Review of Depression Interventions with Minority Populations

Abstract

This document is an exploration of the effects of Cognitive Behavioral Therapy and antidepressants during treatment among ethnic and sexual minorities experiencing depression and depressive symptoms. Culturally adapt approaches may help create a more effective form of treatment for both populations. The research will show the results of increasing patient awareness and integrating anti-oppressive considerations reduce the symptoms of depression. In addition this will also show the effectiveness of Cognitive Behavioral Therapy in reducing depressive symptoms, when used as a therapeutic intervention for minority populations.

Statement of Purpose

Depression is reported to affect approximately 18.8 million people in the United States and is one of the leading clinical diagnoses treated among clients in a psychiatric or mental health setting (Murray & Fortinberry, 2005). Everyone at some point in his or her life time, will personally experience depression or become aware of someone else’s It is important for Social Workers to know that within minority populations under-treatment and misdiagnosis is common within minority populations, especially in the African American community and the Lesbian, Gay, Bisexual, Transgender, Community (LGBT) (National Alliance on Mental Health, 2013). The National Alliance on Mental Health (NAMI) also found that a plethora of health and daily functioning problems, such as a lack of sleep, lack of energy, changing eating habits, and other contributing factors can lead to life threatening problems and even to suicide. Anyone can find his or herself is a state of depression; many factors that lead to depression: lack of family support, stigma, violence, internalized homophobia and racism, poverty, and social status. The key to helping those suffering from depression is the ability to treat the client in a manner that best fits his or her individual needs. One third of patients with depression do not respond to medication interventions or have residual symptoms (Rupke, Blecke & Renfrow, 2006). Cognitive Therapy has been considered one of the leading methods along with Talk Therapy or Psycho-education for treating patients with depressive symptoms (Rupke, Blecke & Renfrow, 2006). With symptoms and diagnoses of depression rising, especially in minority groups, some are finding their treatment for these populations may need to be changed.

Social Work is a field that should be ever-evolving to meet the needs of clients. With changing populations, family dynamics, and cultural evolution there is an increasing need for the type of services Social Workers offer to meet the needs of clients. The National Association of Social Workers (NASW) states that Social Work professionals should make a responsible effort to ensure progress in the field for those served (NASW, 2008). With the recent increase in depressive symptoms and the rise of suicide among minorities, it is imperative that the best treatment modality to address this problem be found. Major depression and symptoms related to depression have recently been found to be more prevalent in minority ethnic groups than among whites, and is an increasing problem that needs to be addressed (Dunlop, Song, Lyons, Manheim & Chang, 2003).

Research Questions

RQ 1: Can antidepressant medication reduce depressive symptoms in minority populations?

RQ 2: Can Cognitive Behavioral Therapy reduce depressive symptoms in minority populations?

Hypotheses

HR 1: Minority clients who participate in antidepressant medication treatment are more likely to show a reduction in depressive symptoms than those who do not.

HR 2: Minority clients who receive Cognitive Behavioral Therapy for treatment of depression are more likely to show a decrease in depressive symptoms than those who do not.

Conceptual Model

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Study Review

Can Talking About Oppression Reduce Depression?

The first study is an uncontrolled group intervention by Ross, Doctor, Dimitto, Kuehl, and Armstrong (2008), to assess the effectiveness of Cognitive Behavioral Therapy (CBT) among LGBT people with depression. During this intervention, CBT is delivered based on anti-oppression principles and is tested by its ability to aid in decreasing depressive symptoms.

Research Questions

RQ 1: Will participants in conducted CBT therapeutic intervention show significantly decreased levels of depression after 14 weeks of therapy?

RQ 2: Will participants in the CBT therapeutic intervention show a decrease in internalized homophobia and increase self-esteem following the 14 week intervention?

Hypotheses

HR 1: Individuals who participate in CBT based interventions will show a significant decrease in levels of depression after 14 weeks of therapy.

HR: 2 Individuals who participate in CBT base interventions will show a significant decrease in levels of internalized homophobia and increase self-esteem.

Variables

Ross et. al (2008), have three variables as a part of the study. Cognitive Behavioral Therapy (CBT) in this model is the independent variable which will affect the level of depression, and self-esteem. Both depression and self-esteem are the dependent variables, which are predicted to be directly affected by the CBT intervention given during group treatment. The moderating variable in the study can be considered the anti-oppressive principles upon which the intervention is based sessions on coming out and internalized homophobia will be conducted.

