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Beliefs about the causes of depression and treatment preferences.

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Beliefs About the Causes of Depression and Treatment Preferences 
Shabad-Ratan Khalsa, 1 Kevin S. McCarthy, 1 Brian A. Sharpless, 1
Marna S. Barrett, 1 and Jacques P. Barber 1,2
1
University of Pennsylvania School of Medicine
2
Philadelphia VA Medical Center

The relation between patients’ beliefs about the causes of their depression, treatment preferences,
and demographic variables was studied in a sample of 156 patients in a randomized controlled trial for
depression (supportive-expressive psychotherapy vs. medication vs. placebo). No gender differences
were found in beliefs or preferences. Racial differences were found for causes endorsed, but not
preferences. Treatment experience predicted endorsement of characterological and biological causes.
Psychotherapy experience predicted preference for medication. Finally, patients preferring psychotherapy
endorsed childhood and complex causes more than those preferring medication, but the groups
did not differ in other reasons endorsed. Implications of findings are discussed. & 2011 Wiley Periodicals,
Inc. J Clin Psychol 67:539–549, 2011.

Keywords: psychotherapy; major depressive disorder; gender; patient preferences; psychodynamics

Patients may presently choose from a variety of efficacious psychotherapeutic and pharmaco-
logical treatments for depression. Psychotherapies such as cognitive, interpersonal, and behavioral
therapies have been established as empirically supported treatments (e.g., Chambless &
Ollendick, 2001), and brief dynamic therapy is gaining in support (e.g., Leichsenring, Rabung, &
Leibing, 2004). Antidepressant medications have been shown to be effective as well, with selective
serotonin reuptake inhibitors being the most widely used (e.g., Cipriani et al., 2005) especially with
more severe depression (e.g., Fournier et al., 2010). However, despite the availability of these
efficacious treatments, there remains a need to understand the reasons why patients prefer
certain treatments. Is it because of how different approaches conceptualize psychopathology?
Understandably, different therapeutic approaches employ different etiological models in their
conceptualization and treatment of depression, with psychotherapy tending towards psycho-
social conceptions, and pharmacotherapy more biological ones (Goldstein & Rosselli, 2003).
Therefore, it is of interest to investigate whether patients’ beliefs about the causes of their
depression are leading them to prefer theoretically consistent treatments.

Beliefs About the Causes of Depression

Studies on beliefs about mental illness have identified a variety of causes that patients endorse
including interpersonal problems (e.g., poor social skills, bad romantic relationships,
mistreatment by others), developmental events (e.g., childhood problems, unresolved issues
with one’s family), personality or cognitive causes (e.g., irrational concerns, emotional upset,
depressive ways of thinking), biological factors (e.g., genetics, biochemical imbalances),
environmental factors (e.g., stress, illness of self or others), and religious causes (e.g., bad luck,
fate, God’s will) among others (Addis, Truax, & Jacobson, 1995; Atkinson, Worthington,

This article was reviewed and accepted under the editorship of Beverly E. Thorn.
Work was conducted at the Center for Psychotherapy Research and the Mood Disorder Section of the
Department of Psychiatry, University of Pennsylvania School of Medicine. Written with support from
National Institute of Mental Health grant R01 MH 061410. The sertraline and the placebo pills were
provided by a grant from Pfizer Corp. Registered in clinicaltrials.gov.
Correspondence concerning this article should be addressed to: Jacques P. Barber, Suite 648, Center for
Psychotherapy Research, Department of Psychiatry, University of Pennsylvania School of Medicine, 3535
Market Street, Philadelphia, PA 19104-3309; e-mail: barberj@mail.med.upenn.edu

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 67(6), 539--549 (2011) & 2011 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20785
540 Journal of Clinical Psychology, June 2011

