Psychological Therapy and Depression

1/5/11.

Science writer Jonah Lehrer on the importance of psychological therapy for depression:

Every period has its signature disorder. We live in the age of depression. Consider a brand new survey published in the Archives of General Psychiatry: Between 1998 and 2007, the percentage of Americans being treated for depression increased by more than 20 percent. Other studies estimate that somewhere between 20 and 40 percent of American adults will suffer from depression at some point in their life.

Obviously, there’s a dizzying array of forces that are causing this rise. Part of the problem is diagnosis, as people like Alan Horwitz and Jerome Wakefield have argued. Thanks to changes in the DSM, Horwitz and Wakefield insist that we’ve medicalized sadness, transforming anguish and its synonyms into a clinical condition.

But it remains unknown how much of the rise in depression is accounted for by changes in diagnosis. And I think it’s extremely important to not dismiss the likely possibility that, even if our diagnostic standards had remained constant, there would still be a rise in depression. In other words, is there something about the way we live now that’s making us extremely sad? Are these intensely negative feelings symptoms of a larger societal problem?

Hard questions, no easy answers. In this blog post, I’d like to focus instead on one of the troubling data points in this most recent medical survey, which is that the percentage of depressed subjects seeking psychotherapy for treatment declined dramatically between 1998 and 2007, from 53.6 percent to 43.1 percent. (This drop has come despite the fact that a majority of subjects say talk therapy is their preferred method of treatment.) Needless to say, pills have taken the place of therapists, as more than 75 percent of depressed patients are now treated with anti-depressants, which has led to a dramatic increase in medical spending on the disorder. Between 1998 and 2007, Medicare expenditures for depression increased from $0.52 billion (1998) to $2.25 billion (2007).

When anti-depressants work, they are little blue miracles. But they often don’t work, at least not at rates higher significantly higher than placebo. (Plus, they often have unpleasant side-effects, which leads more than half of patients to stop taking the drugs shortly after the worst symptoms disappear. And then they relapse, which helps explain why patients treated with SSRI’s have relapse rates above 75 percent.) And that’s why I’m troubled by the drop in talk therapy, as most studies demonstrate that the most effective treatment for depression is pharmaceuticals coupled with a good therapist. Furthermore, many different kinds of therapy can be effective. For instance, the same December 2010 issue of the Archives of General Psychiatry also contains an interesting comparative study of anti-depressants and mindfulness therapy in preventing relapse following an extended depressive episode. The mindfulness therapy itself was straightforward stuff, if time intensive. There were eight weekly group sessions of two hours each, plus a full day retreat and optional one-hour meditation classes. The subjects learned how to reflect upon their feelings with “non-judgmental awareness” and “self-compassion.” They were urged to apply their new mindfulness skills to everyday life challenges.

The results were stark. Not surprisingly, patients who escaped depression with the help of anti-depressants, and then stopped taking the drugs, relapsed about 70 percent of the time. The chemical boost was temporary. However, during the 18 month follow-up period, only 28 percent of patients in mindfulness therapy slipped back into the mental illness.

What we often forget is that therapy alters the chemical brain, just like a pill. It’s easy to dismiss words as airy nothings and talk therapy as mere talk. Sitting on a couch can seem like such an antiquated form of treatment. But the right kind of talk can fix our broken mind, helping us escape from the recursive loop of stress and negative emotion that’s making us depressed. Changing our thoughts is never easy and, in severe cases, might seem virtually impossible. We live busy lives and therapy requires hours of work and constant practice; our cortex can be so damn stubborn. But the data is clear: If we are seeking a long-lasting cure for depression, then it’s typically our most effective treatment.