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Cognitive Behavior Therapy for Depression: A Case Report


Abstract and Figures

Depression is expected to become the most common psychiatric disorder and cognitive Behaviour Therapy (CBT) is recommended for treating depression as an effective treatment. Mental health issues in developing countries are difficult and challenging. It is suggested in many ways that intervention developed in western countries may not be effective for developing countries. Moreover, the findings of the study will help the mental health professional to reduce these symptoms and help them to make better adjustment.
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
Ara. J Clin Case Rep 2018, 8:7
DOI: 10.4172/2165-7920.10001151
Open Access
Case Report
Journal of Clinical Case Reports
ISSN: 2165-7920
Cognitive Behavior Therapy for Depression: A Case Report
Ara J*
Department of Clinical Psychology, Arts Building, Dhaka University, Bangladesh
Depression is expected to become the most common psychiatric disorder and cognitive Behaviour Therapy
(CBT) is recommended for treating depression as an effective treatment. Mental health issues in developing countries
are difcult and challenging. It is suggested in many ways that intervention developed in western countries may not
be effective for developing countries. Moreover, the ndings of the study will help the mental health professional to
reduce these symptoms and help them to make better adjustment.
Keywords: Cognitive behavior therapy; Depression; Psychiatric
disorder; Mental health
Depression is expected to become the most common psychiatric
disorder, and one of the leading causes of disease burden in developing
countries. It is an important global public-health issue, among various
other mental health problems that aect 1 in 20 people in every year [1].
Prevalence of depressive disorders in Bangladesh is 4.6% [2]. Although
these seem small but already the ultimate consequence of depression is
suicide [3]. Depression is more common in women and it is the main
cause of disease burden in Bangladesh [4]. Cognitive Behaviour erapy
(CBT) is recommended for treating depression as an eective treatment
modality for a long time in developed world [5]. Recent ndings suggest
that CBT might be as eective as medication in treating moderate to
severe depressive illness, especially in the initial phases of depressive
illness and CBT has been shown to be eective treatment for depressive
illness [6].
Case Description
Ms. A, a 22-year-old unmarried female Muslim client was referred
for psychological intervention in the Psychiatry Outpatient Department
(OPD) of National Institute of Mental Health (NIMH), Bangladesh. She
was assigned to the present therapist and was diagnosed as depression by
the psychiatrist. In the assessment sessions she presented her problems
along with history. Her problems are presented in the following in
clustered fashion according to dierent areas of functioning. e
client believed that she was suering from psychological illness [7,8].
e client complained lack of concentration, lack of self-condence,
and indecisiveness. She also complained of depressed mood, feeling of
guilt, lack of pleasure, anger and hopelessness. She felt irritability and
fear. She avoids social gathering, friends and sometimes occasionally
she used to cry. e client complained of headache, palpitation. She
also complained that family members usually irritate her especially
eldest brother. Her dress up, appearance and behavior appeared to
be culturally appropriate. At the initial interview she spoke willingly
about her problems. She was well motivated and interested to work
collaboratively with therapist.
Exploration of history revealed that the client was in a middle-class
family of a rural area with two brothers and three sisters. Her father
was 55 years old and he was a small business man. Her mother was a
45 years old house wife. From her childhood she experienced that the
relationship between her parents was not good. e eldest son of their
family maintains everything of the whole family. Her eldest brother
was very dominating. She had to lead her life as to his liking. She was
the last issue of her parents. ough she was meritorious student from
*Corresponding author: Ara J, Department of Clinical Psychology, Arts building-4th oor,
Dhaka University, Bangladesh, Tel: +8801748655577; E-mail:
Received July 19, 2018; Accepted July 30, 2018; Published July 31, 2018
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report.
J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Copyright: © 2018 Ara J. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
childhood she was always underestimated instead of being encouraged.
e senior most brothers always used to apply pressure on her for
studies. ey were not happy with the results she obtained. During any
bad occurrence in her family if she protested, she had been termed as
“disobedient”. She likes reading story, listening to music and reciting
poetry which are not supported by her elder brother. Her brother
doesn’t even like her writing skills. She was physically tortured several
times for doing these [9].
She was sexually abused for several times. At the age of ve or six
years old, some of her playmates abused her. When she was in class
seven her cousin tried the same way. During college life one of her
uncles tried to abuse her also. She couldn’t tell these to her family with
a fear of receiving disbelief of the family. When she was 15years, she
had an aair with a boy. en due to misunderstanding that broke up.