Dana, & Good, 1991; Brown et al., 2001; Foulks, Persons, & Merkel, 1986). In addition to
identifying some of the specific causes that patients endorse, Addis and Carpenter (1999) have
suggested that the complexity of patients’ beliefs about the causes of their depression
(operationalized as the number of different beliefs that patients have about their depression as
well as the intensity with which they endorse those beliefs), may be conceptually important as
well to psychotherapy process and outcome.
Some researchers have sought to determine whether demographic and cultural variables
including gender, race, and previous treatment experience affect patients’ beliefs about the causes of
depression. It has been found by several researchers that men and women differ in the causes they
endorse. Although differences have been found, studies have varied in what those particular
differences are as they have utilized different measures of beliefs (Angst et al., 2002; Atkinson
et al., 1991; Robbins & Tanck, 1991; Schweizer et al., 2009). The findings on racial differences have
been more consistent, with African Americans found to be less accepting of genetic or biological
explanations for mental illness and depression and more accepting of spiritual explanations than
Caucasians (Givens, Houston, Van Voorhees, Ford, & Cooper 2007; Millet, Sullivan, Schwebel, &
Myers, 1996; Schnittker, Freese, & Powell, 2000). Although there have been exceptions (e.g.,
Atkinson et al., 1991), the majority of studies support the idea that ethnic minority and Caucasian
patients differ in their beliefs about the origins of their mental illness.
With regards to prior treatment experience, etiology beliefs have been shown to change
after receiving treatment, with endorsement of treatment-incongruent reasons for depression
diminishing after successful treatment (Leykin, DeRubeis, Shelton, & Amsterdam, 2007). It is
possible that patients may change their beliefs as to what caused their depression to be more
consistent with the treatment they received (Leykin, DeRubeis, Shelton et al., 2007) or with the
beliefs of their counselors (Atkinson et al., 1991). Only Schweizer et al. (2009) seem to have
examined the relationship between receiving prior treatment for one’s current episode of
depression and beliefs about the causes of depression (they reported that patients who
endorsed biological and characterological causes more highly were more likely to have
received previous treatment for their current episode of depression). The present study is the
first to examine the ways in which experience with psychotherapy or medication including that
for previous episodes of depression or other problems might affect these beliefs.

Treatment Preferences
Patients often come to treatment with a preference for the treatment they expect to be most
helpful for them [e.g., psychotherapy generally (‘‘talking treatment’’), a specific type of
psychotherapy (‘‘cognitive–behavioral’’), or medication]. Some of the variables most commonly
associated with preference include gender, race, and previous treatment experience (Churchill
et al., 2000; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000). In surveys of primary care
practice patients, women appear to be more accepting of treatment for depression in general,
and are slightly more likely to prefer counseling as compared to men (Churchill et al., 2000;
Dwight-Johnson et al., 2000). Racial differences are more pronounced than gender differences
in treatment preferences. African Americans appear to be less accepting of treatment in general,
than Caucasians or Hispanics, and are especially reluctant to use antidepressants. When given a
choice, African Americans have been found to be more likely to choose counseling over
medication as compared to Caucasians (Cooper et al., 2003; Dwight-Johnson et al., 2000;
Givens et al., 2007; Schnittker, 2003). These racial differences in treatment preference appear to
be fairly consistent in primary care settings, but have received less research focus in psychiatric
and psychological practice and in randomized controlled trials (RCTs).
Prior psychotherapy experience has also been associated with treatment preference.
Previous experience with counseling was associated with a preference for counseling over
‘‘trying to pull themselves together; seeing a psychiatrist; taking tablets’’ (Churchill et al.,
2000, p. 905). However, previous experience with medication was not related to treatment
preference. In another study, those who had a greater knowledge of counseling were more
likely to prefer counseling over medication. A lack of experience with medication was also
related to preference for counseling (Dwight-Johnson et al., 2000).
 Beliefs About Depression 541

