Of particular importance was the discovery that many patients treated with cognitive therapy improved more rapidly than those successfully treated with drugs. Within the first week or two, there was a pronounced reduction in suicidal thoughts among the cognitive therapy group. The effectiveness of cognitive therapy should be encouraging for individuals who prefer not to rely on drugs to raise their spirits, but prefer to develop an understanding of what is troubling them and do something to cope with it.
How about those patients who had not recovered by the end of twelve weeks? Like any form of treatment, this one is not a panacea. Clinical experience has shown that all individuals do not respond as rapidly, but most can nevertheless improve if they persist for a longer period of time, Sometimes this is hard work! One particularly encouraging development for individuals with refractory severe depressions is a recent study by Drs. Ivy Blackburn and her associates at the Medical Research Council at the University of Edinburg in Scotland.f These investigators have shown that the combination of antidepressant drugs with cognitive ther-
* Table 1-1 was adapted from Rush, A. J., Beck, A. T., Kovacs, M„ and Hollon, S. "Comparative Efficacy of Cognitive Therapy and Pharmacotherapy in the Treatment of Depressed Outpatients." Cognitive Therapy and Research, Vol. 1, No. 1, March 1977, pp. 17-38.
t Blackburn, L M., Bishop, S., Glen, A. I. M, Whalley, L. J. and Christie, J. E. "The Efficacy of Cognitive Therapy in Depression. A Treatment Trial Using Cognitive Therapy and Pharmacotherapy, each Alone and in Combination." British Journal of Psychiatry, Vol. 139, January 1981, pp. 181-189.
15
David D. Burns, M.D.
apy can be more effective than either modality above. In my experience the most crucial predictor of recovery is a persistent willingness to exert some effort to help yourself. Given this attitude, you will succeed.
Just how much improvement can you hope for? The average cognitively treated patient experienced a substantial elimination of symptoms by the end of treatment. Many reported they felt the happiest they had ever felt in their lives. They emphasized that the mood-training brought about a sense of self-esteem and confidence. No matter how miserable, depressed, and pessimistic you now feel, I am convinced that you can experience beneficial effects if you are willing to apply the methods described in this book with persistence and consistency.
How long do the effects last? The findings from follow-up studies during the year after completion of treatment are quite interesting. While many individuals from both groups had occasional mood swings at various times during the year, both groups continued on the whole to maintain the gains they had demonstrated by the end of twelve weeks of active treatment.
Which group actually fared better during the follow-up period? The psychological tests, as well as the patients' own reports, confirmed that the cognitive therapy group continued to feel substantially better, and these differences were statistically significant. The relapse rate over the course of the year in the cognitive therapy group was less than half that observed in the drug patients. These were sizable differences that favored the patients treated with the new approach.
Does this mean that I can guarantee you will never again have the blues after using cognitive methods to eliminate your current depression? Obviously not. That would be like saying that once you have achieved good physical condition through daily jogging, you will never again be short of breath. Part of being human means getting upset from time to time, so I can guarantee you will not achieve a state of never-ending bliss! This means you will have to reapply the techniques that help you if you want to continue to master your moods. There's a difference between feeling better-
16
FEELING GOOD
which can occur spontaneously—and getting better—which results from systematically applying and reapplying the methods that will lift your mood whenever the need arises.
How has this work been received by the academic community? The impact of these findings on psychiatrists, psychologists, and other mental-health professionals has been substantial, and it appears that the main impact is yet to come. As a result of our research, professional publications, lectures, and workshops around the country, an initial skepticism about cognitive therapy is being replaced by widespread interest. Research studies to investigate these findings are now under way at some of the finest academic centers in the United States and Europe. A recent development of great importance was the decision of the federal government to invest millions of dollars over the next several years in a multi-university depression-research program under the spon-sorship of the National Institute of Mental Health. As in the original study, the antidepressant effects of cognitive therapy will be matched against a mood-elevating drug to determine which treatment modality is superior. In addition, a third type of psychotherapy, which focuses on interpersonal factors, will be evaluated. This project, described in a recent issue of Science magazine,* is clearly intended to be the largest and most carefully controlled psychotherapy study in history.
What does all this add up to? We are experiencing a crucial development in modern psychiatry and psychology—a promising new approach to understanding human emotions based on a cogent testable therapy. Large numbers of mental-health professionals are now showing a great interest in this approach, and the ground swell seems to be just beginning.
Since completion of the original study, many hundreds of depressed individuals have become better as a result of treatment with cognitive therapy. Some had considered themselves hopelessly untreatable and came to us as a last-ditch effort before committing suicide. Many others were simply troubled
* Marshall, E. "Psychotherapy Works, but for Whom?" Science, Vol.
