Journal of Rational-Emotive & Cognitive-Behavior Therapy

Volume 17, Number 4, Winter 1999

LAY THEORIES CONCERNING

CAUSES AND TREATMENT
OF DEPRESSION
Lindsey Kirk
Cindy Brody
Ari Solomon
David A. F. Haaga
American University

ABSTRACT: This study compared perceptions of the causes of, therapies for,
and means of coping with, depression between two groups of currently non-
depressed adults: one with a history of major depression and one with no
history of depression. Currently nondepressed participants were selected so
that effects of past experience of depression could be distinguished from those
of current mood. Recovered depressed participants (RD) (n = 25) and Never
depressed participants (ND) (n = 25) recruited via newspaper advertise-
ments completed self-report measures of (a) the perceived utility of either
professional or self-help coping strategies for managing their own experiences
of depression; (b) likely effectiveness of several major therapies for depres-
sion; and (c) perceived accuracy of several etiological theories of depression.
RD participants rated depression as being less amenable to everyday self-
help methods of coping and more in need of professional intervention. How-
ever, RD and ND subgroups did not differ significantly in their perceptions of
the plausibility of etiological theories of depression in general, nor in their
ratings of the likely helpfulness of major therapies.

These data were presented at the annual convention of the Association for Advancement of Be-
havior Therapy, Miami Beach, November 1997. The research was supported by a grant from the
Institute for Rational Emotive Therapy. This manuscript is based on a master's thesis completed
by the first author. We are grateful to thesis committee members Jim Gray and Michele Carter
for comments on earlier versions of this material.
Address correspondence to David A. F. Haaga, Department of Psychology, Asbury Building,
American University, Washington DC 20016-8062; e-mail: dhaaga@american.edu.
237 1999 Human Sciences Press, Inc.
238 Journal of Rational-Emotive & Cognitive-Behavior Therapy

Understanding laypeople's perceptions of the etiology and treatment

of depression is important for several reasons. First, beliefs about the
optimal treatment of depression may affect treatment acceptability
and even treatment outcome. For example, depressed patients appear
to respond better to cognitive therapy of depression if they have an
initial favorable reaction to the theoretical rationale for this treatment
(Fennell & Teasdale, 1987), which may in turn depend upon the good-
ness of fit of this rationale with their own understanding of how de-
pression is caused (Addis & Jacobson, 1996). Second, lay beliefs about
psychological disorders may be a factor in the social context of the
disorder (e.g., Furnham & Haraldsen, 1998). If, for example, friends,
relatives, co-workers and acquaintances tend to perceive depression as
similar to ordinary sadness and as easily overcome via straightforward
coping tactics such as distracting oneself by watching TV, this may
shed light on depressed people's experiences of others as often impa-
tient, lacking in empathy, and even hostile and rejecting (e.g., Feld-
man & Gotlib, 1993).
Several studies have examined lay perceptions of depression. Re-
search by Rippere (e.g., 1977, 1979, 1980) established that lay people
on average have a detailed and reasonably accurate set of beliefs about
depression and about useful techniques for coping with depression.
Nevertheless, there are individual differences in perceptions of depres-
sion. Having suffered a depressive episode oneself appears to be one
correlate of these individual differences. For example, in one study de-
pressed patients were more likely than other non-professional partici-
pants to cite biological or medical causes when asked open-ended ques-
tions about what causes depression and were more likely to consider
antidepressant medication a useful treatment (Kuyken, Brewin,
Power, & Furnham, 1992). It is not known whether such differences
would persist after remission of a depressive episode. People who have
experienced major depression but are not currently in a depressive
state may have a unique vantage point on depression and unique in-
sights (Coyne, 1994). Detailed first-person reports by such individuals
are available (e.g., Styron, 1990), but not systematic comparisons with
demographically similar never-depressed groups on the basis of stan-
dardized measures.
Accordingly, in the study reported in this article we contrasted per-
ceptions of theories, therapies, and coping tactics for depression among
(a) a community sample of people who had recovered (for at least two
months) from a major depressive episode and (b) a demographically
similar group of people with no history of major depression.
Lindsey Kirk, Cindy Brody, Ari Solomon, and David A. F. Haaga 239

