.2, 11-15
Published Online May 2013 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2013.22003
Behavioural and Cognitive Treatment Interventions in Depression:
An analysis of the Evidence Base
Joanna L. Iddon1, Lee Grant2
1Wilbraham Place Practice, London, UK
2Efficacy CBT, London, UK
Received January 30th, 2013; revised March 5th, 2013; accepted March 16th, 2013
Copyright © 2013 Joanna L. Iddon, Lee Grant. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Depression has been determined to be the leading cause of disability and the 4th leading contributor to the
global burden of disease and is characterized by relapse, recurrence and chronicity (WHO, 2007). A sys-
tematic review of several meta-analyses on treatment outcome supports the view that Cognitive Behav-
ioural Therapy (CBT) is an effective treatment (Butler et al., 2006). However, CBT is not a single inter-
vention, but has evolved from various theoretical perspectives, resulting in different theoretically congru-
ent treatment techniques for depression. It is therefore important to understand which treatment ap-
proaches may be the most effective. This review provides an analysis of the evidence base comparing
CBT with Behavioural Activation (Martell et al., 2010). 3rd wave approaches and the Six Cycles Mainte-
nance & Treatment Model (Moorey, 2010) are presented in the context of how they can add to the effec-
tive treatment of depression.
Keywords: Depression; Cognitive Behaviour Therapy; Behavioural Activation; Metacognitive Therapy;
Mindfulness
Introduction
Depression has been determined to be the leading cause of
disability and the 4th leading contributor to the global burden
of disease and is characterised by relapse, recurrence and chro-
nicity (WHO, 2006). A systematic review of several meta-
analyses on treatment outcome supports the view that Cognitive
Behavioural Therapy (CBT) is an effective treatment (Butler et
al., 2006). However CBT is not a single intervention, but has
evolved from various theoretical perspectives, resulting in dif-
ferent theoretically congruent treatment techniques for depres-
sion. It is therefore important to understand which treatment
approaches may be the most effective.
Cognitive Therapy
Aaron Beck’s cognitive model of depression (Beck, 1967,
1976) has been highly influential in informing treatment (Beck
et al., 1979; Fennell, 1989). The central basis of Beck’s theory
is around the development of (dysfunctional) schemas (i.e.
assumptions and attitudes) developed from previous experience,
which lay dormant until activated, thus he advocates an “inter-
nal” causation. The stress diathesis model suggests that certain
beliefs constitute a vulnerability to depression depending on our
life experiences, stressors may interact with specific cognitive
vulnerabilities to trigger depression (Clark, 1989). Anxiety
states. In Hawton (1989) etc. as cited in the Fennel reference
above.
Although the pure practice and effective implementation of
CBT that Beck advocated is complex, the principles for treat-
ment are relatively simple: “the therapist helps a patient to un-
ravel his distortions in thinking and to learn alternative, more
realistic ways to formulate his experiences”. Patients tend to
have a misconception of events and need to reappraise and
learn more adaptive attitudes (Beck, 1976). Beck described the
underlying rationale of a “negative cognitive triad” (self—cur-
rent experience—future). Beck’s cognitive therapy for depres-
sion was designed to be short term and structured (Beck et al.,
1979; Leahy, 2006) and consists of Activity Scheduling (AS) in
the early stages of the treatment of depression, particularly in
those patients with significantly diminished levels of activity
and cognitive techniques (to identify, question and modify
maladaptive thought processes, life rules and core beliefs).
There are multiple studies showing evidence that Beckian
CBT is effective, including being more effective (e.g. Butler et
al., 2006; Fennel, 2002; Rush et al., 1977) or at least as effec-
tive (Blackburn et al., 1981; Murphy et al., 1984) as antide-
pressant medication, although this may depend on therapist
experience Hollon et al., 1992). Beckian CBT has also been
evidenced to be useful in terms of preventing relapse (Murphy
et al., 1984; DeRubeis, 2005; Kovacs et al., 1981; Blackburn et
al, 1986). There have been a number of meta-analyses (Paykel
et al., 2005; Dobson, 1989; Gloaguen et al., 1998) which
showed that CT was no less effective than medication and quite
possibly had longer lasting effects. Studies have hypothesised
that this is related to concrete “symptom focussed” methods of
cognitive therapy (DeRubeis & Feeley, 1990), through teaching
compensatory skills (Barber & DeRubeis, 1989) and through
in-session cognitive changes (Tang & DeRubeis, 1999; 2005).

