Demoralization Predicts Nonresponse to Cognitive Therapy in Depressed Outpatients

Article excerpt

Thirty-nine depressed outpatients meeting DSM-III criteria for nonmelancholic major depression or dysthymic disorder were treated with 16 weekly individual cognitive therapy sessions. Prior to treatment, they completed the Beck Depression Inventory, the Hopelessness Scale, and the Dysfunctional Attitudes Scale. Independent of knowledge of outcome, the authors chose from these scales items indicating demoralization, that is, that patients perceived their ability to positively affect their own future as too likely to be ineffectual to warrant efforts at change. After cognitive therapy, 20 patients were considered responders (51%) although three quickly relapsed (44% responded and maintained). Nonresponders had significantly higher pretreatment demoralization scores than did responders. These results suggest that high levels of demoralization may predict poor response of depression to cognitive therapy, although the small sample size precluded differentiation of demoralization from hopelessness.

Since Beck introduced cognitive therapy (Beck, 1972) numerous reports support its effectiveness (Rush, Beck, Kovacs, & Hollon, 1977; McClean & Hakstian, 1979; Murphy, Simons, Wetzel, & Lustman, 1984; Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Elkin et al., 1989). Several authors have reported that cognitive therapy is more effective for patients with less pathological scores on the Dysfunctional Attitudes Scale (DAS) (Weissman & Beck, 1978) or Self- Control Scale (Rosenbaum, 1980) than those with higher scores (Keller, 1983; Simons, Murphy, Levine, & Wetzel, 1986; Sotsky, et at, 1991; Murphy et al., 1984). This is counterintuitive, since cognitive therapy was evolved to correct dysfunctional attitudes and help patients attain mastery. Thus, deeply ingrained dysfunctional attitudes may not be effectively challenged by short-term cognitive therapy .while patients who feel their lives are not under their own control may not do the homework or may only "go through the motions."

Neimeyer and Weiss (1990) have recently reported attributional style to predict outcome. These authors investigated 10 weeks of group cognitive therapy and group interpersonal psychotherapy as the treatment for 111 depressed outpatients. They report that higher pretreatment severity scores on the Hamilton Rating Scale for Depression (Hamilton, 1960) and the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) accounted for 49% of the variance in outcome scores. Once baseline severity was accounted for in a stepwise regression analysis, cognitive attributional style accounted for an additional 12% of the variance in final depression scores. Specifically, patients who identified very general causes for negative outcomes, but also attributed positive outcomes to only a few sources were more depressed following treatment than were patients who attributed negative outcomes to only a few sources or who found many sources of positive outcomes in their lives. This finding applied whether the treatment was cognitive or interpersonal group psychotherapy.

Our own experience suggested that cognitive therapy often activated inert, immobile patients. Thus, it seemed that patients who had become "demoralized" might be the best candidates. We use the term "demoralized" to describe patients who are distressed by their perception of being unable or unlikely to make positive changes in their lives.

Demoralization is evidenced by such statements as "things won't work out," "why try anyway," "everything is too much of an effort" and "I am unable to accomplish my goals." These patients have lost motivation, feeling they have been beaten down too many times and do not want to risk further hurt or discouragement. There is a belief in personal failure, such that the demoralized person does not want to risk that failure again.

The usual questionnaires utilized in cognitive therapy were scrutinized for items which might reflect demoralization. …