Cognitive Behaviour Therapy A peer reviewed, multidisciplinary journal devoted to the application of behavioural and cognitive sciences to clinical psychology and psychotherapy.
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Depression: Overview
Depression is a highly prevalent mental disorder. Global prevalence estimates indicate that 279.6 million people currently suffer from a depressive disorder. Depression is characterized by, at minimum, the presence of a depressed mood and/or anhedonia for at least two weeks. Other symptoms include changes in sleep, appetite, energy levels, and subjective emotional states such as feelings of worthlessness and guilt.
The core symptomatology in depression includes negative beliefs about oneself, the world, and the future. These beliefs comprise the domains typically associated with the cognitive triad and encompass the essential components of a neurotic temperament: Apprising the world as a dangerous and unpredictable place juxtaposed with the belief of being unable to cope with challenges if they arise.
Depressive disorders are encompassed within the broad category of emotional disorders. Emotional disorders are characterized by frequent experiences of negative emotions coupled with maladaptive reactions to such experiences. These maladaptive reactions, in turn, increase the probability of experiencing negative emotions in the future as well as maintain the presenting disorder symptomology. Put differently, maladaptive reactions to negative emotions produce a self-perpetuating cycle that maintains a depressed state.
Maintaining Factors in Depression
To illustrate this self-perpetuating maintenance cycle in depression, imagine a person called Isak. Isak has recently been diagnosed with major depressive disorder. His presenting symptomology includes a depressed mood, anhedonia, loss of appetite, difficulties sleeping, and difficulties concentrating. Due to the loss of appetite and sleep difficulties, Isak is predisposed to feeling tired, agitated, and low in energy. Furthermore, because of Isak’s anhedonia, he is also less likely to seek out engagement in pleasurable activities and less likely to derive pleasure from such activities when he engages in them. Consequently, Isak is even less likely to engage in such activities which can increase his functional impairment and even induce feelings of worthlessness and guilt. This creates a negative feedback loop–or a self-perpetuating maintenance cycle in Isak’s depression: His depressed mood decreases his likelihood of engaging in adaptive behavior, which decreases the amount of pleasure he derives from such behavior, causing feelings of guilt and worthlessness, and in turn, further perpetuates the depressive symptomology.
Comorbid Presentations
Individuals seeking treatment for depression routinely also meet diagnostic criteria for at least one other psychological disorder. The most common are comorbid presentations of depression and any anxiety disorder. This can readily be understood by referencing the proclivity for repetitive habitual negative thinking among individuals with anxiety and depressive disorders. Repetitive habitual negative thinking has been shown to have a central transdiagnostic value in the treatment of both anxiety and depressive disorders, wherein repetitive worry-laden thoughts characterize anxiety disorders and repetitive ruminative thoughts characterize depressive disorders. As such, precise differential diagnosis at the case conceptualization phase is paramount.
Risk Factors for Onset and Treatment
Several risk factors have been identified for the development of and treatment of depression. For instance, a neurotic temperament, female gender, low socioeconomic status, and lower educational level are all risk factors that make an individual more prone to depression. A tipping-point incident where this person experiences a great loss could exert a kindling effect which culminates in full-blown depression. Risk factors that may interfere with successful recovery from depression include difficult comorbid problems, high functional impairment, suicidality, low quality of life, and low subjective well-being (cf. low positive affectivity).
Positively Valanced Framing of Depression
Although the core characteristics of depressive symptomatology have been extensively researched, recent years have seen an increased awareness of the advantages of conceptualizing well-being as something more than the absence of negative emotions. For instance, researchers and clinicians are becoming increasingly aware of the importance of positive affectivity in therapeutic practice with individuals with depression. Novel positive affect treatment protocols, designed to increase deficits in reward processing and thus target anhedonia, have even shown greater success for depression relief than gold-standard treatment protocols for anxiety and depressive disorders. Consequently, effective therapeutic interventions should aim not only to alleviate suffering but also to increase subjective well-being. Taken together, viewing depression through a positively valenced lens allows for a more holistic overview of all the factors that may be causing functional impairment for the depressed individual.
Positively valenced measurement instruments (e.g., quality of life or subjective well-being instruments) focus on positive functioning, as opposed to pathology, under the assumption that the absence of a mental disorder is not equal to positive functioning. Given this assumption, positively valenced measurements can inform treatment outcomes beyond measurement instruments that only evaluate psychopathology. One such measurement instrument is the Questionnaire on Well-Being, a clinically informed instrument that evaluates subjective well-being.
The Questionnaire on Well-Being
The Questionnaire on Well-Being is a novel measurement instrument designed to assess a person’s subjective well-being. It was developed by clinicians for clinicians and researchers to meet the demand for a comprehensive index of subjective well-being, and inform clinical practice and idiosyncratic case formulation when treating depression.
The theoretical framework underpinning the Questionnaire on Well-Being is nested in the various clinical presentations of major depression. In fact, the Questionnaire on Well-Being can be construed as the inverse of popular depression inventories. For instance, over 10,377 different permutations of depression symptoms have been identified. However, the Questionnaire on Well-Being was explicitly designed to be a positively valenced measurement instrument while adhering to our working assumption: The absence of pathology does not equal well-being. As such, the Questionnaire on Well-Being includes positively phrased items about sleep, energy levels, and appetite. The QWB also assesses other common, albeit non-diagnostic, features of depression such as the meaningfulness of life, optimism, and life satisfaction.
Validation of the Questionnaire on Well-Being
All academics are aware of the importance of measurement. It is very important to get the measurement right! However, all too many well-intentioned researchers and clinicians get it wrong. A plethora of evidence exists supporting the notion that measurement instruments must be validated, psychometric properties need to be evaluated, and clinical utility must be assessed.
Since its development, the Questionnaire on Well-Being has remained a novel and unvalidated measurement instrument for close to a decade. We therefore decided to evaluate the psychometric properties of the Questionnaire on Well-Being across two studies.
In the former, we explored potential factor structures, evaluated internal reliability and temporal reliability, and examined criterion-related validity. Additionally, we derived a clinically relevant cutoff point for the Questionnaire on Well-Being total score. Specifically, a preliminary cutoff was identified: A value below 50 was associated with marked psychopathological symptoms (anxiety symptoms, depressive symptoms, or both). The exploratory factor analysis suggested that the Questionnaire on Well-Being possessed unidimensionality, i.e. a single factor structure was appropriate to explain the variance in a measure of subjective well-being (cf. the Questionnaire on Well-Being). Other results from the former study included high internal reliability, an appropriately high positive correlation with a measure of positive affectivity, and good temporal reliability.
In the second study, we aimed to confirm the factor structure obtained in the previous study while simultaneously seeking to replicate the high internal reliability findings and criterion-related validity findings. The results confirmed the single-factor structure from the foregoing study and replicated previously found internal reliability and criterion-related validity findings.
Implications
The Questionnaire on Well-Being is a freely available, self-report measurement instrument that indexes subjective well-being. Our findings support the unidimensionality and reliability of the Questionnaire on Well-Being as a valid measurement of subjective well-being. As such, our results provide preliminary evidence about the clinical relevance of the Questionnaire on Well-Being as a measure of subjective well-being that may inform treatment outcomes in future studies.
Read the full paper here: Hlynsson, J. I., Sjöberg, A., Ström, L., & Carlbring, P. (in press). Evaluating the reliability and validity of the questionnaire on well-being: A validation study for a clinically informed measurement of subjective well-being. Cognitive Behaviour Therapy. http://dx.doi.org/10.1080/16506073.2024.2402992
Photo: Jón Ingi Hlynsson
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