J. L. IDDON, L. GRANT
Beck’s daughter, Judith has gone on to develop an up-to-date
“brand” of cognitive Therapy (Beck, 1995).
Behavioural Therapy
Behavioural treatment of depression can be traced back at
least to Ferster (1973), based on Skinner’s principles (Skinner
& Burrhus, 1957) who recommended a functional or “behav-
ioural” analysis, which can be used to “discover the kinds of
circumstances that can increase or decrease the frequency of
different ways of acting”. Lewinsohn (1974) took a slightly
different behavioural approach, focusing on increasing reward-
ing behaviour. Behavioural techniques are of course incorpo-
rated into CT (Beck et al., 1979), but are differentiated from
Beckian cognitive approaches of AS focusing on thinking dis-
tortions preventing unhelpful behaviours and maintaining and
developing helpful behaviours; “… the techniques are pre-
sented within the framework of a cognitive rationale, e.g., they
are explicitly used to test thoughts which block engagement
in such activities, or lead people to discount or devalue what
they do, and thus help to maintain the depression” (Fennel,
1989).
But What Is the Active Ingredient?
A Component Analysis
In 1996, Jacobson and colleagues published a landmark pa-
per of a component analysis of cognitive-behavioural treatment
for depression. The study compared three different conditions,
1) Becks behavioural activity monitoring (BA); 2) behavioural
activity with a teaching component designed to schedule activi-
ties to modify automatic thoughts (AS); and 3) full Beckian
Cognitive Therapy (CT). All conditions were administered by
skilled therapists and sessions were monitored for quality con-
trol and adherence to protocol. Its results and conclusions sh-
owed that all three treatments were equally effective both im-
mediately and at 6-month follow-up, but were radical in the
sense that BA and AS were equally as effective as CT at modi-
fying negative thoughts and maladaptive attributional styles,
even though in BA these were not specifically targeted. To be
clear, this component analysis study suggested that the active
ingredient in Beck’s cognitive therapy was the behavioural
activation component, which is distinct from Beck et al. (1979)
which states that interventions aimed at cognitive structures or
core schemas are the active change mechanisms.
Martell and colleagues (Martell et al., 2001) went on to de-
velop “Behavioural Activation” as an individual form of ther-
apy, which is an expanded version of the Beck behavioural
approach of activity scheduling. Veale (2008) describes that
BA has two main focuses:
1) The use of avoided activities as a guide for activity sched-
uling;
2) Functional analysis of cognitive processes that involve
avoidance.
Martell et al. (2001) provides a detailed book on the process,
which provides a clear rationale and detailed discussion of
treatment aims and directions and is associated with a model to
guide formulation and treatment. In BA, “the focus is on the
context of people’s lives rather than their thoughts, neurotrans-
mitters, beliefs or the psychological conflict thought to be in-
side them”, thus it advocates an “external” contextual focus.
Martell and colleagues (2001) provide a compelling argument
for why internal causes may not be the “zeitgeist” after all.
They explore the assumption that people tend to think of depres-
sion as some sort of “medical illness” and this is supported by the
ICD-10 diagnostic criteria of depression (WHO, 1992). Mar-
tell’s concept is that depression is rather a process occurring in
the context of difficult events in people’s lives, for example a
person may feel depressed because their wife leaves them (i.e.
the environment acts upon the person) which leads to a “de-
pressed response” (the person has an impact on the environ-
ment). The basis for their form of BA is that a person’s re-
sponse with depressive behaviour usually makes sense and
Martell points out that given a particular history, and current
context, withdrawal, avoidance, inactivity and rumination can
be understood as “adaptive coping strategies”, and this is the
basis of their theory.