Measurement of Variables

The Cognitive Behavioral Therapy (CBT) intervention conducted with this study was based on the model outlined by Greenberger and Padesky’s (1995) Mind Over Mood manual and was conducted over consecutive 14-week sessions. The weekly sessions were delivered based on Anti-oppression principles and included sessions on coming out and internalized homophobia. The intervention was designed to take participants from conceptual understanding of CBT principles to making behavioral change by weekly concepts outlined during sessions. Weekly sessions were two hours long, with increased CBT techniques over the 14-week course, with each session focusing on an educational concept of the CBT model. The treatment involved techniques identifying situations, thoughts, moods, and behaviors that reinforced depressive symptoms. As the weeks progress, participants are given more homework assignments and activities to teach them how thoughts, reactions, behaviors, and moods can create or maintain symptoms of depression. Participants were questioned as to their level of CBT exposure increased to asses understanding and allow participants to discuss their progress in the CBT model, this assessment will lead to sessions regarding the coming out experience, internalized homophobia, biphobia, and transphobia and the impact of those concepts on depression.

Depression was assessed using the Beck Depression Inventory II (BDI-II). The BDI-II was the primary measure for the severity of depression. Twenty one items on the BDI-II scale that revolved around cognitive concepts of depression, as well as items that are symptoms related to depression such as hopelessness, being punished, guilt, and irritability. This model has been given an alpha of 0.91 (Beck, Steer, & Brown, 1996). The Hamilton Rating Scale for Depression (HAMD) was also used to measure the severity of depression among participants in the group sessions. The HAMD is used to assess changes in energy, appetite, weight, and libido, assessed by qualitative structured interviewing outlined in the HAMD guide (Williams, 1988).

The measurement for self-esteem was using the Rosenberg Self-esteem Scale. This is a self-report measure of self-esteem using a 10 item scale. The reliability of the measurement is in the range of 0.82-0.88 in various samples (Rosenberg, 1986). The Lesbian Internalized Homophobia Scale (LIHS) was used to assess internalized homophobia. The scale was modified to include those who identified as gay, bisexual, and transsexual. The scale assessed personal feelings regarding the thoughts of being LGBT and attitudes towards others who identified with being in the LGBT community. Scores ranged from one to seven with the higher the number meaning a higher level of internalized homophobia.

Sampling Strategy

The selection of participants was a non-random recruitment which was made through paid LGBT advertisements as well as referrals from mental health providers. 70 individuals contacted the study group to participate, and 55 were selected. Participants had to identify as a sexual orientation other than heterosexual or their gender identity as other than male or female. Participants who did not score greater than eight on the 17-item Hamilton Rating Scale for Depression (HAMD) or score greater than 21 on the Beck Depression Inventory II (BDI-II) were excluded for the study.

Study Design

The intervention is a longitudinal quantitative study; participants were interviewed and took a baseline at the beginning of the intervention. Participants then become involved in the 14 week sessions where they took the BDI-II, HAMD, The Rosenberg Self-esteem Scale, and LIHS at the start of the first session, during the third session, and 2 months following the completion of session 14. The decrease or increase of the participant’s score is the considered difference in depression and self-esteem. This was an uncontrolled trial with outcomes recorded through scaled measurements from participants who were in group sessions; each session was two hours in length.

Study Findings

The study shows that 10 of the participants (43%) were in the moderately depressed range and 19 (83%) of the participants scored in the moderate to severe range on the 17-item version of the HAMD (>14) and BDI-II (>19) which were the samples used for the CBT intervention. The study shows that there is a statistically significant decrease in BDI-II score from the first test to the second. On average, the decrease between the testing periods was an 18.9 point decrease. When evaluated with the HAMD, the mean scores decreased from 13.7 to 9.1. The self-esteem evaluations increased from a score of 21.7 during the first test to 24.3 on the second evaluation. Internalized homophobia scores did not have a great change from the first to second evaluation as well as no significant difference between the scores of male and female participants. The first hypothesis was supported; 90% of the participants stated that the intervention was helpful with decreasing depressive symptoms. It also showed that 90.9% of participants showed a decrease in scores on both the BDI-II and HAMD, supporting the hypothesis that CBT is effective in decreasing depressive symptoms among members in the LGBT community. The hypothesis that CBT would increase self-esteem was moderately supported while the hypothesis of CBT having an effect on internalized homophobia is not supported.