Relation of Reasons for Depression and Treatment Preference

Putting these two lines of research together, it is possible patients’ beliefs about the causes of
their depression and their preferences for treatment might be related. Specifically, patients’
explanations for their depression might inform their beliefs as to which treatment they expect
to help them best and, therefore, prefer to receive. Alternatively, patients may initially prefer a
treatment (e.g., favoring medications because they are more heavily marketed or are less costly
or time-consuming than psychotherapy) and then may find beliefs about their depression
congruent with that particular treatment.
Understanding the potential relation between beliefs about the causes of depression and
treatment preferences is important because it may potentially inform psychotherapy. For
instance, congruence between a patient’s beliefs about depression and being provided a
theoretically consistent treatment (such as interpersonal psychotherapy for patients endorsing
that their depression is a result of interpersonal problems) has been shown to increase perceived
treatment credibility, greater motivation to engage in treatment, and greater satisfaction with
that treatment (e.g., Addis & Carpenter, 1999; Addis & Jacobson, 1996; Atkinson et al., 1991;
Meyer & Garcia-Roberts, 2007; for an exception, see Goldstein & Rosselli, 2003). Complexity of
beliefs about the causes of one’s depression (or endorsing more reasons for depressions at higher
levels) has been found to relate to treatment preferences and expectations about treatment.
More specifically, patients with higher complexity of beliefs rated an ‘‘activation-oriented’’ (but
not an ‘‘insight-orientated’’) psychotherapy rationale as presented in videotaped or written
format as less credible and less likely to be helpful. Addis and Carpenter (1999) suggest that one
possible explanation for this finding is that perhaps people who believe that their depression has
many complex causes may be less accepting of a treatment they may view as too simple.
Only one study has examined beliefs about the causes of depression as they relate directly to
treatment preference. This study, conducted by Atkinson and colleagues (1991), found that beliefs
were unrelated to preference for counseling orientation (‘‘thinking,’’ ‘‘feeling,’’ or ‘‘acting’’).
Schweizer and colleagues (2009) found that patient beliefs about the causes of their depression
affected treatment assignment (which was influenced by patient preferences). More specifically,
patients scoring more highly on ‘‘intraindividual’’ items on the Reasons for Depression
Questionnaire (Addis et al., 1995) were more likely to be assigned to cognitive–behavioral therapy,
whereas those endorsing biological causes more strongly were more likely to be assigned to
psychopharmacological treatment. Although patient preference was taken into account for
treatment assignment, treatment type was chosen in conjunction with a therapist (Schweizer et al.,
2009). The present study is the first we are aware of to examine beliefs about the causes of depression
and their relation to preference between medication and psychotherapy in a clinical setting.

Present Study
Therefore, the purpose of this study was twofold: (a) to examine how beliefs about the causes of
depression and treatment preferences (i.e., pharmacotherapy or psychotherapy) relate to each
other, and (b) to determine what factors influence beliefs and preferences. We utilize data from a
RCT comparing psychotherapy versus medication versus pill-placebo for depression that was able
to recruit a relatively diverse sample in terms of gender, race, and previous treatment experience.
Based on the previous literature we hypothesized that treatment preferences would vary based on
beliefs about the causes of depression. Specifically, patients preferring medication were expected to
more strongly endorse biological causes, whereas those preferring therapy would be less likely to
endorse biological causes and more likely to endorse personal or situational factors. Further, we
will investigate how race, gender, and prior treatment experience relate to beliefs and preferences.