The primary focus in BA is targeting avoidance and “acti-
vating clients” but is not simply about getting individuals to do
more. It’s about the quality and precise nature of their behav-
iours and the focus is on function (not form). So, for example,
one may work with a client on refining an over-compensatory
behaviour, e.g. in the example of a man being left by his wife,
he may “overcompensate” by buying elaborate presents for his
children, or taking them on trips after a long day at school,
whereas he found much more value in developing simpler ac-
tivities such as kicking a ball on the common, taking them for
fish & chips, planting tomatoes and reading a story to them in
bed.
Thoughts in Behavioural Activation
In terms of thoughts and beliefs, the BA perspective is dif-
ferent from the cognitive perspective. In BA the process of
thinking, but not the content of thinking is an important focus
of treatment (e.g. “What is useful about that thought?” “What
are the consequences of having that particular thought?” and
may draw on “mindful” techniques to consider the minute de-
tails of an activity. Again beliefs are treated differently, and BA
is not concerned about uncovering the real beliefs of a client (or
‘catching’ their thoughts), the focus is on getting (re-)involved
in their lives so that their behaviours will be positively rein-
forced. Beck et al. (1979), by contrast advocates that negative
automatic thoughts (NATS) are a product of errors in process-
ing and therapy helps a client practice identifying NATS
(within a context) and challenging these “What is the evi-
dence?” “What alternative views are there?” In this context
behavioural change is seen as a necessity to test and challenge
negative automatic thoughts, assumptions and schemata.
Comparison of BA and CT
In 2006, Dimidjian and his team published the outcome data
for a robust RCT, showing that BA was comparable to medica-
tion and both BA and medication significantly outperformed
cognitive therapy. Other studies have shown that BA is at least
as comparable (Butler et al., 2006; Ekers et al., 2008) but there
may be advantages of BA over CT as a more “streamlined”
form of therapy. Spates and colleagues (2006) published a sys-
tematic review of the literature in BA and a meta-analysis
showed an extremely favourable outcome, in terms of both
individual and group treatments, although there was no com-
parison with CT. The authors pointed out that at that stage there
were still only 11 papers to review, which when guiding the
12

J. L. IDDON, L. GRANT
worldwide treatment of depression and influencing government
guidelines is relatively few. Cuijpers et al. (2007) meta analysis
conducted a wider search on BA and was able to compare this
to cognitive treatments finding a greater effect size for BA over
AS and CT. The review has limitations but still has an encour-
aging support for the behavioural approaches. Sturmey (2009),
published a useful systematic review which suggests that BA
may have a lower drop-out rate than CT and CBT, with lower
relapse rates than Paroxetine as well as being cheaper, without
the risk of side effects. He also states the evidence is that BA
may be more useful in certain groups with whom CT and CBT
is less effective such as those with severe or long-term depres-
sion, substance abusers and people with dementia.
So What to Use?
In the UK the NICE guidelines for managing depression in
primary care published in 2007 and 2009 indicated “CBT”
(non-specific) as one of the recommended interventions, along-
side an SSRI antidepressant if appropriate. If there is co-morbid
depression with anxiety, the guidelines recommended targeting
the depression first as this can also help alleviate the symptoms
of anxiety. In the USA in 2010 the American Psychiatric Asso-
ciation published similar guidelines, advocating CBT as do the
Canadian guidelines (CANMAT—Parikh et al., 2009)—in the
Canadian review paper, further research is encouraged before a
clear distinction can be made between the efficacy of CT and
BA.
Roth & Pilling (2008) have included both CT and BA (Beck
et al., 1979; Martell et al., 2001) as evidence based methodolo-
gies in depression in their guidance on competencies. When
looking at the cognitive and behavioural techniques advocated
in their specific CBT competencies framework (www.ucl.ac.
uk/CORE/) it is interesting that they detail activity monitoring
and scheduling, guided discovery and questioning, thought
records and eliciting key cognitions, but in general terms with-
out making reference to choosing between a specific technique,
thus as they say “the jury is still out”. One could argue that one
is “covering the bases” by using traditional CT as it does have
an established and respected evidence base. However, BA does
appear to be a powerful (and relatively straightforward) tech-
nique that should be emphasised in any treatment of depression,
especially during the early stages and in cases that are at least
moderately severe. So BA, with possible effectiveness over CT,
certainly seems to possibly be the treatment of choice for the
future.
