Popping a pill is only part of the solution
LOSS OF pleasure, feelings of worthlessness, fatigue, inappropriate guilt, difficulty concentrating, thoughts of suicide. Every year, depression afflicts an estimated 19 million Americans, making it the leading cause of disability in the US. The good news is that more than four out of five people with depression will improve with appropriate treatment. Better news still is that more and more Americans are seeking treatment for depression, in part due to the decreased stigma associated with mental illness and more public awareness about the condition.
However, as more people get treated, another trend is occurring--they are overwhelmingly being treated with antidepressant medications only. That's at least partly because the front-line treaters of depression tend to be primary care physicians, who are writing prescriptions for antidepressants like Prozac, Paxil, and Zoloft at increasing rates but aren't necessarily recommending psychotherapy as an alternative or complement to medication. Indeed, the proportion of people seeking treatment for depression who were prescribed a drug rose from 45 percent in 1987 to nearly 80 percent in 1997, while the percentage of people receiving psychotherapy for depression during that same 10-year period declined from 71 percent to 60 percent.
In addition to the not uncommon practice by physicians of writing a prescription for an antidepressant after just 15 minutes with a patient, "pressures in managed care settings" are contributing to the "over-emphasis on medication and paucity of psychotherapy," according to Ronald Pies, MD, clinical professor of psychiatry at Tufts University School of Medicine.
Drugs versus psychotherapy: It's not either/or
It's not that antidepressants can't be highly effective--they often are, in fact. But like most drugs, they're not a cure-all. "You wouldn't just give people a pill for heart disease or diabetes," says Helen Mayberg, MD, professor of psychiatry and neurology at Emory University. An equally important part of treating those conditions is addressing people's lifestyle habits, which also play a role in those diseases. It's the same with depression. A reliance solely on pills means that patients miss out on the benefits--the approach to life--psychotherapy can provide.
Indeed, psychotherapy, when provided expertly, may be as effective as medication. For some people it may be even more effective than drugs. "The current system overmedicates people who might just need therapy," says Dr. Mayberg. For instance, a 2003 study found that psychotherapy was more effective than medication for patients who experienced early childhood trauma. But overall, Dr. Mayberg notes, a combination of antidepressants and psychotherapy appears to be better than either alone (although people who are very apathetic or disengaged may need to start taking an antidepressant before they can fully benefit from psychotherapy).
Earlier this year, Dr. Mayberg and colleagues at the University of Toronto published a study that helps explain why people might benefit more from antidepressants and psychotherapy combined than from either alone. The researchers compared brain scans from people with depression who completed psychotherapy with scans from patients who were treated with the antidepressant paroxetine (Paxil). The researchers discovered that the treatments don't act on the same places in the brain. "They target complementary but non-overlapping parts," explains Dr. Mayberg. For example, patients who had psychotherapy had brain changes in the cortex, the brain's "thinking structure," while the Paxil appeared to uniquely target structures deep in the brain like the limbic system, the brain's emotion center. The fact that the two types of treatment target different areas suggests to Dr. Mayberg that the effects of medication and therapy are symbiotic. While antidepressants make biochemical changes, therapy helps the brain "unlearn" depressive thinking.
How psychotherapy combats depressive thoughts
There are several different forms of psychotherapy that have been shown to be effective in treating people with depression, but the form that has been studied most extensively and been found to be particularly beneficial is cognitive therapy. This type of therapy, similar to the type used in Dr. Mayberg's research, teaches patients the connections between their thoughts and their emotions. When depressed, people's thoughts are usually distorted and exaggerated--I'm a failure; I'll never get a job; I'm a terrible mother.
A cognitive therapist helps set things straight by guiding patients in identifying, evaluating, and ultimately changing distorted thinking. What it comes down to is that "patients are taught by a cognitive therapist to be skeptical when in an extreme emotional state," explains Robert DeRubeis, PhD, professor of psychology at the University of Pennsylvania. Thus, "when they are becoming sad or angry, they think about the thoughts behind their emotions and ask whether they stand up to closer inspection."
Dr. DeRubeis provides this example: When a person catches himself having a negative thought, like "I'm a failure," he can ask himself specific questions, such as what is the evidence that this thought is true? What is the evidence that it is not true? Are there alternative ways to view the situation? Then, he may conclude, "I didn't do as well as I would have liked in this situation, but there were other factors involved. And besides, I have sometimes succeeded in similar situations in the past."
Over the course of therapy, which generally involves 15 to 20 sessions over a 3- to 4-month period, "patients begin to see patterns in their thoughts and learn how to step back to get a more accurate view of themselves," says Dr. DeRubeis. After therapy is completed, people can continue to do these exercises in their head or on paper so that even if they "still have a tendency to attribute blame to themselves, they learn how to catch themselves" before negative thinking consumes them. Cognitive therapists generally provide patients with "refresher" sessions following initial treatment to use on an "as needed" basis, if, say, they need help coping with a stressful change in their life.
The life-long skills learned in cognitive therapy may help explain research showing that patients who complete this kind of treatment successfully are better protected against depression relapse than patients on antidepressants who discontinue them. "Patients who are treated successfully with therapy do quite well a year or two following treatment. That's not true of patients on medication who go off it," says Dr. DeRubeis.
Tufts's Dr. Pies agrees, saying that "there's no demonstrable enduring benefit of medication" once it's discontinued. A person who has a single episode of mild to moderate depression will probably be able to go off antidepressants 6 to 9 months after he or she recovers from the episode, Dr. Pies says, but people who have had multiple depressive episodes usually need to stay on medication indefinitely because their risk of recurrence is so high.
The fact that so many people have to take antidepressants long-term weakens the managed-care argument that medication is cheaper than therapy. Unfortunately, health insurance plans still favor drugs over therapy. Even plans that cover psychotherapy often cover only four or five sessions, not a complete course, although that could change through patient advocacy.
For more information on cognitive therapy and how to locate a certified cognitive therapist, including one who provides low-cost treatment, contact the Academy of Cognitive Therapy at www.academyofct.org or 610-664-1273.