Methods
Participants
Data were drawn from a sample of 156 patients taking part in a RCT comparing supportive-
expressive psychotherapy to sertraline/venlafaxine to pill-placebo (authors). Inclusion criteria
542 Journal of Clinical Psychology, June 2011

for the study were an age between 18 and 70, a primary DSM-IV diagnosis of major depressive
disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV; American Psychiatric Association, 1994), and a minimum score of
14 on the 17-item Hamilton Rating Scale for Depression (Hamilton, 1960). Excluded from the
study were patients with a history of psychotic disorder, bipolar disorder, substance
dependence in the last 6 months, seizure disorders, or current suicide risk. Patients were also
excluded if they had a previous nonresponse to a trial of sertraline or venlafaxine of adequate
dose and duration in the last year or had any significant medical conditions (e.g., heart disease,
pregnancy) that would interfere with participation in the study.
Of the 156 patients who entered the study, 92 (59%) were women. Eighty-one (52%)
patients identified themselves as having a minority racial background with 70 (45%) African
American, 3 (2%) Asian, and 8 (5%) Latino/a. Patients in this study were primarily of lower
socioeconomic level (i.e., n 5 119, 76%; with incomes under $30,000) and reporting a mean of
13.5 (SD 5 3.5) years of education. Comorbidity was common, and 76% (n 5 119) of the
patients met criteria for at least one other Axis I disorder in addition to MDD, and 47%
(n 5 73) met criteria for at least one Axis II personality disorder.

Procedures
Following a detailed phone screen, potential patients attended an initial evaluation interview
during which the study was explained and an informed consent was signed. Once agreeing to
participate in the study, patients met with a trained diagnostician who conducted a formal
diagnostic interview. Patients meeting the inclusion criteria for the study then completed
several self-report measures related to beliefs about depression, treatment preferences,
previous experience with mental health treatment, and attitudes and expectations for
treatment.

Measures
Reasons for Depression Questionnaire. The Reasons for Depression Questionnaire
(RFD; Addis et al., 1995) assesses patient’s subjective understanding of the causes of their
depression, including characterological factors, achievement, intimacy, interpersonal conflict,
existential, childhood difficulties, physical problems, and relationship factors (Addis et al.,
1995). In this study, a shortened version of the RFD was used (Leykin, DeRubeis, Shelton
et al., 2007) that included 13 items from the original RFD with an additional item (‘‘I was
born to be this way’’). Prior to treatment assignment, patients were asked to rate how much
they believed each item was responsible for their depression using a 4-point Likert scale
(0 5 definitely not a reason, 1 5 probably not a reason, 2 5 probably a reason, 3 5 definitely
a reason).
The RFD was completed by 145 patients. To group RFD items into meaningful subscales,
a principal axis factor analysis with a promax rotation was conducted. Four factors explained
53% of the variance among items: relationship (a 5 .90), childhood (a 5 .74), characterological
(a 5 .67), and biological (a 5 .53). Two items were excluded as they loaded on more than one
factor with less than the recommended 0.1 difference between the highest and second highest
factor loading (Swisher, Beckstead, & Bebeau, 2004). Leykin and colleagues (Leykin,
DeRubeis, Shelton et al., 2007) found that these two items formed a fifth factor, which they
called the intimacy factor, but the factor analysis conducted with this dataset did not support
a fifth factor. Relationship, childhood, characterological, and biological subscale scores were
created by computing the means of the items that the factor analysis identified as belonging to
the discrete factors. The RFD complexity score consisted of the mean of all 12 RFD items that
were retained after our factor analysis (a 5 .71).

Attitudes and Expectations Questionnaire. This questionnaire (adapted from Elkin

et al., 1985; Sholomskas, 1990) is a face-valid measure of patients’ attitudes toward different
types of treatments and interventions. Two items on this measure were of interest to this study.
 Beliefs About Depression 543

The first served as our measure of treatment preferences and was a forced-choice dichotomous
question of whether the patient preferred to receive either psychotherapy or medication
(‘‘In coming in for treatment of depression, I would prefer to receive [circle one answer]: [a]
drug treatment or [b] talking treatment’’). The other item served as our measure of previous
experience in treatment. Patients were asked to indicate the number of previous times in their
life they had previously undergone psychotherapy (‘‘How many times have you tried
psychotherapy/counseling [at least two sessions] to help you with your problems?’’) and,
separately, the number of times they had tried antidepressant medication (‘‘How many times
have you been placed on medication to help with your problems?’’).

