NUR 7620 Module 1 Individual Therapy Case: CBT, Sertraline or Both for Moderate Depression Example

Talk, Tablets or Both: Choosing Treatment for a Bus Mechanic's Moderate Depression and Planning Fourteen Sessions of CBT

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7620: Family System Psychopathology and Psychotherapeutics Across the Lifespan

Mentor Name

Month Day, Year

Talk, Tablets or Both: Choosing Treatment for a Bus Mechanic's Moderate Depression and Planning Fourteen Sessions of CBT

The Man at the Depot

Mr. O. maintains the city's buses at a depot in Newark, a job he has held for eighteen years. Since spring he has stopped fishing with his brother, eats dinner standing at the counter and lies awake rehearsing every mistake he made at work. He still goes in every day, which is why no one at home realized how bad things were until his wife found him sitting in the car in the driveway for an hour after a shift. He scores 16 on the PHQ-9, says he has never thought of ending his life, and reports neither manic spells nor heavy drinking. When the psychiatric nurse practitioner mentions medication, he shakes his head: his father was prescribed an older antidepressant in the 1990s and, as Mr. O. puts it, "slept through the rest of my childhood." This paper weighs his three options and plans the one he chooses.

What the Evidence Says About Talking Therapy

Cuijpers et al. (2013) pooled 115 studies of cognitive behavioral therapy for adult depression. Against control conditions, CBT had a moderate to large effect, but the authors warned that publication bias and weaker studies inflated it; in the higher-quality trials the effect was smaller, though still meaningful. CBT did no better and no worse than other psychotherapies or medication, and adding CBT to medication outperformed medication alone. Hofmann et al. (2012), surveying more than a hundred meta-analyses across many conditions, reached a compatible view: CBT has some of the broadest support of any psychotherapy, strongest for anxiety and related problems and solid for depression.

Combining Rather Than Choosing

The question Mr. O. faces is not only which treatment works but whether to use one or two. Cuijpers et al. (2020) answered it directly in a network meta-analysis of 101 studies and nearly 12,000 patients, most with moderate to severe depression. Combined treatment was more likely than either psychotherapy or medication alone to produce a response, by roughly a quarter in relative terms, and psychotherapy and medication alone did not differ from each other. Patients were also less likely to drop out of combined treatment or psychotherapy than out of medication alone.

For Mr. O., the evidence supports combining the two, but it also means that CBT alone is a reasonable choice if he declines medication, since psychotherapy matched medication when used on its own.

His Decision

The nurse practitioner explains that sertraline is not the drug his father took, that sedation is uncommon with it and that he can stop if he dislikes it. After a week to think, Mr. O. agrees to start CBT and to try sertraline at a low dose, with a promise that his concerns about feeling flat will be taken seriously at every visit. He chooses combined treatment on the understanding that the medication is the part he can drop first.

His wife joins the end of the visit at his request. She has noticed the evenings in the car and the silence at dinner, and hearing the plan described makes her an ally rather than a worried observer.

Formulating His Depression in CBT Terms

CBT begins with a shared formulation. Mr. O.'s depression is maintained by withdrawal from rewarding activities, which reduces his chances of feeling pleasure or mastery, and by rumination about mistakes, which his core belief that "a man who makes mistakes is useless" turns into self-criticism. His work routine protects him from complete inactivity but leaves evenings and weekends empty. The formulation, drawn as a simple diagram with him in the first session, gives him a reason for each later technique.

Fourteen Sessions

Sessions 1 and 2 build the formulation, set goals and introduce mood monitoring. Sessions 3 to 6 focus on behavioral activation: he schedules one fishing trip, one meal at the table with his family and one walk each week, rating pleasure and mastery afterward. Sessions 7 to 10 address thoughts, using thought records to examine the evidence behind "useless" after a mistake at work and practicing balanced alternatives. Sessions 11 to 13 test his core belief with behavioral experiments, such as asking a younger mechanic how he views his own mistakes. Session 14 builds a relapse prevention plan that names his early warning signs, withdrawal from fishing and evening rumination, and what he will do if they return.

Each session follows the same shape: a mood check, a review of last week's homework, one new skill practiced in the room and a small, specific task for the coming week. Homework is set with him rather than for him, because a mechanic who chooses to fix one thing at home is more likely to do it than one who is told to keep a diary.

Measuring Progress

His PHQ-9 is repeated every two weeks. Response is a fall of at least half, to 8 or below, and remission a score under 5. If his score has not fallen by at least a quarter by week six, the plan is reviewed, starting with homework completion and the sertraline dose. His own measure of success, fishing with his brother again, is recorded alongside the score.

Medication is reviewed on the same schedule. At each visit the nurse practitioner asks directly about the flatness and sleepiness he fears, and if sertraline produces either, the dose is adjusted or the drug is stopped while CBT continues. Recording his answers protects the agreement that made him willing to try it.

Conclusion

The evidence shows that CBT and medication work about equally well alone and better together, with fewer drop-outs from combined treatment than from medication alone. For a man who fears pills, those findings allow a choice rather than an order. A CBT plan built on his own formulation, measured every two weeks and ending in a relapse plan, gives his treatment structure he can see.

References

Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry, 58(7), 376-385. https://doi.org/10.1177/070674371305800702

Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92-107. https://doi.org/10.1002/wps.20701

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. https://doi.org/10.1007/s10608-012-9476-1