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Conditional Beliefs of Primary-Care Patients with Treatment-Resistant Depression

  • Alex Burrage (a1), Samantha Green (a1), Katrina Turner (a1), Willem Kuyken (a2), Chris Williams (a3), Nicola Wiles (a1) and Glyn Lewis (a4)...


Background: Cognitive behaviour therapy (CBT) for patients with treatment-resistant depression (TRD) aims to reframe underlying conditional beliefs that are thought to maintain depression. Aim: To systematically explore conditional beliefs expressed by primary-care based patients with TRD, defined as non-response to at least 6 weeks of antidepressants. Method: Conditional beliefs (stated in an “If. . .then. . .” format) were extracted from a random sample of 50 sets of therapist notes from the CoBalT trial, a large randomized controlled trial of CBT for TRD in primary care. The beliefs were separated into their two constituent parts; the demands (Ifs) and consequences (thens). An approach based on framework analysis provided a systematic way of organizing the data, and identifying key themes. Results: Four main themes emerged from the demand part of the conditional beliefs (Ifs): 1. High standards; 2. Putting others first/needing approval; 3. Coping; and 4. Hiding “true” self. Three main themes emerged from the consequence part of the conditional beliefs (thens): 1. Defectiveness; 2. Responses of others; 3. Control of emotions. Conclusions: Identifying common themes in the conditional beliefs of patients with TRD adds to our clinical understanding of this client group, providing useful information to facilitate the complex process of collaborative case conceptualization and working with conditional beliefs within CBT interventions.


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Reprint requests to Nicola Wiles, Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK. E-mail:


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Barnes, M., Sherlock, S., Thomas, L., Kessler, D., Kuyken, W., Owen-Smith, A., et al. (2013). “No pain, no gain: depressed clients' experiences of cognitive behavioural therapy”. British Journal of Clinical Psychology, 52, 347364.
Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. New York: Penguin.
Beck, A. T., Freeman, A. and Associates (1990). Cognitive Therapy of Personality Discorders. New York: Guilford Press
Beck, A. T., Rush, A. J., Shaw, B. and Emery, G. (1979). Cognitive Therapy of Depression. New York: Wiley.
Beck, A., Steer, R. A. and Brown, G. K. (1996). Beck Depression Inventory – Second edition: manual. San Antonio: The Psychological Corporation.
Beck, J. (1995). Cognitive Therapy: basics and beyond. New York: Guilford Press.
Beevers, C. G., Strong, D. R., Meyer, B., Pilkonis, P. A. and Miller, I. W. (2007). Efficiently assessing negative cognition in depression: an item response theory analysis of the Dysfunctional Attitude Scale. Psychological Assessment, 19, 199209.
Clark, D. M. and Beck, A. T. (1999). Scientific Foundations of Cognitive Theory and Therapy of Depression. New York: John Wiley & Sons Inc.
Craighead, W. E., Sheets, E. S., Brosee, A. L. and Ilardi, S. S. (2007). Psychosocial treatments for major depressive disorder. In Nathan, P. E. and Gorman, J. M. (Eds.), A Guide to Treatments that Work (3rd ed.), pp. 289308. New York: Oxford Press.
Fennell, M.J.V. (1997). Low self-esteem: a cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, 125.
Fostick, L., Silberman, A., Beckman, M., Spivak, B. and Amital, D. (2010). The economic impact of depression: resistance or severity? European Neuropsychopharmacology, 20, 671675.
George, C. F., Peveler, R. C., Heiliger, S. and Thompson, C. (2000). Compliance with tricylic antidepressants: the value of four different methods of assessment. British Journal of Clinical Pharmacology, 50, 166171.
Halvorsen, M., Wang, C. E., Eisemann, M. and Waterloo, K. (2010). Dysfunctional attitudes and early maladaptive schemas as predictors of depression: a 9-year follow-up study. Cognitive Therapy Research, 34, 368379.
Jarrett, R. B., Vittengl, J. R., Doyle, K. and Clark, L. A. (2007). Changes in cognitive content during and following cognitive therapy for recurrent depression: substantial and enduring, but not predictive of change in depressive symptoms. Journal of Consulting and Clinical Psychology, 75, 432446.
Judd, L. L., Akiskal, H. S., Zeller, P. J., Paulus, M., Leon, A. C., Maser, J. D., et al. (2000). Psychosocial disability during the long-term course of unipolar major depressive disorder. Archives of General Psychiatry, 57, 375380.
Kuyken, W., Padesky, C. A. and Dudley, R. (2009). Collaborative Case Conceptualization: working effectively with clients in cognitive-behavioral therapy. New York: Guildford Press.
Lewis, G. (1994). Assessing psychiatric disorder with a human interviewer or a computer. Journal of Epidemiology and Community Health, 48, 207210.
Lewis, G., Pelosi, A. J., Araya, R. and Dunn, G. (1992). Measuring psychiatric disorder in the community: a standardised assessment for use by lay interviewers. Psychological Medicine, 22, 465486.
Moore, R. G. and Garland, A. (2003). Cognitive Therapy for Chronic and Persistent Depression. Chichester: John Wiley & Sons.
Mooney, K. A. and Padesky, C. A. (2000). Applying client creativity to recurrent problems: constructing possibilities and tolerating doubt. Journal of Cognitive Psychotherapy: An International Quarterly, 14, 149161.
Morisky, D. E., Green, L. W. and Levine, D. M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence, Medical Care, 1, 6774.
National Institute for Health and Clinical Excellence (2009). Depression: the treatment and management of depression in adults (updated). Retrieved 17.03.2013 from
Padesky, C. A. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy, 1, 267278.
Paykel, E. S., Scott, J., Teasdale, J. D., Johnson, A. L., Garland, A., Moore, R., et al. (1999). Prevention of relapse in residual depression by cognitive therapy: a controlled trial. Archives of General Psychiatry, 56, 829835.
Power, M. J., Katz, R., McGuffin, P., Duggan, C. F., Lam, D. and Beck, A. T. (1994). The Dysfunctional Attitude Scale (DAS): a comparison of Forms A and B and proposals for a new subscaled version. Journal of Research in Personality, 28, 263276.
Riso, L. P., du Toit, P. L., Blandino, J. A., Penna, S., Dacey, S., Duin, J. S., et al. (2003). Cognitive aspects of chronic depression. Journal of Abnormal Psychology, 112, 7280.
Riso, L. P. and Newman, C. F. (2003). Cognitive therapy for chronic depression. Journal of Clinical Psychology, 59, 817831.
Ritchie, J. and Spencer, L. (1994). Qualitative data analysis for applied policy research. In Bryman, A. and Burgess, R. G. (Eds.), Analysing Qualitative Data. London: Routledge.
Schindler, A., Hiller, W. and Witthoft, M. (2013). What predicts outcome, response, and drop out in CBT of depressive adults? A naturalistic study, Behavioural and Cognitive Psychotherapy, 41, 365370.
Thomas, L. J., Abel, A., Ridgway, N., Peters, T., Kessler, D., Hollinghurst, S., et al. (2012). Cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment resistant depression in primary care: the CoBalT randomised controlled trial protocol. Contemporary Clinical Trials, 33, 312319.
Thomas, L., Kessler, D., Campbell, J., Morrison, J., Peters, T. J., Williams, C., et al. (2013). Prevalence of treatment-resistant depression in primary care: cross sectional data. British Journal of General Practice, 63, e852e858.
Trivedi, M. H., Rush, A. J., Wisniewski, S. R., Nierenberg, A. A., Warden, D., Ritz, L., et al. (2006). Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. American Journal of Psychiatry, 163, 2840.
Vittengl, J. R., Clark, L. A., Dunn, T. W. and Jarrett, R. B. (2007). Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects. Journal of Consulting and Clinical Psychology, 73, 475488.
Vittengl, J. R., Clark, L. A. and Jarrett, R. B. (2010). Moderators of continuation phase cognitive therapy's effects on relapse, recurrence, remission, and recovery from depression. Behaviour Research and Therapy, 48, 449458.
Weissman, A. N. (1979). The Dysfunctional Attitude Scale: a validation study. Unpublished doctoral dissertation, University of Pennsylvania, Philadelphia.
Wiles, N., Thomas, L., Abel, A., Ridgway, N., Turner, N., Campbell, J., et al. (2013). Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. The Lancet, 381, 375384.
Young, J. E. and Brown, G. (1990). Young Schema Questionnaire. New York: Cognitive Therapy Center of New York.


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Conditional Beliefs of Primary-Care Patients with Treatment-Resistant Depression

  • Alex Burrage (a1), Samantha Green (a1), Katrina Turner (a1), Willem Kuyken (a2), Chris Williams (a3), Nicola Wiles (a1) and Glyn Lewis (a4)...


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Conditional Beliefs of Primary-Care Patients with Treatment-Resistant Depression

  • Alex Burrage (a1), Samantha Green (a1), Katrina Turner (a1), Willem Kuyken (a2), Chris Williams (a3), Nicola Wiles (a1) and Glyn Lewis (a4)...
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