The 3rd Wave Approaches
Or is it? The evidence base suggests that at present, BA is at
least equal to CT when treating depression and may be superior.
However, it is important to mention two further recent cogni-
tive approaches of changing patients’ relationships to their
thoughts, which whilst having limited evidence bases at this
time, seem to hold promise: Meta-Cognitive Therapy (Wells,
2009; Fisher & Wells, 2009) and Mindfulness approaches (Wil-
liams et al., 2007).
Metacognitive therapy (Wells, 2009; Fisher & Wells, 2009)
puts another “spin” on the consideration of thoughts. Once
again it is distinct from Beck’s schema theory (Beck, 1967;
1976) and instead proposes that an “executive control proces-
sor” influences firstly metacognitive process (i.e. referring to
the level of thinking process that involves the generation over
the content of thoughts) responsible for healthy and unhealthy
regulation of the mind. Secondly the process of selective atten-
tion attends the person to ambiguous triggers and thus increases
the vulnerability of activation to NATs. An example of a meta-
cognitive process might be:
Content Thought “I am completely useless as a husband
and parent and will never be any good to anyone”.
Underlying Metatcognitive beliefs: “If I can understand {a-
ka ruminate} what I did wrong then I can fix it” leading to
worry or rumination; or “I am responsible and should be pun-
ished” leading to self attaching thoughts.
Wells (2009) proposes that emotional disorders such as de-
pression are caused by the “metacognitions that give rise to
thinking styles that lock the individual into prolonged and re-
current states of negative processing”. Treatment for depression
focuses on understanding the causes of rumination and then
removing this unhelpful process. A model and treatment plan is
proposed, including specific interviews which guide the thera-
pist to developing a formulation diagram (Wells, 2009). The
focus of treatment is on first recognising and then changing the
metacognitive beliefs (e.g. from “I cannot control my negative
thoughts” to “I can postpone worrying”; or from “I need cer-
tainty” to “I can accept uncertainty”) and not to focus on the
content of the rumination.
Mindfulness based cognitive therapy (Williams et al., 2007)
is also emerging as a treatment with a significant following
currently considered to be most useful in treating patients with
recurrent depression, whilst they are in remission. However,
mindfulness potentially has a wider application and there are
integral components to other evidence based CBT interventions
(Linehan, 1993). This approach has been developed from me-
ditative practices encouraging patients to adopt an observat-
ional stance to the continuous flow of automatic thoughts, emo-
tions and the corresponding physical reactions. The basic pre-
mise is that it is how we attend to internal process and react to
what is in our mind that is important. In essence by disengaging
from negative patterns of mental activity in a “mindful” way
(i.e. focussing in the “present”) promotes wellbeing. Rebecca
Crane (2009) has provided a useful summary book outlining the
basic principles and treatment approach based on Williams and
colleagues (2007).
Summary, Conclusion and Future Directions
As Roth & Pilling (2008) point out:
“CBT—gives the appearance of a unitary therapy, but CBT
is better seen as an increasingly diverse set of problem-specific
interventions. What is more, these draw on a common base of
cognitive and behavioural models, the techniques overlap, but
show significant variations in application”.