METHOD

Participants

The participants were 50 adults (25 Recovered Depressed [RD] and

25 Never Depressed [ND] who had responded to newspaper advertise-
ments. To be included in either group, participants needed to meet the
following criteria: (a) Currently non depressed (Beck Depression In-
ventory of 9 or lower, as recommended by Kendall, Hollon, Beck, Ham-
men, & Ingram, 1987); (b) No history of manic or hypomanic episodes;
(c) No history of primary psychotic ideation, and no bizarre behavior of
impaired mental status evident on the day of the study; (d) No current
suicidality; (e) No substance abuse or dependence (other than nicotine
dependence) in the past six months; (f) No use of antidepressant medi-
cation or of psychotherapy for depression in the past two months; and
(g) Age at least 18 years.
ND participants had to meet two additional criteria: (a) No past ma-
jor depressive episodes (MDE); and (b) No history of dysthymic disor-
der. RD participants had to meet three additional criteria: (a) Positive
history of major depressive disorder by DSM-IV (American Psychiatric
Association, 1994) criteria; (b) Experience of at lest one MDE in the
previous three years not precipitated and sustained by drug or organic
factors; and (c) Complete recovery from the most recent MDE (asymp-
tomatic by SCID criteria) at least two months prior to the study. Re-
quiring at least two months of asymptomatic functioning is consistent
with the recommendation of the MacArthur Foundation Research Net-
work on the Psychobiology of Depression (Frank et al., 1991) that at
least 8 symptom-free weeks by considered a consensus definition of
full recovery from a major depressive episode.

Measures

Beck Depression Inventory. The Beck Depression Inventory (BDI; Beck,

Rush, Shaw, & Emery, 1979) is a self-report measure of current de-
pressive symptom severity, with extensive evidence of high internal
consistency and high convergent validity with independent inter-
viewer ratings (Beck, Steer, & Garbin, 1988). As indicated earlier, par-
ticipants in either group had to score 9 or below on the BDI to be
included in the study.
240 Journal of Rational-Emotive & Cognitive-Behavior Therapy

Inventory to Diagnose DepressionLifetime. The lifetime version of

the Inventory to Diagnose Depression (IDD-L; Zimmerman & Coryell,
1987), a 22-item self-report measure designed to correspond to DSM-
III depression criteria, was used for sample description purposes and
to corroborate the RD/ND diagnoses we derived from structured inter-
views.

Beck Scale for Suicide Ideation. The Beck Scale for Suicide Ideation
(BSI; Beck, Steer, & Ranieri, 1988) is a 19-item self-report measure of
suicidality that is highly correlated (> .90) with clinical ratings of sui-
cidal ideation (Beck, Steer, & Ranieri, 1988). The first five questions of
this measure, which serve as an overview of suicidality, were used to
screen out potentially suicidal people (i.e., anyone scoring above 0).

Structured Clinical Interview for DSM-IV. Diagnoses were derived on

the basis of relevant portions of the non-patient edition of the Struc-
tured Clinical Interview for DSM-IV (SCID-I/NP; First, Gibbon, Spit-
zer, & Williams, 1995). Williams et al. (1992) reported adequate inter-
rater reliability for major depression diagnoses based on an earlier
version of the SCID. In the present study SCID interviews were con-
ducted by clinical psychology Ph.D. students, under the supervision of
a licensed psychologist with experience using SCID protocols in re-
search and the immediate direction of an advanced Ph.D. candidate
with independent SCID-I training and certification and experience
conducting SCIDs in several clinical trials. All SCID interviews were
audiotaped to facilitate evaluation of interrater agreement. A ran-
domly-selected subset of 20 SCID audiotapes (40% of the total sample,
n = 11 RD, n = 9 ND) were submitted to the supervising psychologist
for an independent diagnostic evaluation conducted without aware-
ness of the original diagnosis. There was 100% agreement between
these judgements.

Helpfulness of Antidepressive Activities Questionnaire. The Helpful-

ness of Antidepressive Activities Questionnaire (Rippere, 1979) con-
sists of a list of 15 things "that people sometimes do when they are
feeling depressed or low." Respondents give a rating from zero (least
helpful) to 20 (most helpful), based on how helpful they think they
would find each activity. Of the 15 items, we identified 13 a priori as
reflecting genuinely common sense everyday self-help activities (e.g.,
"go for a walk," "watch TV," "see a friend"). Two other items ("read
about depression and how to cure it" and "take antidepressants") ap-
Lindsey Kirk, Cindy Brody, Ari Solomon, and David A. F. Haaga 241

peared to reflect instead a somewhat more professional approach to

managing depression. Accordingly, we conducted analyses involving
this measure with the 13-item and 2-item subsets separately; in each
case, results are reported in terms of the mean item score on the sub-
scale.