One-Year Outcomes of a Randomized Clinical Trail Treating Depression in Low-Income Minority Women

This is a random longitudinal study. The variables are all controlled and outcomes were measured periodically over the course of one year. Participants who are diagnosed with depression are placed in 3 treatment groups consisting of either CBT interventions, community referrals, or anti-depressants. Oppressive factors were taken into consideration with this study, and all participants were considered to be low-income based on information given by the District of Columbia guidelines for ability to receive federal supplemental support.

Research Questions

RQ 1: Is Cognitive Behavioral Therapy an effective therapeutic intervention when used among minority low-income women?

RQ 2: Will participants who are administered antidepressant medications more likely to decrease depressive symptoms than those who are referred to community services?

RQ3: Will low-income minority clients who have been offered community referrals show a greater decrease in depression than those who receive antidepressants or participate in Cognitive behavioral Therapy?

Hypotheses

HR 1:Low-income minority women who have been diagnosed as clinically depressed will show a greater decrease in depressive symptoms when given community referrals than those who are receiving Cognitive Behavioral Therapy.

HR 2: Low-income minority women who are receiving antidepressants will show a greater decrease in depressive symptoms than those who participate in Cognitive Behavioral Therapy.

HR 3: Low-income minority women receiving antidepressants will show a greater decrease in depression than those who receive community referrals.

Variables

Clinical Depression is the dependent variable for all of the hypotheses in this study. The authors predict that antidepressants, Cognitive Behavioral Therapy (CBT) or community referrals will all have an effect on the diagnosis for clinical depression given to clients. In this study CBT, antidepressants, and community referrals are independent variables.

Measurements of Variables

Depression was evaluated with the mood disorders section of the Primary Care Evaluation of Mental Disorders. All participants needed to qualify as suffering from Major Depressive Disorder with no contributing factors to their mood such as alcohol or other substances. Alcohol problems were ascertained with the 5- item TWEAK (Tolerance, Worry about drinking, Eye-opener drinks, Amnesia, Cut down on drinking). The maximum score that can be obtained is a seven (National Institute on Alcoholism and Alcohol Abuse, 2004). If participants received a score of two or more during the testing, they were considered to have harmful drinking habits. Substance abuse was measured with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) . The BDI-II was also used during this study to assess the participant’s level of depression; participants needed to score a 21 or higher on the BDI-II. Participants also were measured with the Hamilton Depression Rating Scale monthly after a baseline was conducted. All participants needed to also complete a diagnostic interview which was administered over the phone. The interview assessed for 12 month major depressive episodes, alcohol abuse or dependence, and lifetime mania or psychosis.

Sampling Strategy

16,286 possible participants were found through the Prince George County, Montgomery County, MD as well as Arlington and Alexandria, VA. These women were identified through the Women, Infants, and Children food subsidy programs that target low-income pregnant women. 2,311 were excluded because 1,345 were Non-US Born Black, 343 were Asian/American Indian, 67 were non-US Born White, 184 US-Born Latina, 178 were Multiple ethnicities, and 194 were unknown. To be eligible, the women had to identify specifically as black women born in the US, Latinas born in Latin America, and white women born in the United States. Of this 13975 were culturally eligible, only 1,538 were positive for MDD, and 566 were excluded because of factors such as bereavement, alcohol or drug problems, planned pregnancy, breastfeeding, and current mental health treatment. Of the remaining 1,017, 560 were excluded for not meeting the MDD diagnosis after further evaluation. 11 refused to participate, and 149 did not complete a clinical interview, so 267 total participants were a part of the study conducted. 88 were assigned to receive anti-depressants, 90 were assigned to receive CBT, and 89 were referred to community services to meet their needs.

Study Design

This was a trial conducted in the Washington DC suburban area from March1997 through May 2002. The study was a randomized controlled trial that had 267 women as participants. The women had to have a current diagnosis of depression and also had to attend the county-run Women, Infants, and Children food subsidy programs and Title X family planning clinics.

