Background: Cognitive behavioural models of anxiety disorders often include visual representations of feedback loops that maintain the disorder. Cognitive therapy for depression is the prototype for therapy for many other disorders, and there is now good evidence for factors that maintain depression, yet there is still no accepted diagrammatic form of the maintenance model. Aims: To develop a simple, clinically acceptable and empirically based version of the “vicious flower” for depression. Method: Current theoretical developments in depression (Differential activation and Beck's concept of modes) and empirical findings on maintenance factors were reviewed. A model was developed based on clinical utility and current knowledge of the processes and maintenance factors in depression. This model was tested for its usefulness with a small sample of IAPT trainees. Results: The model contained 6 cycles comprising 2 cognitive cycles (automatic negative thinking and rumination/self-attacking), 2 behavioural cycles (withdrawal/avoidance and unhelpful behaviour), a mood/emotion cycle, and a motivation/physical symptoms cycle. Students found it a very useful tool for understanding maintenance factors. Conclusions: This diagrammatic maintenance model of depression, like similar “vicious flowers” for anxiety, may be helpful in conceptualization, socialization and treatment planning as well as teaching CBT.
