Feeling Good: The New Mood Therapy

by Burns, David D.

  With regard to bipolar manic-depressive illness, the answer is clear. This disorder appears to have an extremely strong biological cause, and although we don’t yet know exactly what this cause may be, treatment with a mood stabilizer such as lithium or valproic acid (Depakene) is usually a must. Other medications will also be used during episodes of depression or severe mania. However, good psychotherapy can also make a big contribution in the treatment of bipolar illness. In my experience, the combination of a drug like lithium or valproic acid along with cognitive therapy has been far more effective than treatment with medications alone.

  From a practical point of view, the question I face as a clinician is this: How can I best treat each particular patient who is suffering from depression, regardless of the cause? Whether or not genes play a role, drugs can sometimes help and psychotherapy can sometimes help. Sometimes, a combination of psychotherapy and antidepressant medications seems to be the best approach.

  Is It Better to Be Treated with Drugs or Psychotherapy?

  A number of studies have compared the effectiveness of antidepressant drug treatment with cognitive therapy.5–8 On the whole, these studies have indicated that during the acute phase of treatment, when patients first seek treatment for their depressions, both treatments seem to work reasonably well. Following recovery, the picture is a little different. Several long-term studies indicate that patients who receive cognitive therapy, alone or in combination with antidepressant medications, appear to stay undepressed longer than patients who receive only antidepressant medication therapy and no psychotherapy.5 This is probably because cognitively treated patients have learned many coping tools to help them to deal with any mood problems they might experience in the future.

  If you would like to learn more about recent research on the effectiveness of drugs versus psychotherapy, you can read an excellent article on this topic by Drs. David O. Antonuccio and William G. Danton from the University of Nevada and Dr. Gurland Y. DeNelsky from the Cleveland Clinic.5 These authors reviewed the world research literature on the effectiveness of psychotherapy versus medications for depression and came up with some rather startling conclusions that are quite different from the popular perceptions about these treatments. They argue that cognitive therapy appears to be at least as effective, if not more effective, than medications in the treatment of depression. They conclude that this is even true for severe depressions that appear to be “biological” because they have many physical side effects such as fatigue or a loss of interest in sex. The authors also question the methods used by drug companies to test new antidepressants. This scholarly and provocative article is clearly written, so look it up if you are curious.

  My own clinical experience has convinced me that pure “test-tube treatment” with drugs alone is not the answer for most patients. There appears to be a definite role for effective psychological interventions, even if you have had the good fortune to respond to an antidepressant medication. If you learn cognitive therapy self-help techniques like those described in this book, I believe you will be better prepared to cope with any mood problems that develop again in the future.

  My clinical practice has always been predicated on an integrated approach. At my clinic in Philadelphia, approximately 60 percent of our patients received cognitive therapy with no drugs, and approximately 40 percent of our patients received a combination of cognitive therapy along with antidepressants. Patients in both groups did well, and we found both types of treatment tools to be valuable. We did not treat patients with drugs alone and no psychotherapy because in my experience this approach has not been satisfactory.

  It may be that for certain types of depression, the addition of the proper antidepressant to help your treatment program might make you more amenable to a rational self-help program and greatly speed up the therapy. As I have mentioned earlier above, I can think of many depressed individuals who seemed to “see the light” with regard to their illogical, twisted, negative thoughts more rapidly once they began taking an antidepressant. My own philosophy is this: I’m in favor of any reasonably safe tool that will help you!

  I believe that your feelings about the type of treatment that you receive may be important to the outcome. If you are more biologically oriented, you may do better with drug treatment. In contrast, if you are more psychologically oriented, you may do better with psychotherapy. If you and your therapist do not see eye to eye, you may lose confidence and resist the treatment, and this can reduce the chances for a successful result. In contrast, if the treatment makes sense to you, you will feel more hope, trust and confidence in your doctor. Consequently your chances for a positive outcome will be increased.

  I have also seen that certain negative attitudes and irrational thoughts can interfere with proper drug treatment or with psychotherapeutic treatment. I would like to expose twelve hurtful myths at this time. The first eight myths concern medication treatment and the last four myths concern psychotherapy. With regard to medications, I believe that enlightened caution in taking any drug is well advised, but an excessively conservative attitude based on half-truths can be equally destructive. I also believe that one should be appropriately skeptical and cautious about psychotherapy, but that too much pessimism can also interfere with effective treatment.

  Myth Number 1. “If I take this drug, I won’t be my true self. I’ll act strange and feel unusual.” Nothing could be further from the truth. Although these drugs can sometimes eliminate depression, they do not usually create abnormal mood elevations and, except in rare cases, they will not make you feel abnormal, strange, or “high.” In fact, many patients report that they feel much more like themselves after they take an antidepressant medication.