This statement summarises the complex nature of the field of
formulation and treatment in depression as it is today. The cur-
rent evidence base suggests BA be the current treatment of
choice, (which is distinct from AS in the cognitive paradigm)
but the landscape may look very different in even a few years
and so it is important to keep an open mind. Indeed further
evidence is warranted before “doing away” with Beckian CBT,
which has proved so successful in the clinical setting. Roth &
Pilling in 2008 point out that their research and recommenda-
tions will be out of date very quickly and will need constantly
reviewing and updating to take into account new evidence of

J. L. IDDON, L. GRANT
effectiveness of different treatment approaches prioritising be-
havioural change or cognitive change. Emerging new app-
roaches appear to overlap, particularly in terms of working with
the process of thoughts, and these may prove complementary to
each other. It would be naive to think that “one size fits all”, but
arguable that you cannot have process change without content
change and you cannot have content change without process
change. As clinicians we are left with the dilemma of which
intervention to match with particular presentations. Presently
the literature does not clarify how the variance in effect size for
a particular intervention is influenced by particular presenta-
tions.
It is important to state that depression, can present for many
different reasons and each client needs to be treated individu-
ally and appropriately. For example the authors have found a
non-genital sensate focus approach (Masters & Johnson, 1970)
useful for a couple who had ceased to have sexual intercourse,
that led to one partner developing symptoms of depression.
Another client depressed about being obese with cognitive and
behavioural distortions around approaches to food and eating
was successfully treated using Fairburn’s (2003) transdiagnos-
tic approach to eating disorders. Thus when choosing an appro-
priate treatment approach, both context and the collaborative
conceptualisation of the presenting problem needs to be taken
into account.
Looking to the Future
So ... for future consideration
1) What exactly are the differences between the CBT ap-
proaches (BA, AS, CT, MCT and Mindfulness) to treating de-
pression in practice (rather than theory) and how do these com-
plement each other?
2) What is the best approach to use with different clients? i.e.
when do we know what is the best approach to use with whom?
3) Given that the approaches draw on a common base of cog-
nitive and behavioural models, would a “trans-therapeutic”
approach or single conceptualisation be appropriate, whereby
overlapping evidence based approaches were incorporated into
a unified application?
Based on this principle, Stirling Moorey (2010) has devel-
oped an empirically based six cycles maintenance model for
depression in the form of a “vicious flower”. This was devel-
oped based on clinical utility and current knowledge of the
processes and maintenance factors in depression, with the aim
to inform formulation, socialisation and treatment planning. It
is a simple and clear model which will also be useful in teach-
ing CBT, incorporating 2 cognitive cycles (automatic negative
thinking and rumination/self attacking), 2 behavioural cycles
(withdrawal/avoidance and unhelpful behaviour), a mood/emo-
tion cycle and a motivation/physical symptoms cycle. Further-
more the model is innovative in having a potentially useful role
in relapse prevention work.
Acknowledgements
With thanks to Stirling Moorey for allowing us early access
to his manuscript.
REFERENCES
Barber, J. P., & DeRubeis, R. J. (1989). On second thought: Where is
the action in the cognitive therapy for depression. Cognitive Therapy
and Research, 13, 441-457. doi:10.1007/BF01173905
Beck, A. T. (1976). Cognitive therapy and the emotional disorders.
London: Penguin.
Beck, A. T. (1967). Depression: Clinical, experimental and theoretical
aspects. New York: Harper and Row.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive
therapy of depression. New York: Guilford Press.
Beck, J. S. (1995). Cognitive Therapy: basics and beyond. New York:
The Guilford Press.
Blackburn, I. M., Bishop, S., Glen, I. A. M., Whalley, I. J., & Christie, J.
E. (1981). The efficacy of cognitive therapy in depression: A treat-
ment trial using cognitive therapy, pharmacotherapy, each alone and
in combination. British Journal of Psychiatry, 139, 181-189.
doi:10.1192/bjp.139.3.181
Blackburn, I. M., Eunson, K. M., & Bishop, S. (1986). A two year
naturalistic follow-up of depressed patients treated with cognitive
therapy, pharmacotherapy and a combination of both. Journal of Af-
fective disorders, 10, 67-75. doi:10.1016/0165-0327(86)90050-9
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006).
The empirical status of cognitive behaviour therapy: A review of
meta-analyses. Clinical Psychology Review, 26, 17-31.
doi:10.1016/j.cpr.2005.07.003
Crane, R. (2009). Mindfullness based cognitive therapy. London: Rout-
ledge Press.
