Skip to main content Accessibility help

Early Intervention for Adults at High Risk of Recurrent/Chronic Depression: Cognitive Model and Clinical Case Series

  • Stephen Barton (a1), Peter Armstrong (a2), Mark Freeston (a1) and Vivien Twaddle (a2)


This paper describes a cognitive model for first/second onset depression that has been precipitated by major life stress, entrenched for several months and is unresponsive to pharmacotherapy. These conditions create high risks for recurrent/chronic depression and early intervention is proposed to identify, treat and protect against relapse/recurrence. Severe life stress interacts with an individual's core self-representations and personal values, identity is disrupted and depression is maintained by dysfunctional goal engagement and disengagement. Treatment aims to restore functional self-regulation by increasing self-diversification and creating balanced goal investments. Outcome and follow-up data are reported in a case series of five consecutive patients. There was good therapist adherence to the prescribed targets and pre-post effect sizes were comparable or larger than published outcome studies. At the 12 month follow-up, three of the four treatment completers (75%) had made reliable and clinically significant changes and were in full remission. This provides encouraging preliminary evidence for the model's validity and the therapy's efficacy.


Corresponding author

Reprint requests to Stephen Barton, Consultant Clinical Psychologist, Transitions Service, Chester le Street Health Centre, Newcastle Road, Chester le Street, Co Durham DH3 3UR, UK. E-mail:


Hide All
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: APA.
Barton, S. B. (2000). New possibilities in cognitive therapy for depression. Behavioural and Cognitive Psychotherapy, 28, 14.
Barton, S. B. and Morley, S. J. (1999). Specificity of reference patterns in depressive thinking: agency and object roles in self-representation. Journal of Abnormal Psychology, 108, 655661.
Barton, S. B., Morley, S. J., Bloxham, G., Kitson, C. and Platts, S. (2005). Sentence completion test for depression (SCD): an idiographic measure of depressive thinking. British Journal of Clinical Psychology, 44, 2946.
Bebbington, P. E., Brugha, T., MacCarthy, B., Potter, J., Sturt, E., Wykes, T., Katz, R. and McGuffin, P. (1988). The Camberwell collaborative depression study. 1. Depressed probands: adversity and the form of depression. British Journal of Psychiatry, 152, 754765.
Beck, A. T., Rush, A. J., Shaw, B. F. and Emery, G. (1979). Cognitive Therapy of Depression: a treatment manual. New York: Guilford Press.
Beck, A. T. and Steer, R. A. (1991). Manual for the Beck Depression Inventory. San Antonio, TX: The Psychological Corp.
Beck, A. T., Steer, R. A. and Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review, 8, 77100.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E. and Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561571.
Beck, A. T., Weissman, A., Lester, D. and Trexler, I. (1974). The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861865.
Brewin, C. R. (2006). Understanding cognitive behaviour therapy: a retrieval competition account. Behaviour Research and Therapy, 44, 765784.
Brown, G. W. and Harris, T. (1978). Social Origins of Depression: a study of psychiatric disorder in women. London: Tavistock Publications.
Brown, G. W., Harris, T. and Hepworth, C. (1994). Life events and endogenous depression: a puzzle re-examined. Archives of General Psychiatry, 51, 525534.
Cahill, J., Barkham, M., Hardy, G., Rees, A., Shapiro, D. A., Stiles, W. B. and Macaskill, N. (2003). Outcomes of patients completing and not completing cognitive therapy for depression. British Journal of Clinical Psychology, 42, 133143.
Carver, C. S. and Scheier, M. F. (1998). On the Self-Regulation of Behavior. New York: Cambridge University Press.
Carver, C. S. and White, T. L. (1994). Behavioural inhibition, behavioural activation, and affective responses to impending reward and punishment: the BIS/BAS scales. Journal of Personality and Social Psychology, 67, 319333.
Champion, L. A. and Power, M. J. (1995). Social and cognitive approaches to depression: towards a new synthesis. British Journal of Clinical Psychology, 34, 485503.
Chisholm, D., Sanderson, K., Ayusi-Mateos, J. L. and Saxena, S. (2004). Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in 14 world regions. British Journal of Psychiatry, 184, 393403.
Clark, D. M. (2004). Developing new treatments: on the interplay between theories, experimental science and clinical innovation. Behaviour, Research and Therapy, 42, 10891104.
DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., O'Reardon, J. P., Lovett, M. L., Gladis, M. M., Brown, L. L. and Gallop, R. (2005). Cognitive therapy versus medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62, 409416.
Dobson, K. (1989). A meta-analysis of the efficacy of cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 57, 414419.
Dolan, R. J., Calloway, S. P., Fonagy, P., De Souza, F. V. A. and Wakeling, A. (1985). Life events, depression and the hypothalamic-pituitary-adrenal axis function. British Journal of Psychiatry, 147, 429433.
Dozois, D. J. A. and Dobson, K. S. (2001). Information processing and cognitive organisation in unipolar depression: specificity and comorbidity issues. Journal of Abnormal Psychology, 110, 236246.
Dozois, D. J. A. and Dobson, K. S. (2003). The structure of the self-schema in clinical depression: differences related to episode recurrence. Cognition and Emotion, 17, 933941.
Ezquiga, T. E., Ayuso Gutierrez, J. L. and Garcia Lopez, A. (1987). Psychosocial factors and episode number in depression. Journal of Affective Disorders, 11, 135138.
Fava, G. A., Rafanelli, C., Grandi, S., Conti, S. and Belluardo, P. (1998). Prevention of recurrent depression with cognitive behavioural therapy: preliminary findings. Archives of General Psychiatry, 55, 816820.
First, M. B., Spitzer, R. L., Gibbon, M. and Williams, J. (1996). Structured Clinical Interview for DSM-IV Axis I disorders – Patient Edition (SCID I/P, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.
Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Horne, R., Keitner, G. I. and Miller, I. W. (2004). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science and Practice, 11, 4768.
Gilbert, P., Gilbert, J. and Irons, C. (2004). Life events, entrapments and arrested anger in depression. Journal of Affective Disorders, 79, 149160.
Gloaguen, V., Cottreaux, J., Cucherat, M. and Blackburn, I.-M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 5972.
Hamilton, M. A. (1960). A rating scale for depression. Journal of Neurological and Neurosurgical Psychiatry, 23, 5961.
Hammen, C. (1991). Generation of stress in the course of unipolar depression. Journal of Abnormal Psychology, 100, 555561.
Hammen, C. (2003). Interpersonal stress and depression in women. Journal of Affective Disorders, 74, 4957.
Harkness, K. L., Monroe, S. M., Simons, A. D. and Thase, M. (1999). The generation of life events in recurrent and non-recurrent depression. Psychological Medicine, 29, 135144.
Hirschfield, R. M., Montgomery, S. A., Aguglia, E., Amore, M., Delgado, P. L., Gastpar, M., Hawley, C., Kasper, S., Linden, M., Massana, J., Mendlewicz, J., Moller, H. J., Nemeroff, C. B., Saiz, J., Such, P., Torta, R. and Versiani, M. (2002). Partial response and nonresponse to anti-depressant therapy: current approaches and treatment options. Journal of Clinical Psychiatry, 63, 826837.
Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D., Salomon, R. M., O'Reardon, J. P., Lovett, M. L., Young, P. R., Haman, K. L., Freeman, B. B. and Gallop, R. (2005). Prevention of relapse following cognitive therapy versus medications in moderate to severe depression. Archives of General Psychiatry, 62, 417422.
Hollon, S. D., Jarrett, R. J., Nierenberg, A. A., Thase, M. E., Trivedi, M. and Rush, A. J. (2005). Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? Journal of Clinical Psychiatry, 66, 455468.
Hollon, S. D. and Kendall, P. C. (1980). Cognitive self-statements in depression: development of an automatic thoughts questionnaire. Cognitive Therapy and Research, 4, 383395.