Data Analysis
For the purposes of this article, analyses were conducted on available data. Therefore, the
number of subjects varied between analyses based on how many patients had completed each
measure. Independent sample t tests were used to assess possible differences in the any of the
RFD factors based on gender, race, or treatment preference. Independent sample t tests were
also used to determine whether the number of previous courses of psychotherapy differed
based on patients’ treatment preference. Regression analyses were employed to test whether
previous experience with psychotherapy predicted greater endorsement of psychosocial causes
of depression.

Results
Beliefs About the Causes of Depression
As can be seen in Table 1, across the sample the RFD complexity score and subfactors
averaged between 1 and 1.5, indicating that the factor was rated as somewhere between
probably not a reason (1.0) and probably a reason (2.0). We used independent sample t tests to
assess for gender differences on any of the RFD factors. Contrary to expectations, no
significant differences were found between males and females on any of the factors or the
complexity scores (all ps4.25).
We then used independent sample t tests to determine whether there were any differences in
RFD factors by minority status (see the last two columns of Table 1). As predicted, ethnic
minorities endorsed biological (d 5 0.39) and characterological (d 5 0.42) causes of depression
at significantly lower levels than Caucasian individuals with all other comparisons
nonsignificant. We also tested for an interaction between race and gender in an ANOVA
predicting each of the RFD factors and complexity scores separately, but all interaction tests
were nonsignificant (ps4.40)
We then conducted regression analyses to test whether previous experience with
psychotherapy predicted greater levels of endorsement of psychosocial causes of depression.

Table 1
Descriptive Statistics for Reasons for Depression Factors for the Entire Sample and by Gender
and Minority Status

Gender Minority status

RFD factor Total Women Men Minority Caucasian

Complexity 1.32 (0.49) 1.32 (0.53) 1.31 (0.41) 1.28 (0.51) 1.36 (0.45)
Relationship 0.96 (0.97) 0.94 (0.98) 0.99 (0.98) 1.00 (0.97) 0.91 (0.98)
Childhood 1.55 (0.82) 1.61 (0.87) 1.46 (0.71) 1.67 (0.81) 1.43 (0.81)
Characterological 1.42 (0.67) 1.39 (0.70) 1.46 (0.62) 1.28 (0.66) 1.56 (0.66)
Biological 1.29 (0.80) 1.34 (0.81) 1.21 (0.79) 1.14 (0.84) 1.45 (0.74)

Note. RFD 5 Reasons for depression. Table values are mean scores, and values in parentheses are
standard deviations.
544 Journal of Clinical Psychology, June 2011

Patients had been in psychotherapy an average of 1.65 (SD 5 2.20) times in their lifetime.
Number of previous courses of psychotherapy did not predict endorsement of relation-
ship causes of depression, r 5 .14, F(1, 130) 5 2.66, po.11; childhood causes, r 5 .06,
F(1, 131) 5 .496, po.48; nor complexity scores, r 5 .12, F(1, 131) 5 1.92, po.17. However,
greater number of previous courses with psychotherapy did predict greater levels of
characterological causes, r 5 .21, F(1, 131) 5 5.83, po.02, and biological causes r 5 .24,
F(1, 131) 5 7.57, po.007. We also tested whether previous experience with medication
predicted endorsement of biological causes of depression. Patients reported an average of 1.17
(SD 5 1.55) previous trials with medication. Greater number of previous courses of
medication did not predict relationship, r 5 .02, F(1, 135) 5 .03, po.86; or childhood,
r 5 .12, F(1, 136) 5 1.87, po.17, causes of depression. However, greater number of previous
courses of medication significantly predicted greater endorsement of biological, r 5 .22,
F(1, 136) 5 6.74, po.01, and of characterological causes of depression, r 5 .20,
F(1, 136) 5 5.66, po.02. Greater number of previous courses of medication also predicted
higher complexity scores, r 5 .19, F(1, 136) 5 5.20, po.02.