When she was in college she again got involved with a boy only to pass
time with that boy. Now she is having third aair. She is a graduate
student. Since having all these she thinks that if she had got family
support enough, there wouldn’t be so many problems. ere was no
history of psychiatric problem in her childhood and adolescence.
In clinical interview the client was asked the reason for referral, why
she sought for help and how long the main complaint had persisted,
when did the problem rst occur, what was the subsequent development
in her life (occupation, living with parents, at school), what were the
impairments that have been produced by the her diculties, how
have she and others coped with the problem, what her belief about the
problem, what was the attitude to her diculties, what was her cognitive
functioning, what was her prevailing mood, what was her background
history, early development history, occupational and educational
history, sexual history and what previous psychiatric, psychological or
medical help she had taken [10-12]. e client asked to nd out and list
up her main problems. ought diary was applied to assess situation
specic negative automatic thoughts (NATs) and corresponding
emotion, physiological changes and behavior for the client. It was
administered to identify the NATs about the social situation and the
relation to changes in emotion, physical reaction, and behavior [13].
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 2 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
According to the client though she was meritorious student in early
age she was always underestimated in stead of being encouraged, she
did not get any attention and care for doing good result or doing any
thing good. In general, behavioral models claim that depression comes
about because the person is receiving inadequate or insucient positive
reinforcement or reward from him or her environment [4]. According
to the client the relationship between her parents was not so good. Her
senior most brothers always used to apply pressure on her for studies.
She likes reading story, listening to music and reciting poetry which are
not supported by her elder brother. Even she was physically tortured
several times for doing these. She was sexually abused for several times
[8]. Propose that “Sometimes individual process traumatic information
in a way that produces a sense of current threat, whether this is physical
or psychological”. Crittenden reported that a child exposed to repeated
early traumatic experiences is likely to show a disruption in normal
Personality development. Children who experience a trauma exhibit
discernable long-term eect [1]. Since she had some diculties in
making close relationship and the entire incidence seemed to develop
her problem gradually.
e client came from a restricted family. e relationship
among parents was disharmonious which maintained her problem.
Domination of elder brother and lack of support from family also
maintained his problem. She was withdrawn from daily activities &
social gathering. is avoidance was also acting as a maintaining factor
for her current illness. She was passive and angry in nature and couldn’t
express her emotion in appropriate way. But aer then when realized
the mistake she was suering from serious guilt feelings. e client had
some NAT’s which helped to maintain her problems, such as- “I am
helpless”, “I am not good enough”, “I never get any good things in my
life”. She was sexually abused for several times, for these incidents she
thinks herself as untouchable and feels guilty. She shows herself to be a
rather introverted who had some diculties in making close relation.
She has diculties in situations where she must assert herself and
lacking in self condence. She sets herself high standards in relation to
work performance and in her role as a dicult daughter. e client also
had some social skill decit which helped to maintain her problems.
All these lead to indecisiveness, lack of concentration, lack of self
condence and maintain his problem. Aer obtaining information on
predisposing, precipitating and maintaining factors, client’s problem
was formulated based on the cognitive model described by Beck
(Figure 1).
Course of treatment
e formulation of the client’s problem was drawn based on
cognitive model, cognitive behavior therapy was chosen for the client’s
problem. Formulation was shared with the client to make her prepared
to follow psychological treatment. Goals of the treatment were set and
dened collaboratively with Ms. A, which were as follows: 1) to reduce
depressive symptoms 2) to terminate avoidance and 3) reduction of
guilt feelings. Priorities were then set by negotiating to which problems
were to be dealt with rst. Following cognitive-behavior therapeutic
techniques were followed in the sessions.
e client could not express her feelings and past experiences.
In therapy session the rst treatment session focused on establishing
sucient rapport, educating the patient about depression and
psychotherapy in general, emphasizing the importance of homework,
taking responsibility for change,
empathy was given aiming to open
her feelings and thoughts
adjusting her expectations about what
can be gained through therapy.
erapist conducted both type of measurement, subjective &
objective measurement. In assessment session client mentioned her
overall problems severity at ‘100’ point on (0-100) rating scale. For
objective measure Depression scale [14] was used to assess the severity
of depression. e highest possible score of 30 items form of depression
scale was 150 and the lowest possible score was 30. Higher score on
the scale indicates high level of depression and lower score indicates
low level of depression. Both the split-half reliability (Guttman split-
half r=0.7608) and test-retest reliability (r=0.599) of this scale ensured
that the scale is a reliable instrument. Estimation of concurrent
Validity shows that, rating of depression by the psychiatrist (r=0.377)
and self-rating of depression by the patients (r=0.558) were positively
correlated with the obtained scores on the current depression scale (p<
0.01). Discriminability (F= 85.386, p< 0.01) concluded high concurrent
validity of the scale. Construct validity were found satisfactory.
Anxiety scale [15] was developed in the cultural context of
Bangladesh. It assesses the severity level of anxiety from the very
begging sessions. Score ranges for mild, moderate, severe and profound
severity were 27-54, 55-66, 67-77, and 78-144 respectively. A higher
score indicates a higher level of anxiety. e anxiety scale poses sound
internal consistency (Cronbach’s alpha = 0.9468) and temporal stability
(test rest reliability = 0.688, p<0.01).
Ms. A was assessed for eligibility for treatment with the Depression
Scale and Anxiety scale. Following the initial assessment, the patient
was assigned to treatment and evaluated psychologically regularly as
detailed in Tables 1 and 2.
Case conceptualization
Ms. A 22-year-old unmarried female Muslim client was referred
with the complain of depressed mood, lack of concentration, lack of
self-condence, indecisiveness, guilt feelings, anger, felt irritability,
headache, and avoidance behavior. In-depth interview and the
exploration of her thought revealed that she was suering from
depression. Based on information’s collected from the client, her
formulation was done in predisposing, precipitating and maintaining
factors [16].
Sessions Severity of the problem (0-100)
1st Session 90
2nd Session 90
3rd Session 75
6th Session 60
9th Session 50
10th Session 45
13th Session 25
Table 1: Subjective report of the client.
No of sessions Anxiety scale Depression scale
1st Session 62 (Moderate) 135 (Severe)
3rd Session 54 (Mild) 120 (Moderate)
5th Session 45 (Below cut off point) 113 (Mild)
7th Session 38 (Below cut off point) 106 (Mild)
9th Session 30 (Below cut off point) 92 (Below cut off point)
11th Session 30 (Below cut off point) 72 (Below cut off point)
13th Session 28 (Below cut off point) 63 (Below cut off point)
Table 2: Anxiety and depression scores.
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 3 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
Figure 1: Information on predisposing, precipitating and maintaining factors, client’s problem was formulated based on the cognitive model.
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 4 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
ought Challenge technique was used to modify the client’s
NAT’s by examining the evidence for against the NAT’s of the client.
Cognitive therapy was given to reduce her NAT’s as NAT’s maintaining
her problem.
e steps that were involved in challenging a thought
were as follows-
1) What is the worst thing that, suggested by the perceived
threat can happen?
2) What are the points that supports that the worst thing will
3) What are the points that indicate the impossibility of the
worst thing to happen?
4) What are the benets of thinking about the worst?
5) What are the costs of thinking about the worst and nally?
6) Considering these points what should I do? i.e., what does
all these points suggests.
Pie chart was used to reduce feelings of guilt (especially which
was related to sexual abuse). It helped the client to determine her
responsibility for an incident. Decision making problem is common
problem of depressed client. If decision making is not appropriate
that time person not feels comfort and self blame and guilt feeling
come. ere are some steps of decision making. ese are isolating
the problem, decide to act gather resource, plan, visualize your plan of
action and act.
To make the client more assertive she was trained assertive training.
is training helped her to communicate with her family members.
Assertive training helps people to express how they feel without
trampling on the rights of others in the process [15].
Muscular relaxation was to teach to reduce headache and tension.
Evidence suggests that relaxation procedure have been eective for a
vast array of problems including headace, insomnia, anxiety, temper
outburst [12-16]. e client was taught how to express anger in a
constructive way. ese include dening the anger, being assertive and
nding some mutual way of solving the problem.
e client oen underestimated her positive qualities which
maintained her problems. So, the client was asked to write down at least
two good qualities every day. So that she could aware about her positive
qualities, it would help her to perceive herself in another perspective.