207, February 1, 1980, pp. 506-508.
17
David D. Burns, M.D.
by the nagging tensions of daily living and wanted a greater share of personal happiness. This book is a carefully thought-out practical application of our work, and it is designed for you. Good luck!
18
CHAPTER 2
How to Diagnose Your Moods:
The First Step in the Cure
Perhaps you are wondering if you have in fact been suffering from depression. Let's go ahead and see where you stand.
The Beck Depression Inventory (BDI) (see Table 2-1, page 20) is a reliable mood-measuring device that detects the presence of depression and accurately rates its severity. This simple multiple-choice questionnaire will take only a few minutes to complete. After you have completed the BDI, I will show you how to make a simple interpretation of the results, based on your total score. Then you will know immediately whether or not you are suffering from a true depression and, if so, how severe it is. I will also lay out some important guidelines to help you determine whether you can safely and effectively treat your own blue mood using this book as your guide, or whether you have a more serious emotional disorder and might benefit from professional intervention in addition to your own efforts to help yourself.
As you fill out the questionnaire, read each item carefully and circle the number next to the answer that best reflects how you have been feeling during the past few days. Make sure you circle one answer for each of the twenty-one questions.* If more than one answer applies to how you have
* Several questions ask if you have recently been experiencing a particular symptom such as irritability or insomnia, ". .. any more than usual," or ". . . more than before." If the symptom has been present for a long time because of chronic depression, you are to answer the question based on a comparison of how you are feeling now with how you were feeling the last time you were happy and undepressed. If you believe you have never felt happy and undepressed, then answer the question based on a comparison of how you are feeling now with how you imagine a normal, undepressed person would feel.
19
Table 2-1. Beck Depression Inventory •
1. 0 I do not feel sad.
1 I feel sad.
2 I am sad all the tim
e and I can't snap out of
3 I am so sad or unhappy that! can't stand it.
2. 0 lam not particularly discouraged about the future.
1 I feel discouraged about the future.
2 I feel I have nothing to look forward to
3 I feel that the future is hopeless and that things cannot improve.
3. 0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see is a lot of failures.
3 I feel I am a complete failure as a person.
4. 0 I get as much satisfaction out of things as I used to.
1 I don't enjoy things the way I used to.
2 I don't get real satisfaction out of anything anymore.
3 I am dissatisfied or bored with everything.
5. 0 I don't feel particularly guilty.
1 I feel guilty a good part of the time.
2 I feel quite guilty most of the time.
3 I feel gtulty all of the time.
6. 0 I don't feel l am being punished.
1 I feel' may be punished.
2 I expect to be punished.
3 I feel I am being punished.
7. 0 I don't fed disappointed in myself.
1 I am disappointed in myself.
2 I am disgusted with myself.
3 I hate myself.
8. 0 I don't feel I am any worse than anybody else.
1 I am critical of myself for my weaknesses or mistakes.
2 I blame myself all the time for my faults.
3 I blame myself for everything bad that happens.
9. 0 I don't have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would not carry them out.
2 I would Me to kill myself.
3 I would kill myself if I had the chance.
• Copyright 1978, Aaron T. Beck, M.D.
20
Table 2-1. Continued.
10. 0 I don't cry any more than usual.
I I cry more now than I used to.
2 I cry all the time now.
3 I used to be able to cry, but now I can't cry even though I want to.
11. 0 I am no more irritated by things than I ever am.
1 I am slightly more irritated now than usual.
2 I am quite annoyed or irritated a good deal of the time.
3 I feel irritated all the time now.
12. 0 I have not lost interest in other people.
1 I am less interested in other people than I used to be.
2 I have lost most of my interest in other people.
3 I have lost all of my interest in other people.
13. 0 I make decisions about as well as I ever could.
1 I put off making decisions more than I used to.
2 I have greater difficulty in making decisions than before.
3 I can't make decisions at all anymore.
14. 0 I don't feel that I look any worse than I used to.
1 I am worried that I am looking old or unattractive.
2 I feel that there are permanent changes in my appearance that make me look unattractive.
3 I believe that I look ugly.
15. 0 I can work about as well as before.
1 It takes an extra effort to get started at doing something.
2 I have to push myself very hard to do anything.
3 I can't do any work at all.
16. 0 I can sleep as well as usual.
1 I don't sleep as well as I used to.
2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
3 I wake up several hours earlier than I used to and cannot get back to sleep.
17. 0 I don't get more tired than usual.
1 I get tired more easily than I used to.
2 I get tired from doing almost anything.
3 I am too tired to do anything.
18. 0 My appetite is no worse than usual.