  Myth Number 2. “These drugs are extremely dangerous.” Wrong. If you are receiving medical supervision and cooperate with your doctor, you will have no reason to fear most antidepressant drugs. Adverse reactions are rare and can usually be safely and effectively managed when you and your doctor work together as a team. The antidepressants are far safer than the depression itself. After all, depression, if left untreated, can kill—through suicide!

  This does not mean you should be complacent about antidepressant drugs—or any drug you take, for that matter, including aspirin. In the following chapters, you will learn about the side effects and toxic effects of all the different antidepressants and mood-stabilizing agents. If you are taking one or more of these drugs, educate yourself and read about them in Chapter 20. This should not be difficult, and the information will enhance your chances of having a safe and effective experience with the antidepressant your doctor has prescribed.

  Myth Number 3. “But the side effects will be intolerable.” No, the side effects are mild and can usually be made barely noticeable by adjusting the dose properly. If in spite of this you find the medication uncomfortable, you can usually switch to another medication that will be equally effective with fewer side effects.

  Remember, too, that untreated depression also has many “side effects.” These include feelings of tiredness, increases or decreases in appetite, difficulties sleeping, a loss of motivation and energy, a loss of interest in sex, and so forth. And if you respond favorably to an antidepressant, these “side effects” will usually disappear.

  Myth Number 4. “But I’m bound to get out of control and use these drugs to commit suicide.” Some of the antidepressant drugs do have a lethal potential if you take them in overdose or combine them with certain other drugs, but this need not be a problem if you discuss your concerns with your physician. If you feel actively suicidal, it might be helpful to obtain only a few days’ or one week’s supply at a time. Then you will not be likely to have a lethal supply on hand. Your doctor may also decide to treat you with one of the newer antidepressant drugs that are much safer than the older antidepressants if taken in accidental or intentional overdose. Remember that as the drug begins to work, you will feel less suicidal. You should also see your therapist frequently and receive intensive thera
py, either as an outpatient or as an inpatient, until any suicidal urges have passed.

  Myth Number 5. “I’ll become hooked and addicted, like the junkies on the street. If I ever try to go off the drug, I’ll fall apart again. I’ll be stuck with this crutch forever.” Wrong again. Unlike sleeping pills, opiates, barbiturates, and minor tranquilizers (benzodiazepines), the addictive potential of antidepressants is extremely low. Once the drug is working, you will not need to take larger doses to maintain the antidepressant effect. As noted above, if you are learning cognitive therapy techniques and focusing on relapse prevention, in most instances your depression will not return when you discontinue the drug.

  When it is time to go off the medicine, it would be advisable to do this gradually, tapering off over a week or two. This will minimize any discomfort that might occur from abruptly stopping the medicine, and will help you nip any relapse in the bud before it becomes full blown.

  Many doctors now advocate long-term maintenance therapy for patients with severe depressions that return on many occasions. A prophylactic effect can sometimes be achieved if you take the antidepressant over a period of a year or two after you have recovered. That can minimize the probability of your depression returning. If you have had a significant problem with recurrences of depression over a period of years, this might be a wise step for you. But you should be reassured that antidepressant drugs are definitely not addictive. In my practice through the years, I have had very few patients who had to remain on antidepressant drugs for more than a year, and almost no patients who stayed on antidepressants indefinitely.

  Myth Number 6. “I won’t take any psychiatric drug because that would mean I was crazy.” This is quite misleading. Antidepressants are given for depression, not for “craziness.” If your doctor recommends an antidepressant, this would indicate he or she is convinced you have a mood problem. It does not mean that she or he thinks you are crazy. However, it is crazy to refuse an antidepressant on this basis because you may bring about greater misery and suffering for yourself. Paradoxically, you may feel normal more quickly with the help of the medicine.

  Myth Number 7. “But other people are bound to look down on me if I take an antidepressant. They’ll think I’m inferior.” This fear is unrealistic. Other people will not know you’re taking an antidepressant unless you tell them—there’s no other way they could know. If you do tell someone, they’re more likely to feel relieved. If they care about you, they’ll probably think more of you because you’re doing something to help eliminate your painful mood disorder.

  Of course, it is possible that someone might question you about the advisability of taking a drug, or even criticize your decision. This will give you the golden opportunity to learn to cope with disapproval and criticism along the lines discussed in Chapter 6. Sooner or later, you’re going to have to decide to believe in yourself and stop giving in to the disabling terror that someone might or might not agree with something you do.

  Myth Number 8. “It is shameful to have to take a pill. I should be able to eliminate the depression on my own.” Research on mood disorders conducted throughout the world has clearly shown that many individuals can recover without pills if they engage in an active, structured, self-help program of the type outlined in this book.5, 9–13

  However, it is also clear that psychotherapy does not work for everyone, and that some depressed patients recover faster with the help of an antidepressant. In addition, in many cases an antidepressant can facilitate your efforts to help yourself, as described above.

  Does it really make sense to mope and suffer endlessly, stubbornly insisting you must “do it on your own” without a medication? Obviously, you must do it yourself—with or without a pharmacological boost. An antidepressant may give you that little edge you need to begin to cope in a more productive manner. This can accelerate the natural healing process.