Ratings of Causal Theories and Therapies of Depression. Participants'

perceptions of several major etiological theories and therapies of de-
pression were measured via rating scales developed by Kuyken et al.
(1992). The rating scales consist first of descriptions of biological, di-
athesis-stress, cognitive, and psychodynamic theories of depression,
each of which the participant rates on seven-point scales (anchored
with: "explains the causes of depression" not at all and completely).
Next, depression treatments (medication, ECT, psychoanalysis, cogni-
tive therapy) are described, and the participant rates each of these on
a seven-point scale as well, based on the perceived helpfulness of the
treatment (anchored with not at all helpful and extremely helpful). The
descriptions of theories and therapies are approximately 100-150
words long. Kuyken et al. (1992) wrote the descriptions and edited
them on the basis of comments made by clinical psychologists asked to
evaluate their accuracy.

Semi-Structured Interview on Depression Experience. Participants

were asked about any previous academic or professional experience
they may have had dealing with depression. In addition, they were
asked to describe what types of formal treatment, if any, they had
received for their depression.

Procedure

Participants took part in the study individually. After completion of

informed consent, the Beck Depression Inventory (BDI) and The Beck
Scale for Suicide Ideation (BSI) were administered. Those scoring 9 or
under on the BDI and zero on the BSI (thus remaining eligible for the
study) next completed the exclusionary portions of the SCID. Partici-
pants who were not excluded based on the SCID then completed the
standardized measures regarding lay perceptions of depression, as
well as other measures not relevant to this report. Finally, partici-
pants were interviewed regarding any past academic or professional
experiences with depression, treatment history, and detailed histories
of mood disturbances among the RD participants. At the end of this
242 Journal of Rational-Emotive & Cognitive-Behavior Therapy

interview and testing session, participants were debriefed and paid 20

dollars for their time.

RESULTS

Descriptive Data

Demographics and Depressive Symptoms. Descriptive data on demo-

graphics and depression variables are summarized in Table 1. As in-
tended, RD and ND groups were very similar demographically. Corrob-
orating the SCID results used in group classification, the RD group
reported much more severe depression in the past on the IDD-L
(M = 41.48) than did the ND participants (M = 12.67). RD partici-
pants also obtained significantly higher scores on the BDI (M = 3.88)
than did the ND group (M = 2.04). Although this is not ideal from the
standpoint of clearly distinguishing effects of current vs. past depres-
sion, the RD average is still well within the nondepressed range.

Table 1

Demographics and Depression Data for Recovered

Depressed and Never Depressed Participants

RD ND t(48) P
Demographics
Age 37.28(12.18) 40.04 (13.08) .77 .44
% Female 76 76
% Caucasian 76 76
Depression History
IDD-L 41.48 (12.00) 12.67 (10.55) 8.91 < .01
# Prior MDEs Median = 3
Current Depressive
Symptoms (BDI) 3.88 (2.65) 2.04 (2.44) 2.55 .01
Note. Except as noted otherwise, numbers are means, with standard deviations in parentheses.
IDD-L = Inventory to Diagnose Depression, Lifetime version. MDEs = Major Depressive Epi-
sodes. BDI = Beck Depression Inventory, n = 25 in each group. RD = Recovered Depressed.
ND = Never Depressed
Lindsey Kirk, Cindy Brody, Ari Solomon, and David A. F. Haaga 243

Personal Experience. Most participants had little relevant academic or

professional experience. Five participants (10% of total sample; 4 RD
people, 1 ND) had master's degrees in health-related fields (e.g., nurs-
ing, vocational rehabilitation), but none of these was a depression spe-
cialist. Thus, the sample appears representative in terms of having
largely a lay rather than professional/scholarly perspective on depres-
sion.

Tests of Primary Research Questions

There were no significant sex differences on any of the dependent

measures. Also, the distribution of each variable was explored and
found not to violate the assumptions of normality. Accordingly, RD/ND
comparisons were based on -tests, and male and female participants
were considered together in these analyses.