1 My appetite is not as good as it used to be.
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David D. Burns, M.D.
Table 2-1. Continued.
2 My appetite is much worse now.
3 I have no appetite at all anymore.
19. 0 I haven't lost much weight, if any, lately.
1 I have lost more than five pounds.
2 I have lost more than ten pounds.
3 I have lost more than fifteen pounds.
20. 0 I am no more worried about my health than usual.
I I am worried about physical problems such as aches and pains, or upset stomach, or constipation.
2 I am very worried about physical problems and it's hard to think of much else.
3 I am so worried about my physical problems that I cannot think about anything else
21. 0 I have not noticed any recent change in my interest in sex. I I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
been feeling, circle the higher number. If in doubt, make your best guess. Do not leave any questions unanswered. Regardless of the outcome, this can be your first step toward emotional improvement.
Interpreting the Beck Depression Inventory. Now that you have completed the test, add up the score for each of the twenty-one questions and obtain the total. Since the highest score that you can get on each of the twenty-one questions is three, the highest possible total for the whole test would be sixty-three (this would mean you circled number three on all twenty-one questions). Since the lowest score for each question is zero, the lowest possible socre for the test would be zero (this would mean you circled zero on each question).
You can now evaluate your depression according to Table 2-2. As you can see, the higher the total score, the more severe your depression. In contrast, the lower the score, the better you are feeling.
Although the BDI test is not difficult or time-consuming to fill out and score, don't be deceived by its simplicity. You 22
FEELING GOOD
Table 2-2. Interpreting the Beck Depression Inventory Total Score
Levels of Depression *
1-10
These ups and downs are considered•normat
11-16
Mild mood disturbance.
17-20
Borderline clinical depression
21-30
Moderate depression
31-40
Severe depression
over 40
Extreme depression
* A persistent score of 17 or above indicates you may need professional treat.
meat.
have just learned to use a highly sophisticated tool for diagnosing depression. Many research studies in the past decade have demonstrated that the BDI test and similar mood-rating devices are highly accurate and reliable in detecting and measuring depression. In a recent study in a psychiatric emergency room, it was found that a self-rating depression inventory similar to the one you just filled out actually picked up the presence of depressive symptoms more frequently than formal interviewing by experienced clinicians who did not use the test. You can use the BDI with confidence to diagnose yourself and monitor your progress.
As you apply the various self-help techniques described in this book, take the BDI test at regular intervals to assess your progress objectively. I suggest a minimum of once a week.
Compare it to weighing yourself regularly when you're on a diet. You will notice that various chapters in this book focus on different symptoms of depression. As you learn to overcome these symptoms, you will find that your total score will begin to fall. This will show that you are improving. When your score is under ten, you will be in the range considered normal. When it is under five, you will be feeling especially good. Ideally, I'd like to see your score under five the majority of the time. This is one aim of your treatment.
Is it safe for all depressed individuals to try to treat themselves using the princ
iples and methods outlined? The answer is—definitely yes! This is because the crucial decision to try to help yourself is the key that will allow you to feel better as 23
David D. Burns, M.D.
soon as possible, regardless of how severe your mood disturbance might seem to be.
Under what conditions should you seek professional help?
If the BDI test showed that you were depressed but your total score was under seventeen, your depression—at least at this time—is mild and should not be a cause for alarm. You will definitely want to correct the problem. but professional intervention may not be necessary. Systematic self-help efforts along the lines proposed in this book, combined with frank communication on a number of occasions with a trusted friend, will probably suffice If your score is above sixteen, you are more seriously depressed. Your moods are apt to be intensely uncomfortable and possibly dangerous While most of us feel extremely upset for brief periods, if your score remains in this range for more than two weeks, you should consider seeking a professional consultation. I am convinced you can still benefit greatly by applying what I teach you, and you might very well conquer your depression entirely on your own, but it might not be smart to insist on trying it out without professional guidance. Seek out a trusted and competent counselor.
In addition to evaluating your total BDI score, be sure to pay attention to question 9, which asks about any suicidal tendencies. If you score a two or a three on this question, you may be dangerously suicidal. I strongly recommend that you obtain professional help right away. I have provided some effective methods for assessing and reversing suicidal impulses in a later chapter, but you must consult a professional when suicide begins to appear to be a desirable or necessary option. Your conviction that you are hopeless is the reason to seek treatment, not suicide. The majority of seriously depressed individuals believe they are hopeless beyond any shadow of a doubt. This destructive delusion is merely a symptom of the illness, not a fact. Your feeling that you are hopeless is powerful evidence that you are actually not!
The Feeling Good Handbook Page 3