  Myth Number 9. “I feel so severely depressed and overwhelmed that only a drug could help me.” Drugs and psychotherapy both have a lot to offer in the treatment of severe depression. I believe that the passive attitude of letting a drug do it for you is unwise. My own research has indicated that the willingness to do something to help yourself can have powerful antidepressant effects, whether or not you are also taking a medication. The self-help work patients complete between sessions also seems to speed recovery.14, 15 So if you combine a medication with a good form of psychotherapy, you will have more weapons in your arsenal.

  As I have already stated, many patients I have treated with drugs alone did not recover completely. When I added the cognitive therapy, many of them improved. I believe that the combination of drugs and psychotherapy can work better and quicker than drugs alone and frequently leads to better long-term results. This seems to be true for mildly depressed patients and for severely depressed patients as well. For example, we treat many severely depressed inpatients at the Stanford University Hospital with group cognitive therapy techniques. These techniques are similar to the ones you have learned about in this book. We have found that the group format can be especially helpful. I have seen many of these patients improve significantly during these therapy groups. The improvement often occurs within the actual therapy group. At the moment the patient sees how to talk back to his or her negative thoughts in a convincing manner, there is often a strong, immediate uplift in mood and outlook. Keep in mind that these inpatients also receive antidepressant drugs that their attending psychiatrists prescribe for them. So nearly all of them receive a combination of drugs and psychotherapy—we are not purists devoted only to one approach or the other.

  I can recall one woman who was so severely depressed that she would burst into tears almost every time she tried to speak. If you even looked at her, it seemed it was enough to trigger an outburst of uncontrollable sobbing. I asked what she was thinking about when she was sobbing. She said she was thinking about something that her psychiatrist told her. He said her depression was “biological” and the causes were genetic. She concluded that if the depression was genetic, it meant she must have passed it down to her children and her grandchildren. One of her sons was, in fact, having a hard time. She attributed this to his “depression gene” and blamed herself for ruining his life. She castigated herself for even having gotten married and given birth to children in the first place and felt certain they would all endure horrible suffering forever. As she explained this, she began sobbing again.

  Now from your perspective, her self-blame may seem incredibly unrealistic. Her insistence that all her children and grandchildren would lead lives of endless and irreversible suffering may seem equally unrealistic. But from her perspective, all her self-criticisms seemed entirely justified and negative predictions seemed completely valid. Her self-loathing and suffering were incredibly intense.

  After she stopped crying, I asked what she would say to another depressed woman with children. Would she be so hard on her? This intervention did not work. She did not even seem to comprehend what I said. Instead of answering my question, she sobbed so uncontrollably that her entire body shook as the tears streamed down her cheeks.

  After a while she stopped crying again. I asked if two other patients would volunteer to do a role-play to help her out. I call this exercise “externalization of voices” because you verbalize the negative thoughts in your mind and learn to talk back to them. I wanted the other patients to illustrate how she might talk back to her own negative thoughts so that all she would have to do was watch. I told her to imagine that these other women were very similar to her. They were depressed and had children and grandchildren.

  The first volunteer played the role of the negative part of her mind and said out loud the sort of things the depressed woman had been thinking: “If my depression is partly genetic, then it means I am to blame for my son’s depression.” The second volunteer played the role of the more positive, realistic, self-loving part of her mind. This volunteer talked back to the negative thought along these lines: “I certainly wou
ldn’t blame another depressed woman for her son’s depression, so it makes no sense to blame myself, either. If there is a conflict with my son, or if he is having problems, I can try to be helpful to him. That’s what any loving mother would try to do.” Then they continued with this dialogue and modeled ways she could talk back to her other self-critical thoughts. The two volunteers took turns in the roles of the negative thoughts and the positive thoughts.

  After the role-play was over, I asked the tearful patient which voice was winning and which voice was losing. Was it the negative voice or the positive voice? Which voice was more realistic, more believable? She said that the negative voice was unrealistic, and that the positive voice was winning. I pointed out that the volunteers were actually verbalizing her own self-criticisms.

  Although her depression did not improve dramatically by the end of that group, it seemed that the clouds lifted just a little bit. The next time I saw her in a group, her mood had brightened up considerably. She was quite personable and could talk without crying for the first time since admission. She said she wanted to practice the role-playing in the group so she could learn how to do it. She said she was also intent on getting a referral to a cognitive therapist near her home after discharge so she could continue the work that was proving to be so helpful to her.

  The method that helped this patient is also called the “double-standard technique.” It is based on the idea that many of us operate on a double standard. We may judge ourselves in a harsh, critical, demanding way, and yet we judge others in a more compassionate and reasonable manner. The idea is to give up this double standard and agree to judge all human beings, including ourselves, by one set of standards that is based on truth and compassion instead of using a separate standard that is distorted and mean when we judge ourselves.