Moderate to severely depressed clients showed greater improvement in cognitive therapy when therapists emphasized changing how they think rather than how they behave, new research has found.

The results suggest cognitive therapists should concentrate, at least during the first few sessions, on using cognitive techniques to help those with more severe depression to break out of negative thought patterns and to see events in their lives more realistically.

The study found that a concentration on changing behavior -- such as having patients schedule activities to get them out of the house, and tracking how they spent their time -- did not significantly predict subsequent change in depressive symptoms.

"There has been a lot of attention recently on behavioral approaches to treating severe depression, and that may lead some people to suspect that cognitive techniques are not important for more severely depressed patients," said Daniel Strunk, co-author of the study and assistant professor of psychology at Ohio State University.

"But our results suggest that it was the cognitive strategies that actually helped patients improve the most during the first critical weeks of cognitive-behavioral therapy."

Strunk conducted the study with Melissa Brotman of the National Institute of Mental Health and Robert DeRubeis of the University of Pennsylvania. Their results appear online in the journal Behaviour Research and Therapy and will appear in a later print edition.

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The study involved 60 patients who were diagnosed with major depression and who were being treated at two university clinics.

All the patients were being treated by one of six cognitive therapists and agreed to have their therapy sessions videotaped for study.

Two trained raters reviewed the videotapes of the first through the fourth therapy sessions. They rated how much the therapists relied on cognitive and behavioral methods and other aspects of the sessions.

In addition, patients completed a questionnaire at each session that measured their depression levels.

The researchers examined the relationship between specific techniques used by their therapists and the extent of improvement in patients' depression scores from one session to the next.

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The study focused on the first few weeks of therapy because other studies suggest that is when patients make the largest improvement in depression levels, Strunk said.

Results showed that patients' depression scores improved significantly when their therapists focused on cognitive techniques, but didn't change when their therapists focused on behavioral techniques.

Other factors were also associated with patient improvement, the study found.

Patients improved more when they collaborated with their therapists about a plan for treatment and followed that plan.

Not surprisingly, patients also showed greater improvement when they were more engaged in the therapy process and were open to suggestions from their therapist.

"If you're a patient and willing to fully commit to the therapy process, our data suggest you will see more benefit," Strunk said.

Strunk said this research is being continued at Ohio State's Depression Treatment and Research Clinic. Researchers there are working with people suffering from depression to understand the nature of cognitive change and how it affects their improvement.

"We're trying to understand if cognitive therapy leads people to a profound change in their basic self view, or if it teaches them a set of skills that they have to continually practice over time," he said.

Strunk said these results suggest that, despite the recent attention given to behavioral approaches to treating depression, cognitive techniques appear to be quite powerful.

"In our sample of cognitive therapy patients, cognitive techniques appeared to promote a lessening of depression symptoms in a way that was not true of behavioral techniques," he said.