Treatment Preferences
At intake, 151 patients indicated their preference for either psychotherapy or medication.
Fifty-nine percent (n 5 89) of patients in this subsample preferred psychotherapy whereas 41%
(n 5 62) preferred medication. Broken down by gender, 58% (n 5 53) of the 91 women in the
subsample and 60% (n 5 36) of the 60 men preferred psychotherapy over medication.
However, contrary to predictions, there were no significant gender differences in treatment
preference, w2(1) 5 0.05, ns.
Sixty-two percent (n 5 48) of the 77 individuals of minority status preferred psychotherapy
over medication, whereas 55% (n 5 41) of the 74 Caucasian individuals preferred
psychotherapy over medication. This was not significantly different, w2(1) 5 0.75, ns.
We also tested for an interaction between gender and race to predict treatment preference in
a logistic regression; however, this was nonsignificant as well, exp(b) 5 .97, w2(1) 5 .002, po.97.
The relation between treatment preference and previous experience with psychotherapy was
examined. Contrary to predictions, patients preferring psychotherapy reported fewer previous
courses of psychotherapy (M 5 1.23, SD 5 1.74) than did patients preferring medication
(M 5 2.30, SD 5 2.64; d 5 0.49, df 5 135, po.005).
We also examined the relation between treatment preference and previous experience with
medication. Patients preferring medication reported an average of 1.43 (SD 5 1.79) courses of
medication in the past, whereas patients preferring psychotherapy reported an average of 0.99
(SD 5 1.34) courses of medication; however, this difference was not significant (d 5 0.29,
df 5 142, po.09).

Relation of Beliefs About the Causes of Depression and Treatment Preferences

Table 2 presents the mean RFD factor and complexity scores for patients preferring
psychotherapy and those preferring pharmacotherapy. Consonant with our predictions, those
patients who preferred psychotherapy endorsed childhood reasons for depression more
strongly than those who preferred medication (d 5 0.47, df 5 140, po.008). However, no
differences were found between those preferring psychotherapy and those preferring
medication on the relationship (d 5 0.25, df 5 139, ns), characterological (d 5 0.12, df 5 140,
ns), or biological (d 5 0.06, df 5 140, ns) factors. As one of the two items of the biological
factor relates to genetic causes of depression (which may not be seen as affected by
medication), a t test was conducted with the biochemical item alone. This test approached
significance (d 5 0.32, df 5 132, po.07), such that those preferring medication endorsed the
biochemical imbalance item more strongly than those preferring psychotherapy. As predicted,
we found that patients preferring psychotherapy endorsed more complex causes of depression
than those preferring psychopharmacotherapy (d 5 0.39, df 5 140, po.02).
 Beliefs About Depression 545

Table 2
Descriptive Statistics for Reasons for Depression Factors by Treatment Preferences

Treatment preference

RFD factor Psychotherapy Medication

Complexity 1.40 (0.46) 1.21 (0.50)

Relationship 1.07 (1.01) 0.82 (0.93)
Childhood 1.71 (0.79) 1.33 (0.84)
Characterological 1.46 (0.67) 1.38 (0.67)
Biological 1.32 (0.83) 1.27 (0.77)

Note. RFD 5 Reasons for depression. Table values are mean scores, and values in parentheses are
standard deviations.

Discussion
This study represents one of the first examinations of the association between patient beliefs
about the causes of their depression and their preferences for treatment. Further, with more
than 50% of the sample comprised of ethnic minorities, we were able to examine racial
differences in beliefs about the causes of depression and treatment preferences, which is not
possible in many clinical settings.