Women who were in the antidepressant study group were evaluated and participated in 8 sessions with practical nurses regarding the importance of medication routines and to express any of the concerns of side effects they may be experiencing. Those who were having negative reactions were placed on modified dosages. Participants who were apprehensive about medication first completed 3 psycho-education courses regarding antidepressant medication. The participants who were given paroxetine and switched to buproprion reported adverse effects. Participants in the CBT group were given at least 8 CBT sessions. The CBT sessions were conducted through 8 weeks of CBT manual based interventions.

Findings

The Cognitive Behavioral psychotherapy intervention was proven to be more effective in reducing depressive symptoms in women than the county referrals (P=.006). The participants who were given antidepressant medication showed more of a decrease in symptoms as opposed to those who received referrals as well (<.001). The psychotherapy also resulted in improved social functioning (P=.02). This study showed that women who receive antidepressant medications were twice as likely to receive a Hamilton Depression Rating Scale score of 7 or less by the 6th month of the intervention (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P=.057). The study also showed that women were more likely to complete the duration of antidepressant use than those who participated in psychotherapy. The results indicate that women were more willing to participate in treatment with medication rather than men and outcomes were more extensive for the medication participants. The research also suggests that the results were similar for African American, Latina, and White participants; however the remission rates for those who participated in the CBT intervention were significantly more than participants who were given antidepressants. On average, those who participated in CBT were 69.2% more likely to be in a depressive state within 12 months of the intervention than those who were on antidepressants. This finding suggests that Cognitive Behavioral Therapy was not as effective as antidepressants. (Miranada, Chung, Green, Krupinck, Siddique, Revicki, & Belin, 2003).

Evaluating the Impact of a Cognitive-Behavioral Intervention with Depressed Latinas

This study was conducted in New York with Latina women reporting to the New York University School of Social Work. It was intended to measure and evaluate the effects of Cognitive Behavioral Interventions (CBT) with Latina women reporting to suffer from depression and depressive symptoms.

Research Questions

RQ: Will depressed Latinas report lower depressive symptoms after participating in Cognitive Behavioral Therapy?

Hypothesis

HR: Latinas who participate in Cognitive Behavioral interventions will show a decrease in depressive symptoms.

Variables

The study conducted by Gelman, Lopez, and Foster had two variables: Cognitive behavioral therapy (CBT) and depressive symptoms. CBT in this study is the independent variable, and depressive symptoms is the dependent variable. The researchers wanted to see if CBT would have a direct effect on the level of depression the participants reported on the Beck Depression inventory Scale (BDI-II).

Measure of Variables

Depressive symptoms among the participants were measured using the Beck Depression Inventory Scale. This scale rated the women’s levels of depression before the beginning of the intervention to create a baseline. Scores were also taken after the intervention to record improvement or a decrease in depression and depressive symptoms.

The Cognitive Behavior intervention was conducted using the Cognitive Behavioral Treatment protocol for depression developed at the San Francisco General Hospital . The participants’ scores were measured and reordered after successfully completing 12 sessions.

Sampling Strategies

The participants were voluntary and were recruited through the New York University School of Social Work. The participants filled out applications to participate and needed to score a 21 or higher on the Beck Depression Inventory Scale. 5 participants were chosen and successfully completed the CBT intervention with the School. All participants reported to the school of social work and agreed to participate. Participants were not interviewed and reasoning for depression, depressive symptoms, and life circumstance were not assessed for participation.

Study Design

Gelman, Lopez, and Foster conducted an uncontrolled pilot study. This was set up to have Latina women participate in 12 sessions of individual treatment conducted with the Beck Cognitive Behavioral Therapy Manual. Each session was 2 hours and was completed over the course of 12 weeks. The participants were given a baseline at the start of the intervention as well as recording scores following the completion of the study.

Study Findings

After the completion of the 12 week interventions, the pre and post-treatment BDI scores for the 5 participants were reduced. On average, all of the participants decreased in BDI scores by 12 points, which is a 95% decrease in depression (p<0.001). This suggests that the intervention was successful and supports the hypothesis that CBT interventions are effective in depressed Latina women. The authors report that the findings should be taken with caution due to a lack of study control when conducting the 12 sessions. The authors also report that due to the small sample size, these findings cannot be generalized to be beneficial for the Latina population. This study should also be taken with caution due to the lack of examination of factors contributing to the intervention and evaluation of environmental and personal contributors to depressive symptoms; due to this, the study was decided to be not feasible for the use of social workers.