Cuijpers, P., van Straten, A., & Warmerdam, L. (2007). Behavioural
activation treatments of depression: A meta analysis. Clinical Psy-
chology Review, 27, 318-326. doi:10.1016/j.cpr.2006.11.001
DeRubeis, R. J. (2005). Cognitive therapy vs medications in the treat-
ment of moderate to severe depression. Archives of General Psy-
chiatry, 62, 409-416. doi:10.1001/archpsyc.62.4.409
DeRubeis, R. J., & Feeley, M. (1990). Determinants of change in cog-
nitive therapy for depression. Cognitive Therapy and Research, 14,
469-482. doi:10.1007/BF01172968
DeRubeis, R. J., Gelfand, L. A., Tang, T. Z., & Simons, A. D. (1999).
Medications vs cognitive behaviour therapy for severely depressed
outpatients: A mega-analysis of four randomised comparisons. Ame-
rican Journal of Psychiatry, 156, 1007-1013.
Dimidjian, S., & Team of 12 (2006). Randomized trial of behavioural
activation, cognitive therapy, and antidepressant medication in the
acute treatment of adults with major depression. Journal of Consult-
ing and Clinical Psychology, 74, 658-670.
doi:10.1037/0022-006X.74.4.658
Dobson, K. (1989). A meta analysis of the efficacy of cognitive therapy
for depression. Journal of Consulting and Clinical Psychology, 57,
414-419. doi:10.1037/0022-006X.57.3.414
Ekers, D., Richards, D., & Gilbody, S. (2008). A Meta-analysis of
randomised trials of behavioural treatment in depression. Psycho-
logical Medicine, 38, 611-623. doi:10.1017/S0033291707001614
Fairburn, C. (2003). Cognitive behaviour therapy and eating disorders.
New York: The Guilford Press.
Fennel, M. (2002). Depression. In K. Hawton, P. M. Salkovskis, J. Kirk,
& D. M. Clark (Eds.), Cognitive behaviour therapy for psychiatric
problems (pp. 169-253).
Ferster, C. B. (1973). A functional analysis of depression. American
Psychologist, 28, 857-870.
Fisher, P., & Wells, A. (2009). Metacognitive therapy. London: Rout-
ledge Press.
Gloaguen, V., Cottraux, J., Cucharet, M., & Blackburn, I. (1998). A
meta-analysis of the effects of cognitive therapy in depressed patients.
Journal of Affective Disorders, 49, 59-72.
doi:10.1016/S0165-0327(97)00199-7
Hawton et al. (1989). D Clark Chapter in cognitive behaviour therapy
for psychiatric problems. Oxford: Oxford University Press.
Hollon, S. D., DeRubeis, R. J., Evans, M. D., Wiemer, M. J., Garvey,
M. J., & Grove, W. M. (1992). Cognitive therapy, pharmacotherapy
and combined cognitive-pharmacotherapy in the treatment of depres-
sion. Archives of General Psychiatry, 49, 774-781.
doi:10.1001/archpsyc.1992.01820100018004
World Health Organisation (1992). International classification of dis-
14

J. L. IDDON, L. GRANT
eases. Geneva: World Health Organisation.
Jacobson, N. S., Dobson, K. S., Truax, P., Addis, M. E., Koerner, K.,
Gollan, J. K., Gortner, E., & Prince, S. E. (1996). A component ana-
lysis of cognitive-behavioural treatment for depression. Jounral of
Consulting and Clinical Psychology, 64, 295-304.
doi:10.1037/0022-006X.64.2.295
Kovacs, M., Rush, A. T., Beck, A. T., & Hollon, S. D. (1981). De-
pressed outpatients treated with cognitive therapy or pharmacother-
apy: A one year follow-up. Archives of General Psychiatry, 38, 33-
39doi:10.1001/archpsyc.1981.01780260035003
Leahy, R. L. (2006). Contemporary cognitive therapy. New York: The
Guilford Press.
Lewinsohn, P. M. (1974). A behavioural approach to depression. In R. J.