Beliefs About the Causes of Depression

In contrast to previous studies (Angst et al., 2002; Atkinson et al., 1991; Robbins & Tanck,
1991; Schweizer et al., 2009), no differences were found between women and men in terms of
beliefs about the causes of their depression. As previous examinations of the relation between
gender and beliefs about the causes of depression have used different measures and
populations, it is perhaps not so surprising that our findings differed from theirs. Our finding
that minority patients were less likely to endorse biological reasons is consistent with the
published literature (e.g., Givens et al., 2007; Schnittker et al., 2000). However, we did not
predict our finding that minority status individuals would endorse characterological reasons
for depression at lower levels than Caucasian individuals.
Previous experience with psychotherapy or medication both significantly predicted greater
endorsement of the characterological and biological causes, but not relationship or childhood
causes. Interestingly, Schweizer and colleagues found a very similar relationship, such that
patients endorsing biological and characterological beliefs more highly were more likely to
have previously received some sort of treatment for their current episode of depression
(Schweizer et al., 2009). Speculating as to why this relation was found, patients who greatly
endorse these two factors may represent a group that has tried different treatments for
depression, failed to improve, and accepted characterological and biological explanations,
which are somewhat more fundamental to their sense of self than the possibly more tractable
relationship and childhood causes.

Treatment Preferences
Neither gender nor minority status were related to treatment preference. There are several
possible explanations for these findings. Other studies that have found racial differences in
preference for treatment (e.g., Cooper et al., 2003) were conducted in a primary care or
otherwise naturalistic setting. Considering there is some evidence that minority individuals are
less likely to seek out specialty mental health services than Caucasians (e.g., Cooper-Patrick,
Crum, & Ford, 1994), our patients may differ in some way from the population at large.
Furthermore, our patients may not have had strong preferences (as strength of preference was
546 Journal of Clinical Psychology, June 2011

not measured), and those who had a strong preference may not have enrolled in the study with
the possibility of assignment to a nonpreferred treatment modality.
The finding that patients preferring medication and those preferring psychotherapy differed
in previous experience with psychotherapy but not previous experience with medication could
be due to several factors. Perhaps patients are more likely to accept that the medication that
they would be receiving as part of the study would be sufficiently different from the medication
they had tried in the past. For patients who do not know much about psychotherapy, all
different types of therapies may be viewed as similar. The patients who preferred medication
after several attempts at psychotherapy may represent a group of people who have tried
therapy in the past, failed to improve, and decided that therapy was not effective for them.
Unfortunately, we did not have the data available as to whether previous treatment courses
resulted in improvement or not.

Relation of Beliefs About the Causes of Depression and Treatment Preferences

Our hypothesis that patients preferring medication and those preferring psychotherapy would
differ in beliefs about the causes of depression was partially supported. It makes intuitive sense
that one’s beliefs about the causes of mental illness would affect one’s preference for
treatment, and there is some evidence to support the idea that when etiological beliefs are
congruent with a treatment rationale, the treatment is rated as more helpful (Iselin & Addis,
2003). Of course, there may not be perfect synchrony between beliefs about the causes of one’s
depression and preferences for treatment. For example, many patients may believe that their
depression has a biological cause, but may be wary of the side effects common in
pharmacotherapy and therefore prefer psychotherapy.
Patients preferring psychotherapy endorsed childhood reasons for depression more strongly
than those preferring medication. As some forms of psychotherapy directly target such
problems (e.g., psychodynamic therapies such as object relations therapy), patients may view
such therapeutic orientations as potentially more beneficial than medication. Whereas we
expected that depressed patients who preferred medication would endorse biological causes of
depression more strongly than those who preferred psychotherapy, this was not found to be
the case. Perhaps this was because there are biological causes for depression that can be
treated by medication (such as biochemical imbalance), whereas other biological causes (such
as genetic contributions) are not treated in such a manner. In fact, when we examined whether
the biochemical item alone predicted treatment preference, the test approached significance,
providing some evidence as to why the biochemical factor as a whole was not associated with
treatment preference.
Contrary to predictions, those preferring psychotherapy did not endorse relationship and
characterological causes of depression more than those preferring medication. This is
somewhat surprising, as many types of psychotherapy seek to ameliorate problems in these
domains. One possible explanation is that patients may have a stereotypical view of
psychotherapy in which the patients’ childhood is the only focus, and current relationships and
ways of thinking are ignored. It is also possible that patients simply did not feel that those
causes of depression were amenable to change. Unfortunately, the study did not collect
detailed information on what patients expected to happen in psychotherapy.
Finally, as expected, patients preferring psychotherapy endorsed more complex beliefs
about the causes of depression (as represented by endorsing more items more strongly on the
RFD) than those preferring medication. People who feel that their depression has a more
complicated etiology may be less likely to believe that their underlying problems cannot be
solved with just medication.