Outcome results of Two Levels of Intervention in Low-income Women with Depressive Symptoms

Lara et. al, (2003) arranged this study to assess the levels of intervention with depressed women. Using a comparison, the participants were in 6 weekly sessions with poor minority depressed clients. This study was arranged to provide brief CBT interventions for clients and measure the effectiveness. Two groups were compared; a group condition and minimum individual condition group of women diagnosed with a depressive episode. The idea of this study was to show that CBT would be more effective with Latina women if they were in group settings than with women who share the same ethnicity and disparities. With those who are depressed, the researchers are seeking to understand if commonalities in oppression and life situations play a role in treatment.

Research Questions

RQ: 1 Will Cognitive interventions with Latina women participants in a group setting show more of a reduction in depression than those who do not?

RQ: 2 Will individual brief cognitive interventions with Latina women decrease the depressive symptoms more than those who participate in group cognitive interventions?

Hypotheses

HR: 1 Latina Women who participate in group cognitive interventions will show more of a decrease in depression than those who participate in individual interventions.

Variables

The first variable, Cognitive Behavioral Therapy, with the individual client is predicted to have an effect on the diagnosis of depression in Latina women. The second is the cognitive behavior therapy with Latina women in a group setting. These two are the independent variables in the study. The participant’s depression diagnosis is the dependent variable. The researchers are predicting that both will have a direct effect on the depression diagnosis of the participants.

Measurement of Variables

Participants in both the group and individual sessions needed to be diagnosed with the DSM as a participant with current depressive episode, previous depressive episodes, and dysthymia. Participants initially needed to be deemed symptomatic when measured with the Center for Epidemiologic Studies Depression Scale (CES-D). The participants were given a baseline before the start of interventions for both the individual intervention and group interventions. There were also recordings made during the third session of interventions as well as completing the intervention and three months following. The Beck Depression Inventory Scale was used with all participants as well as the Somatic and Anxiety Symptoms Checklist by Derogatis.

Sampling Strategy

To be eligible for the study, participants needed to be between the ages of 25-45 years old, and have been diagnosed with the DSM as well as the CES-D. 254 women were randomly selected from the data base of primary care institutions in Mexico City. These women were given two pretreatment assessments to determine eligibility for the study. Those who were excluded were deemed to be of high suicidal risk, pregnant, have a terminal illness, drug or alcohol abuse, or were currently receiving mental health treatment elsewhere. Participants were selected from primary health institutions in Mexico City. 93 women were eligible and agreed to participate in the study.

Study Design

The participants were randomly selected for treatment options in group or individual treatment. 47 women were placed in the group studies and 46 participated in the individual intervention. There were seven study groups that were conducted over a six week period. The participants were given pretreatment, post treatment, and follow-up assessments. Participants in the group intervention participated in six, two hour group sessions with CBT and those selected in the individual cohort, completed six individual two hour sessions. Participants that completed the group study were reassessed two weeks after the intervention then again four months later. Those who participated in the individual intervention were assessed one and four months after the completion of the intervention.

Study Findings

Findings for both group and individual interventions were significant in the decrease of depressive symptoms and results continued to decrease when follow-ups were conducted. Of the two, the group intervention participants showed more of a reduction in depressive symptoms following the intervention supporting the researcher’s hypothesis. On average the group participants showed a 66.7% decrease in depressive symptoms, which on average was a decrease from a 32 on the BDI-II to a 9.8 average score. The study showed p=.01 values for participants in the group in general, p=.026 for participants with dysthymia, and a p=.024 value for participants with a previous depressive episode. Those who participated in the individual intervention showed a decrease in depressive symptoms on an average of 41.2%. This is a decrease from an average of 28 on the BDI-II to a 16.5 score on average for participants (p=0.1). This showed values of p=.02 for participants with dysthymia and p=.01 for those who have had a previous depressive episode. This study suggests that participants who participated in group therapy with those who had similar oppressive factors showed a greater decrease in depressive episodes and symptoms.

Findings

These research models tested the effectiveness of Cognitive Behavioral Therapy (CBT) and antidepressant interventions as a treatment for depressive symptoms. The first hypothesis predicting that participants given antidepressant medication would be an effective treatment for minority populations was supported. Miranda et. al (2003), showed that over a 12 month measurement antidepressant medication proved to be successful. It also suggested that the intervention was more effective than CBT when working with minority women of low SES.

Gelman, Lopez and Foster’s findings suggest that CBT is effective when working with Latina women, but the findings are to be taken with great caution due to the lack of control of the research variables and the failure to properly evaluate the possible contribution to participant’s depression, and the study sample size. Research supporting the hypothesis of CBT as an effective method to use when intervening with minorities was suggested to be successful when client’s oppressive factors are taken into consideration. Ross et. al (2008), showed this when creating a CBT model revolving around factors relating to the life and commonalities found with those who identify as Lesbian, Gay Bisexual, or transgender. Lara et. al (2003), found that those who were participates in the CBT interventions with other they could identify with in regards to oppression and status showed more successful outcomes than those who participated in individual sessions.

Discussion

The research collected was based on models to explore the effectiveness of depression intervention with minority populations. Antidepressants proved to be an effective use; CBT was effective when considering oppressive factors among client in when interventions included anti-oppression and it is relation to depressive factors integrated into treatment. When comparing the interventions using CBT with minority individuals or groups, the research suggests that the most effective method is the group CBT method. This may allow for clients to feel they have commonalities and can relate their conditions and feelings to surroundings and social stigmas or statues. A study conducted by Diaz, Ayala, Bein, Henne (2001), and Marvin suggest that social discrimination directly effects mental health. It is important that as researchers and Social Workers we seek to find all factors that can interfere and possibly affect the life of our clients. Recognizing and addressing the direct issues, one may be able to more accurately treat a client’s condition. This research shows that when racism, homophobia, sexism, and socioeconomic status are taken into consideration with treatment of depression the outcomes are significantly better.

References

Diaz, R., Ayala, G., Bein, E., Henne, J., Marin, B. (2001) The Impact of Homophobia, Poverty, and Racism on the Mental Health of Gay and Bisexual Latino Men: Findings From 3 US Cities. American Journal of Public Health. 19(6), 927-930.

Dunlop, D., Song, J., Lyons, J., Manheim, L., & Chang, R. (2003). Racial/Ethnic Differences in Rates of Depression among Preretirement Adults. US National Library of Medicine National Institutes of Health, 93 (11), 1945-1952.

Gelman, C., Lopez, M., & Foster, R. (2005). Evaluating the Impact of a Cognitive-Behaviora Intervention with Depressed Latinas: Social Work Mental Health, 4 (2), 38-42. doi:0.1300/J200v04n2_01

Greenberger, D. & Padesky, C.A. (1995). Mind over Mood: Change How You Feel by Changing the Way You Think. New York: Guilford

Lara, M. A., Navarro, C., Rubi, N. A., & Mondragon, L. (2003). Outcome Results of Two Levels of Interventions in Low-Income Women With Depressive Symptoms. American Journal of Orthopsychiatry, 73 (1), 35-43. doi: 10.103710002-943.73.1.35

National Institute on Alcoholism and Alcohol Abuse (2004). Instrument Facts Sheet.

Miranada, J., Chung, J., Green, B., Krupinck, J., Siddique, J., Revicki, D., & Belin, T. (2003). Treating Depression in Predominantly Low-income Young Minority Women. Journal of the American Medical Association, (290), 57-65.

Murray, B., & Fortinberry, A. (2005, January 15). Uplift Program. Retrieved from http://www.upliftprogram.com/depression_facts.html

NASW. (2008). NASW Code of Ethics Retrieved from http://www.sp2.upenn.edu/docs/resources/nasw_code_of_ethics.pdf

National Alliance on Mental Health. (2013). NAMI. Retrieved from http://www.nami.org/Template.cfm?Section=depression

Rosenberge, M. (1986). Conceiving the Self. Krieger: Malabar FL.

Ross, L., Doctor, F., Kuehl, D., & Armstron, M. S. (2008). Can talking About Oppression Reduce Depression. Journal of Gay and Lesbian Social Services, 19 (1), 1-15.

Rupke, S., Blecke, D., & Renfrow, M. (2006). Cognitive Therapy for Depression. Retrieved from http://www.aafp.org/afp/2006/0101/p83.html

Williams, J. (1988). A Structured Interview Guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry, 45, 742-747.