Major depressive disorder (MDD) is one of the most widespread mental diseases across the globe. It affects approximately 25 percent of women and 12 percent of men throughout the lifespan and may have multiple severe, adverse effects on individual condition including impaired functioning, reduced productivity and motivation, poor quality of life, and others (Zhou, Hou, Liu, & Zhang, 2017). Cognitive behavioral therapy (CBT) is one of the available options that can be implemented to treat MDD. It is a type of non-pharmacological, psychological intervention, which can be regarded as an alternative to the principal pharmacological remedy for depression ̶ second-generation antidepressants (SGAs). CBT is based on the assumption that maladaptive information processing and impaired behavioral responses are the primary causes of MDD (Zhou et al., 2017). Thus, through this practice, practitioners aim to impact individuals’ cognitive and behavioral structures linked to adverse affects by teaching them how to think and behave differently.
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Currently, there is a great interest in the research of CBT effectiveness because “approximately 40 percent of patients treated with SGAs do not respond to first-step treatment and approximately 70 percent do not achieve remission, indicating the need for a different treatment strategy” (Agency for Healthcare Research and Quality [AHRQ], 2016, para. 2). Moreover, the evidence provided by the AHRQ (2016) shows that SGAs have multiple adverse side effects including weight gain, insomnia, headaches, and even the increased risk of suicidal thoughts. At the same time, psychological interventions are associated merely with possible dissatisfaction with treatment (AHRQ, 2016). Despite the low risk of severe side effects, it is observed that CBT may be as effective as antidepressants and is suitable for the first-step treatment of severe MDD forms (AHRQ, 2016). For this reason, the implementation of the given practice may be highly beneficial.
Extent of Implementation
According to Cuijpers, Cristea, Karyotaki, Reijnders, and Huibers (2016), approximately 75 percent of patients with depression and anxiety disorders prefer psychotherapies over pharmacological interventions. Nevertheless, compared to medications, they are less accessible particularly for people with lower-income and middle-income statuses (Cuijpers et al., 2016). Still, when an opportunity exists, SGA treatment can be combined with CBT. Patients also often switch to psychological therapies as second-step interventions in case antidepressant-related adverse effects and the lack of benefits lead to discontinuation of treatment (AHRQ, 2016).
Barriers to Implementation
Barriers to CBT implementation can be found at the individual, intervention, organizational, and provider levels. Ringle et al. (2015) suggest that individual characteristics such as personal traits, perceptions of treatment methods, level of motivation, the presence of co-morbidities, severity of the disorder, as well as demographic features, including age and social-economic status, can significantly affect the degree of the patient’s adherence to treatment. It is possible to say that since hopelessness and reduced motivation are the major symptoms of MDD, it may be particularly challenging to engage patients with this disorder in CBT and sustain their progress.
At the organizational and community levels, the use of CBT may be challenged by the reduced accessibility of the given treatment option. This type of barriers includes poor awareness of CBT benefits among providers and patients, as well as the lack of training, resources, and support needed to initiate the non-pharmacological intervention (Ringle et al., 2015).
Intervention-level barriers or, in other words, counterproductive “characteristics of the innovation being implemented,” refer to the necessity to expose patients to feared stimuli (Ringle et al., 2015). This activity is one of the core components of CBT, and it implies that patients with MDD need to face some memories of trauma, social anxiety, and other problems during the intervention. For this reason, providers’ knowledge of how to deal with possible negative perceptions of treatment, to choose and to structure the intervention content and practices based on individual characteristics is of great importance. It is also observed that the level of translation of evidence into practice may be limited by “the availability and experience of the psychotherapists who provide CBT” (AHRQ, 2016, para. 6). In this way, the healthcare provider’s competence and quality of communication with the patient may serve either as barriers to or facilitators of continual CBT implementation.
Ways to Overcome Barriers
It is possible to address the existing limitations in the implementation of CBT by increasing the accessibility of this treatment option to those who need it. According to Ringle et al. (2015), at the organizational level, “ongoing support has been identified as an important strategy to improve adoption of evidence-based practices” (p. 944). It may take multiple forms including supervision, allocation of necessary resources, provision of staff education, and others. For example, by training healthcare practitioners to administer CBT, endowing them with sufficient autonomy to perform, and giving tools for monitoring the efficacy of the practice, the clinical setting may significantly increase the level of adherence to this intervention.
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It is apparent that in order to realize the given initiative, hospitals should locate and use high-quality evidence. Nevertheless, research findings summarized by the AHRQ (2016) were estimated on the Strength of Evidence Scale as associated with low to moderate confidence. Additionally, Cuijpers et al. (2016) observe that the effects of CBT could be significantly overestimated in previous research because most of the conducted trials have some problems with the design, including inadequate sampling, as well as publication biases. It means that further research of CBT effectiveness is required in order to understand its actual benefits and side effects and increase the efficacy of MDD treatment across various populations. By obtaining higher-quality evidence through empirical research, it would be possible to improve the perception of CBT and increase its implementation rates.
Conclusion: Resources to Inform Translation
Resources on CBT and other MDD treatment options located at the AHRQ site can provide practitioners and patients with some general information regarding the disorder and available intervention methods. These resources include systematic reviews and consumer summaries, which compare SGA, CBT, and other alternatives. Although it is concluded that CBT may be as effective as antidepressants, the information summarized on the website is rather not detailed enough to inform the design of comprehensive treatment strategies, yet it may serve as a guide and can stimulate further investigation of evidence. The main benefit of the systematic review by the AHRQ (2016) is that it helps to rationalize the choice of the treatment method and identifies multiple knowledge gaps. For instance, it is stated that “evidence-based information about the comparative risk of adverse effects and patient-centered outcomes related to a range of issues, including functional capacity and quality of life, is generally lacking” (para. 6). Based on this, practitioners may choose to investigate the given gap in evidence while working with patients and, in this way, contribute to better understanding of CBT effects and improve its implementation.
Agency for Healthcare Research and Quality. (2016). Nonpharmacological versus pharmacological treatment for patients with major depressive disorder: Current state of the evidence. Web.
Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence. World Psychiatry, 15(3), 245–258.
Ringle, V. A., Read, K. L., Edmunds, J. M., Brodman, D. M., Kendall, P. C., Barg, F., & Beidas, R. S. (2015). Barriers to and facilitators in the implementation of cognitive-behavioral therapy for youth anxiety in the community. Psychiatric Services (Washington, D.C.), 66(9), 938–945.
Zhou, S.-G., Hou, Y.-F., Liu, D., & Zhang, X.-Y. (2017). Effect of cognitive behavioral therapy versus interpersonal psychotherapy in patients with major depressive disorder: A meta-analysis of randomized controlled trials. Chinese Medical Journal, 130(23), 2844–2851.