Theories and Therapies. Ratings of the explanatory power of biological,

diathesis-stress, cognitive, and psychodynamic theories of depression,
as well as antidepressant medication, electroconvulsive therapy, psy-
choanalysis, and cognitive therapy are presented separately for RD
and ND subsamples in Table 2. There were no significant differences
between RD and ND groups on ratings of any of the theories or thera-
pies.
Given that there were no significant differences between the RD and
ND groups' ratings of the theories and therapies, all participants were
combined for supplementary analyses of which theories and therapies
were considered most plausible by the sample as a whole. The biolog-
ical theory (M = 4.90, SD = 1.15) was significantly more strongly en-
dorsed than either cognitive (M = 4.26, SD = 1.68), t(49) = 2.39,
p < .03 or psychodynamic (M = 4.00, SD = 1.67), t49) = 3.21,
p < .01, theory. In addition, the diathesis-stress theory (M = 4.59,
SD = 1.20) was rated significantly higher than the psychodynamic
theory (M = 4.00, SD = 1.67), t(49) = 2.32, p < .03.
With respect to therapies, in the sample as a whole cognitive ther-
apy (M = 5.12, SD = 1.43) was endorsed significantly more strongly
than either ECT (M = 3.04, SD = 1.43), t(49) = 6.84, p < .001 or
psychoanalysis (M = 4.38, SD = 1.75), t(49) = 2.78, p < .01. Anti-
depressant medication (M = 5.21, SD = 1.53) was also rated signifi-
cantly higher than either ECT, t(49) = 8.56, p < .001, or psycho-
analysis, t(49) = 2.59, p < .02. Finally, psychoanalysis was endorsed
significantly more than was ECT, t(49) = -4.59,p < .001.
244 Journal of Rational-Emotive & Cognitive-Behavior Therapy

Table 2
Ratings of Theories and Therapies of Depression, by
Recovered Depressed and Never Depressed Participants

RD ND
M(SD) M(SD) t(df) P
Theory
Biological 4.68 (1.38) 5.12 (0.83) 1.37 (39.5) .18
Diathesis-Stress 4.74(1.11) 4.44 (1.29) -0.88(48) .38
Cognitive 4.08 (1.73) 4.44 (1.64) 0.76 (48) .45
Psychoanalytic 4.40 (1.58) 3.60 (1.68) - 1.73 (48) .09
Therapy
Drug 5.02 (1.74) 5.40 (1.29) 0.88 (48) .38
Electroconvulsive 2.79 (1.59) 3.28 (1.24) 1.20 (43.6) .24
Psychoanalysis 4.44 (1.66) 4.32 (1.87) -0.24(48) .81
Cognitive 5.04 (1.58) 5.20 (1.29) 0.39 (48) .70
Note, n = 25 in each group. RD = Recovered Depressed. ND = Never Depressed.
Meats are reported with corrected degrees of freedom when variances were unequal.

Coping Tactics. The RD subgroup endorsed the 13 self-help activities

in terms of helpfulness in coping with depression significantly less
(M = 11.12, SD = 2.98) than did their ND counterparts (M = 13.18,
SD = 2.60), *(48) = 2.59, p < .02, Cohen's (1988) d = .74. Con-
versely, recovered depressed people gave significantly higher ratings
to the two professional antidepressive activities (reading about depres-
sion and taking antidepressants) (M = 8.52, SD = 5.03) than did the
never depressed participants (M = 5.62, SD = 4.17), t(48) = -2.22,
p < .04, d = .63.
As indicated earlier, the RD group scored significantly higher on the
BDI as a measure of current depressive symptoms than did the ND
group. Because of this unintended group difference, we repeated the
significant RD/ND analyses on perceptions of coping tactics with sta-
tistical control of BDI. An ANCOVA with BDI as covariate again
showed the ND group to score significantly higher on the 13 self help
items, F (1, 47) = 4.07, p < .05. The higher mean score among RD's
than among ND's for the 2 professional items was, however, not signif-
icant when we controlled for BDI scores, F(l, 47) = 3.23, p < .08.
Lindsey Kirk, Cindy Brody, Ari Solomon, and David A. F. Haaga 245

DISCUSSION

Two groups of currently non depressed peopleone with a history of

major depression and one withoutresponded to questions about the
utility of various means of coping with depression, and the adequacy of
several major explanatory theories and professional therapies for de-
pression.
The main difference between the groups' perceptions was that the
recovered depressed were especially likely to indicate that they would
find the more professional coping strategies (reading about depression,
taking medication) helpful, whereas the never-depressed group signifi-
cantly exceeded the recovered-depressed participants in perceiving
self-help strategies as likely to be effective. These differences seem log-
ical in that responses to the Helpfulness of Antidepressive Activities
Questionnaire are referenced to the extent to which one perceives the
various coping methods as likely to be helpful for one's own depression.
Given the much more severe depression the RD subsample had experi-
enced (reflected in IDD-L group differences), it stands to reason that
they would be less optimistic about the sufficiency of going for a walk,
watching TV, etc. than would the Never-depressed participants.
Perceptions of " depression" in the abstract (as opposed to one's own
depressions), however, were actually quite similar across groups.
There was no difference between the RD and ND groups in their rat-
ings of the adequacy of several theories of the causes of depression, nor
in their ratings of the likely utility of some major treatments for de-
pression. Our findings differed from those of the Kuyken et al. (1992)
study of currently depressed patients, in that the recovered depressed
participants in the present sample did not endorse drug treatment
more than did never-depressed people. One possible explanation for
the discrepant findings is that depressed people's beliefs about etiology
and treatment change after recovery. Another possible explanation is
that sampling from an inpatient setting was at least in part responsi-
ble for Kuyken et al.'s finding of a preference for biological theorizing
and drug treatments among depressed participants. Future research
sampling from multiple settings and including both currently and for-
merly depressed participants could resolve this issue.
Interpretation of our null results regarding etiological theories and
therapies must be tentative in view of the modest sample size in this
project, limiting statistical power for detecting between-group differ-
ences. For two-tailed f-tests, with comparisonwise alpha level of .05,
and 25 participants in each group, power to detect conventionally-
246 Journal of Rational-Emotive & Cognitive-Behavior Therapy