Sessions 8-13 focused on monitoring activities. e client complained
of lack of pleasure, so a record-sheet was given to client to record what
he did on an hour-by-hour basis, and to rate each activity out of 10 for
pleasure (P) and for mastery (M). It was used to improve mood and to
increase level of pleasurable activities.
Subjective rating of the client’s problem was taken intermittently
in assessment and treatment sessions. Verbal rating of the clients’
problem was taken in a 0 to 100-point scale, where 0 means lower level
and 100 means high level of problem.
Table 1 indicates that client’s subjective rating about the problem
was reducing gradually. Standardized scale was applied in most of the
session to get an objective measure of the improvement and to provide
an objective feedback about improvement to the client and therapist.
Anxiety and depression scale were used as objective measures of
improvement. Session wise scores of these scales are presented in
following (Table 2).
e subjective and objective report of the result of intervention
strongly suggests that improvement have occurred.
Discussion and Conclusion
e client was very much sensitive about her problem.
When she got the impression that the therapist understood her
problems she became very much motivated and
showed high
level of compliance with psychotherapy, it’s helped the therapist to
deal with her problem. She accepted psychotherapeutic formulation of
her problems and she could internalize therapeutic technique and its
rational. Her NAT’s was reduced, and she started thinking positively.
She could generalize psychotherapy and applied skills in dierent
settings. So, it can be said that it will be disturb his improvement
and chance to future relapse.
e client was asked to practice all
technique which he learnt.
But if the she continued 2nd and 3rd follow
up session the therapist could feel more condent about the client’s
improvement due to psychotherapy.
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... This decision was based on research in other non-western countries (e.g. Hwang et al., 2015;Naeem et al., 2015), effectiveness studies of CBT in multicultural communities (Embling, 2002;Kohn et al., 2002), and the authors' clinical experience with depressed patients in Bangladesh (Ara, 2018;Ara & Deeba, 2018). Information about the nature of depressive disorders and relevant assessment methods and interventions in Bangladesh were incorporated (Firoz et al., 2007;Hosain et al., 2007). ...
... This study received ethical approval from the Faculty of Biological Science, University of Dhaka (Ref-49/ Biol.Scs./ 2017-2018, and from the Department of Clinical Psychology, University of Dhaka (Ref-PH180701). The trial was registered retrospectively during the review process of the manuscript with Clinical ...
This was a randomized controlled trial, conducted to determine the effectiveness of CBT for depression delivered by trained therapists with an adapted Bengali CBT (BaCBT) manual, as compared to a control group. A total of 148 patients with a diagnosis of depression and attending psychiatry departments of three hospitals in Dhaka, Bangladesh, were assessed for eligibility, and 107 were randomly allocated to either treatment (n = 54) or a waitlist (n = 53). Assessments of outcome were completed at 3 time points (pre-test, post-test, and 1-month follow-up). The results revealed significant reductions in depression severity, anxiety, perceived stress, and suicidal ideation in the group that received the intervention, but modest to no significant changes in the control group. This is the first report of the results of an adapted CBT program for depression from Bangladesh. Although several limitations of the study are noted, and further studies are needed to generalize these current results, they indicate that CBT is an efficacious treatment option for depression in varied cultures.
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Antenatal depression occurs in about 20% of all pregnancies and gestational diabetes occurs in up to 14% of all pregnancies. Although there is sufficient information on (1) depression during pregnancy and (2) depression and diabetes, there is little information about depression and gestational diabetes. This comparative, longitudinal research study was done to better understand the relationship between gestational diabetes and depression. The study aims were the following: (1) to determine whether women with gestational diabetes had more depression than women without gestational diabetes, (2) to determine whether factors predictive of depression in pregnant women with gestational diabetes were different from women without gestational diabetes, and (3) to determine if minorities were more at risk for depression during pregnancy than Caucasians. The sample included 135 pregnant women between 24 and 40 weeks' gestation, of which 65 had gestational diabetes (GDM) and 70 had no gestational diabetes (NGDM). Depression, anxiety, stress, and social support were measured using self-report questionnaires completed during a prenatal care visit. Delivery outcomes were collected from the electronic medical record. Using the CES-D, 28% of the entire sample had depression and 32% of women with GDM had depression compared to 24% of women with NGDM, although the difference was not statistically significant. However, women with GDM were 2.7 times more likely to have depression (OR=2.72, 95% CI, 1.04, 7.13, p =.041). Also, women with GDM were 3.07 times as likely to have a history depression (OR=3.07, 95% CI, 1.01, 9.49, p = .05). Trait anxiety was found to be a significant predictor of prenatal depression (p
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This study of maltreated infants offers evidence supporting a model of bidirectional effects in which the mother initiates the maltreatment but both mother and infant behave so as to maintain the situation. Maltreated infants were found not to differ from control infants in congenital characteristics. They did, however, display deviance in learned behavior patterns. After intervention with the mother the infants showed behavioral improvement. These results suggested that maltreated infants were not inherently different from other children and that they were resilient in response to environmental improvement. Their earlier behavior may, however, have functioned to maintain their mothers' maltreating responses.