Limitations
There are a number of limitations to the present study, and as such, this should be considered
a preliminary investigation in a relatively newly studied area. As a number of analyses were
conducted, one must interpret significant findings with caution, as type II errors are of
 Beliefs About Depression 547

concern. With regards to the factor analyses of the RFD, three of the four subscales had low
to very low alphas. It must also be noted that mean scores on the subscales generally fell
between 1 and 2 (with the exception of the biological subcale, which had a mean a little under 1).
Thus, most patients felt that the reasons were in between ‘‘probably not a reason’’ and
‘‘probably a reason.’’ Therefore, although some patients did find the reasons listed on the scale
to describe the reasons they were suffering from depression, many did not. These mean scores
were similar to those found by Leykin, DeRubeis, Shelton et al. (2007) who also used the
shortened version of the RFD. Future research could explore the relationships between
variables found in the present study utilizing a measure listing more comprehensive reasons (as
the full version of scale does) and with a more nuanced Likert scale that would allow for a
clearer picture as to what patients thought was causing their depression.
One must also be cautious in the interpretation of complexity score. Thus far, there has
been little study of what endorsing a greater number of reasons for depression at higher
levels might actually represent. Complexity is simply one possible explanation, and our index
(mean RFD item scores) was only a crude measure of complexity that did not distinguish
between the number of separate causes of depression endorsed and the intensity with which
each reason was endorsed (for discussions of the measurement of complexity, see Locke, 2003;
McCarthy, Connolly Gibbons, & Barber, 2008). Endorsing numerous causes may represent a
realistic assessment of stressors in one’s life, or may be excuse giving and reluctance to change
(Addis & Carpenter, 1999).

Future Directions
In closing, it is apparent that future studies could benefit by examining in more detail the
strength of patients’ preferences, what patients know about therapy, and the quality and
duration of previous treatment as they relate to patients’ beliefs about the causes of their
depression and their preferences for treatment. Both the specific causes endorsed and the
complexity of causes endorsed have been previously shown to affect various aspects of
psychotherapy process such as homework compliance, attendance, and outcome, making
these beliefs of potential importance to psychotherapy researchers (Addis & Carpenter, 1999;
Addis & Jacobson, 1996; Foulks et al., 1986). More investigation into whether higher mean
score on measures of patient beliefs about the causes of their depression truly represents
complexity is also necessary, as current conclusions regarding this construct are fairly
speculative.
Studies have shown that preference can affect both the process and outcome of
psychotherapy (e.g., Iacoviello et al., 2007; Leykin, DeRubeis, Gallop et al., 2007; Lin
et al., 2005). One recent meta-analysis found a small, but significant effect of treatment
preference on outcome. Specifically, patients matched to their preferred treatment were found
to experience a greater chance of improvement than those who were not matched to their
preferred treatment (Swift & Callahan, 2009). Previous research examining patient treatment
preference has tended to focus on demographic variables that are not modifiable. As beliefs
about the causes of depression may be amenable to change, future research could examine
whether therapists who address these beliefs may be able to counter the effect of a belief-
treatment incongruence. Greater study of how treatment preferences and beliefs about the
causes of depression may interact to affect psychotherapy process and outcome, and how
amenable they are to change is warranted.

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