defined (Cohen, 1988) "small" effects (d = .20) was just .11, and for
"medium" effects .43. Our power was adequate (.81) for detecting a
large effect (d = .80). Low power is thus a limitation of the study.
However, it should be noted that group mean differences in ratings of
theories and therapies were small, not just statistically nonsignificant
(see Table 2). Also, our subgroups were well-defined, eliminating some
possible sources of nuisance variation and bolstering power even at a
small sample size (Hallahan & Rosenthal, 1996). For example, RD and
ND groups were matched on sex and ethnicity, and diagnoses were in
perfect agreement when evaluated by a second rater.
An additional methodological issue is that the tests used to measure
our main variables were not psychometrically matched, and our re-
sults could conceivably have stemmed from differential reliability
rather than differences in the constructs being measured. It is note-
worthy in this regard that the test showing significant RD/ND differ-
ences (Helpfulness of Anti-Depressive Activities Questionnaire) in-
volved multi-item subscales, whereas the tests not differentiating
subgroups (ratings of etiological theories and therapies) consisted of
1-item subscales. Nevertheless, these 1-item subscales did yield signif-
icant differences across items, even if not RD/ND differences. Consid-
ering the sample as a whole, a biological theory of depression received
the strongest endorsement, significantly higher than cognitive or psy-
chodynamic. Both cognitive therapy and antidepressant medication
treatments were rated significantly more favorably than psycho-
analysis, which in turn was seen as significantly more likely to be
helpful than ECT.
It might seem that these varying ratings of therapies could simply
reflect differential exposure to the therapies in one's treatment history.
Given that our sampling procedure selected for patients' having recov-
ered from any previous depressive episodes, their preferring a particu-
lar therapy may amount to a testimonial from a satisfied customer
rather than a more detached, dispassionate consideration of all the
possible treatments. This interpretation is difficult to rule out alto-
gether; for instance, the lowest-rated therapy (ECT) is one that none of
our participants had undergone.
However, two considerations argue against interpreting the therapy
ratings as direct reflections of treatment experience. First, as noted
above, the ND groupwhose ratings are presumably not driven by
personal experience with therapy for depressiondid not differ signif-
icantly from the RD group in ratings of any of the treatments and
rank-ordered them similarly (see Table 2). Second, to explore this issue
Lindsey Kirk, Cindy Brody, Ari Solomon, and David A. F. Haaga 247

further we examined therapy ratings in relation to RD participants'

responses to our open-ended questions about past treatments. Of the
25 RDs, 84%, (n - 21) reported having received some sort of treat-
ment for their depression. Of these 21, 15 had taken antidepressant
medication, while 8 had received cognitive therapy (with respect to all
psychotherapies, the labels are ours based on participants' descrip-
tions, not the participants'), 9 psychodynamic therapies, and 6 de-
scribed another psychotherapy approach such as gestalt or eclectic
(numbers total more than 21 because some participants reported mul-
tiple therapy experiences). Among RD participants, ratings of the
likely helpfulness of antidepressant medication, psychoanalysis, and
cognitive therapy did not differ significantly between those who had
experienced that particular treatment and those who had not. Thus,
people did not seem to be giving ratings based on which treatments
they had personally experienced.
ECT is a unique case in that not even the most ardent advocate of
this treatment would claim that it is a first-line treatment of choice for
most depressed people; rather, it would typically be considered only in
severe cases after other treatments had failed. For dynamic therapies,
though, the issue arises as to whether one is to some extent fighting
an uphill battle against laypeople's perceptions that the therapy is less
plausible as a treatment for depression.
One issue that should be considered in future research on lay per-
ceptions as a factor in treatment process and outcome is whether opti-
mal results are obtained by matching patients with treatments they
already believe in (cf. Addis & Jacobson, 1996) or by therapists taking
pains to persuade patients of what might seem initially unlikely ap-
proaches by providing a very convincing rationale.

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