Aim To examine the process and outcome of the use of cognitive behavioural therapy (CBT) to treat depression. Method The study was undertaken at an acute psychiatric assessment and treatment centre based in the community. The centre operates an open referral system. The study sample was taken from clients attending the centre for mental health assessment who were subsequently diagnosed with unipolar depression. The total sample of 38 clients were allocated to either a treatment group (n=19) or waiting list control group (n=19) matching for age, gender and social support. The treatment group was divided into four groups. Each of these groups received 12 sessions of CBT, derived from the procedures described by Beck et al (1979). Data from dysfunctional thought diaries and Beck depression inventory scores were analysed. Results The results confirm those of previous outcome studies, that CBT is an effective treatment for depression. The results also indicate some interesting points relating to the expression of negative emotions as depression scores improve. It appeared that the expression of sadness preceded the expression of anger. Expression of sadness may be a precursor to expression of anger and necessary for recovery from depression. Conclusion The findings of this study indicate that dimensions of an individual’s personality, such as perfectionism and sociotropy, may be influential in determining the outcomes of CBT. Further research in this area is indicated.
The purpose of the present study was to examine the relationship between suicidal ideation and depression, loneliness, hopelessness among University students. Study sample is comprised of 112 University students (51 males and 61 females) drawn by using purposive sampling technique. Standard questionnaires were used to obtain the data from the participants in a cross‐sectional survey. The obtained data were analyzed by using Pearson product moment correlation and stepwise multiple regression. Results showed that suicidal ideation was positively correlated with depression, loneliness and hopelessness. Stepwise multiple regression analysis further reveals that depression, loneliness and hopelessness significantly predict suicidal ideation among university students. Study limitations and implications are also discussed.Dhaka Univ. J. Biol. Sci. 25(1): 57-64, 2016
A central theoretical principle guiding cognitive therapy is that mediation by cognitive processes is linked to the successful treatment of depression. The most recent review of the literature on this question is over a decade old and was suggestive of cognitive mediation for cognitive therapy, but was not conclusive. Since this review, a number of studies have been published that address cognitive mediation. The mediation hypothesis can be broadly defined as encompassing two related questions: cognitive mediation framed as “are cognitive changes associated with therapeutic improvement,” and cognitive specificity from the perspective of “are changes in cognition specific to cognitive therapy?” This latter question is particularly important when cognitive therapy is compared to pharmacotherapy. This article reviews the current literature associated with these questions. Our review indicates that the current body of research generally supports cognitive mediation, but is considerably more mixed for cognitive specificity. However, some evidence suggests that cognitive changes associated with pharmacotherapy are more superficial than those associated with cognitive therapy.
Examined the association between depression and parental loss by death by administering the Centre for Epidemiological Studies Depression scale to 1,250 patients in general practitioners' offices. Ss were asked to indicate whether they had lost a mother or father by death and their age when this loss occurred. One-way ANOVA produced a significant father-loss effect on depression, with Ss reporting a father loss in the 0–6 yr and 10–25 yr age ranges having the highest depression scores. No significant effect for mother loss occurred. The father-loss effect remained the same when other demographic factors including city of testing, sex, marital status, occupational status, age, and education were controlled. (23 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reciprocal inhibition is a process of relearning whereby in the presence of a stimulus a non-anxiety-producing response is continually repeated until it extinguishes the old, undesirable response. A variety of the techniques based on reciprocal inhibition, such as systematic desensitization, avoidance conditioning, and the use of assertion, are described in detail. Behavior therapy techniques evaluated on the basis of their clinical efficacy are found to have striking success over traditional psychoanalytic methods. Currently, more comparative studies are required which will validate the merit of behavior therapy in the psychotherapeutic field while experimental research should continue to refine the techniques.