Freedman, & M. Katz (Eds.), The psychology of depression (pp.
157-174). Oxford: Wiley.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline
personality disorder. New York: Guilford.
Martell, C. R., Addis, M. E, & Jacobsen, N. S. (2001). Depression in
context: strategies for guided action. New York: WW Norton.
Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy.
London: Churchill.
Moorey, S. (2010). The six cycles maintenance model: Growing a
“Vicious Flower” for depression. Behavioural & Cognitive Psycho-
therapy, 38, 173-184. doi:10.1017/S1352465809990580
Murphy, G. E., Simons, A. D., Wetzel, R. D., & Lustman, P. J. (1984).
Cognitive therapy and pharmacotherapy, singly and together, in the
treatment of depression. Archives of General Psychiatry, 30, 667-
674.
NICE (2007). Clinical guidelines for the management of depression.
NICE (2009). Depression in adults (update). Depression: The treat-
ment and management of depression in adults. National clinical
practice guideline.
Parikh, S. V., Segal, Z. V., Grigoriadis, S., Ravindran, A. V., Kennedy,
S. H., Lam, R. W., & Patten, S. B. (2009). Canadian network for
mood and anxiety treatments (CANMAT) clinical guidelines for the
management of major depressive disorder in adults II. Psychotherapy
alone or in combination with antidepressant medication. Journal of
Affective Disorders, 117, S15-S25.
Paykel, E. S., Scott, J., Cornwall, P. L., Crane, C., Pope, M., & Johnson,
A. L. (2005). Duration of relapse prevention after cognitive therapy
in residual depression: Follow-up of controlled trial. Psychological
Medicine, 35, 59-68. doi:10.1017/S003329170400282X
American Psychiatric Association (2010). Practice guidelines for the
management of patients with major depressive disorder (3rd ed.). Ar-
lington: American Psychiatric Association.
Roth, A. D., & Pilling, S. (2008). Using an evidence-based methodol-
ogy to identify the competencies required to deliver effective cogni-
tive and behavioural therapy for depression and anxiety disorders.
Behavioural and Cognitive Psychotherapy, 36, 129-147.
doi:10.1017/S1352465808004141
Rush, A. J., Beck, A. T., Kovacs, M., & Hollon, S. D. (1977). Com-
parative efficacy of cognitive therapy and pharmacotherapy in the
treatment of depressed outpatients. Cognitive Therapy and Research,
1, 17-38. doi:10.1007/BF01173502
Skinner, B. F., & Burrhus, F. (1957). Verbal behavior. Acton, MA:
Copley Publishing Group.
Spates, R. C., Pagoto, S., & Kalata, A. (2006). A qualitative and quan-
titative review of behavioural activation treatment of major depres-
sive disorder. Behaviour Analyst Today, 7, 508-521.
Sturmey, P. (2009). Behavioural activation: Is an evidence-based treat-
ment for depression. Behaviour Modification, 33, 818-829.
doi:10.1177/0145445509350094
Tang, T. Z., & DeRubeis, R. J. (1999). Sudden gains and critical ses-
sions in cognitive-behavioural therapy for depression. Journal of
Consulting and Clinical Psychology, 67, 894-904.
doi:10.1037/0022-006X.67.6.894
Tang, T. Z., DeRubeis, R. J., Beberman, R., & Pham, T. (2005). Cogni-
tive changes, critical sessions, and sudden gains in cognitive-beha-
vioural therapy for depression. Journal of Consulting and Clinical
Psychology, 73, 168-172. doi:10.1037/0022-006X.73.1.168
Veale, D. (2008). Behavioural activation for depression. Advances in
Psychiatric Treatment, 14, 29-36.
Wells, A. (2009). Metacognitive therapy for anxiety & depression. New
York: The Guilford Press.
Williams, M., Teasdale, J., Segal, Z., & Kabat-Zinn, J. (2007). The
mindful way through depression. New York: The Guilford Press.
World Health Organisation Statistics (2007) Mental illness, depression.
Geneva: World Health Organisation.