Jacobsen, N. S., Roberts, L. J., Berns, S. B. and McGlinchey, J. B. (1999). Methods for defining and determining the clinical significance of treatment effects: description, application and alternatives. Journal of Consulting and Clinical Psychology, 67, 300307.
Jacobsen, N. S. and Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 1219.
Jarrett, R. B., Kraft, D., Doyle, J., Foster, B. M., Eaves, G. G. and Silver, P. C. (2001). Preventing recurrent depression using cognitive therapy with and without a continuation phase. Archives of General Psychiatry, 58, 381388.
Johnson-Laird, P. N. (1983). Mental Models: towards a cognitive science of language, inference and consciousness. Cambridge: Cambridge University Press.
Joiner, T. E. (2000). Depression's vicious scree: self-propagating and erosive processes in depression chronicity. Clinical Psychology: Science and Practice, 7, 203218.
Judd, L. L., Paulus, M. J., Scheffler, P. J., Akiskal, H. S., Endicott, J., Leon, A. C., Maser, J. D., Mueller, T., Solomon, D. A. and Keller, M. B. (2000). Does incomplete recovery from first lifetime major depressive episode herald a chronic course of illness? American Journal of Psychiatry, 157, 15011504.
Lam, D. H., Green, B. and Power, M. J. (1994). The impact of social cognitive variables on the initial level of depression and recovery. Journal of Affective Disorders, 32, 7583.
Lam, D. H., Green, B., Power, M. J. and Checkley, S. (1996). Dependency, matching adversity and relapse in major depression. Journal of Affective Disorders, 37, 8190.
Lewinsohn, P. M., Allen, N. B., Seeley, J. R. and Gotlib, I. H. (1999). First onset versus recurrence of depression: differential processes of psychosocial risk. Journal of Abnormal Psychology, 108, 483489.
Lewinsohn, P. M., Zeiss, A. M. and Duncan, E. M. (1989). Probability of relapse after recovery from an episode of depression. Journal of Abnormal Psychology, 98, 107116.
Ma, S. H. and Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72, 3140.
McGlinchey, J. B. and Dobson, K. S. (2003). Treatment integrity concerns in cognitive therapy for depression. Journal of Cognitive Psychotherapy: An International Quarterly, 17, 299317.
Mitchell, P. B., Parker, G. B., Gladstone, G. L., Wilhelm, K. and Austin, M-P. V. (2003). Severity of stressful life events in first and subsequent episodes of depression: the relevance of depressive subtype. Journal of Affective Disorders, 73, 245252.
Monroe, S. M. and Harkness, K. L. (2005). Life stress, the “kindling” hypothesis, and the recurrence of depression: considerations from a life stress perspective. Psychological Review, 112, 417445.
Monroe, S. M. and Simons, A. D. (1991). Diathesis-stress theories in the context of life stress research: implications for the depressive disorders. Psychological Bulletin, 110, 406425.
Moore, R. G. and Blackburn, I. M. (1997). Cognitive therapy in the treatment of non-responders to antidepressant medication: a controlled pilot study. Behavioural and Cognitive Psychotherapy, 25, 251259.
Murray, C. J. L. and Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet, 349, 14361442.
Nietzel, M. T., Russel, R. L., Hemmings, K. A. and Gretter, M. L. (1987). Clinical significance of psychotherapy for unipolar depression: a meta-analytic approach to social comparison. Journal of Consulting and Clinical Psychology, 55, 156161.
Oatley, K. and Johnson-Laird, P. N. (1987). Towards a cognitive theory of emotions. Cognition and Emotion, 1, 2950.
Papakostas, G. I., Petersen, T., Pava, J., Masson, E., Worthington, J. J., Alpert, J. E., Fava, M. and Nierenberg, A. A. (2003). Hopelessness and suicidal ideation in outpatients with treatment-resistant depression: prevalence and impact on treatment outcome. Journal of Nervous and Mental Disease, 191, 444449.
Segal, Z. V., Kennedy, S., Gemar, M., Hood, K., Pedersen, R. and Buis, T. (2006) Cognitive reactivity to sad mood provocation and the prediction of depressive relapse. Archives of General Psychiatry, 63, 749755.
Solomon, D. A., Keller, M. B., Leon, A. C., Mueller, T. I., Shea, M. T., Warshaw, M., Maser, J. D., Coryell, W. and Endicott, J. (1997). Recovery from major depression: a 10-year prospective follow-up across multiple episodes. Archives of General Psychiatry, 54, 10011006.
Spijker, J., de Graaf, R., Bijl, R. V., Beekman, A. T. F., Ormel, J. and Nolen, W. A. (2002). Duration of major depressive episodes in the general population: results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS). British Journal of Psychiatry, 181, 208213.
Spitzer, R. L., Williams, J. B. W., Gibbon, M. and First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID): 1. history, rational, and description. Archives of General Psychiatry, 49, 624629.
Taylor, J. L., Morley, S. and Barton, S. B. in press. Self-organization in bipolar disorder: compartmentalization and self-complexity. Cognitive Therapy and Research.
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M. and Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615623.
Thase, M. E. (2004). Therapeutic alternatives for difficult-to-treat depression: a narrative review of the state of the evidence. CNS Spectrums, 9, 808821.
Vallacher, R. R. and Wegner, D. M. (1989). Levels of personal agency: individual variation in action identification. Journal of Personality and Social Psychology, 57, 660671.
Waltz, J., Addis, M. E., Koerner, K. and Jacobson, N. S. (1993). Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 620630.
World Health Organization (2002). The World Health Report 2002: reducing risks, promoting healthy life. Geneva: WHO.
Wrosch, C., Scheier, M. F., Carver, C. S. and Schultz, R. (2003). The importance of goal disengagement in adaptive self-regulation: when giving up is beneficial. Self and Identity, 2, 120.
Wrosch, C., Scheier, M. F., Miller, G. E., Schultz, R. and Carver, C. S. (2003). Adaptive self-regulation of unattainable goals: goal disengagement, goal reengagement, and subjective well-being. Personality and Social Psychology Bulletin, 29, 14941508.


Early Intervention for Adults at High Risk of Recurrent/Chronic Depression: Cognitive Model and Clinical Case Series

  • Stephen Barton (a1), Peter Armstrong (a2), Mark Freeston (a1) and Vivien Twaddle (a2)


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Early Intervention for Adults at High Risk of Recurrent/Chronic Depression: Cognitive Model and Clinical Case Series

  • Stephen Barton (a1), Peter Armstrong (a2), Mark Freeston (a1) and Vivien Twaddle (a2)
Submit a response


No Comments have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *