CBT fundamentals — structured clinical viva

Markers want a consultant-level account of the depression CBT model, practical structure, BA prioritisation when activation is collapsed, fair reading of CT-versus-meds evidence (including relapse prevention), homework science, drift, and integrated care without anti-medication ideology or anti-therapy nihilism.[1][3][4]

Biased information processing; negative views of self, world, and future; schema/core belief activation under stress; automatic thoughts driving affect and withdrawal; withdrawal reducing reinforcement and confirming hopelessness.[1][2]

Cross-sectional: trigger (waking / empty day) → AT “I’m a failure / nothing will help” → low mood/shame → lie in bed, cancel social contact, stop running → less mastery/pleasure → belief strengthened. Longitudinal: explore early experiences and core beliefs (failure/defectiveness) and rules (“If I rest I’m lazy”). Sertraline partial response = biological treatment incomplete; inactivity is a major psychological-behavioural maintaining factor.[1][2]

Bridge, agenda, homework review, active work, new homework, feedback. Early: activity monitoring and BA scheduling (mastery/pleasure), rumination as behaviour to interrupt, simple thought records once activation allows. Avoid premature deep schema excavation while he is bed-bound.[1][5]

DeRubeis 2005: CT comparable to medication for moderate–severe depression in specialised settings. Hollon 2005: CT associated with better protection against relapse after discontinuation compared with patients taken off medication. Caveats: therapist competence, selection, access; combination often pragmatic. Do not claim all community CBT equals trial CT.[3][4]

Homework quantity and quality relate to outcome — design specific tasks and always review.[5] Drift = supportive chat without activation, agenda, or cognitive-behavioural methods; supervision and measures correct it.[6]

Collaborative decision: options include continue sertraline + add CBT/BA (often best given partial response), optimise dose/switch meds, or trial CT-focused pathway if preferred and accessible — not a moral either/or. Review risk, side effects, and goals. Stopping medication abruptly because therapy starts is poor care unless a planned, monitored strategy exists.[3][4]