Feeling Good: The New Mood Therapy

by Burns, David D.

  Myth Number 10. “It is shameful to receive psychotherapy because it means I am weak or neurotic. It is more acceptable to be treated with a drug because it means I have a medical illness, like diabetes.” Actually, the sense of shame is common in depressed patients who are treated with drugs or psychotherapy. Often, the double-standard technique just described above can be helpful. Imagine, for example, that you’ve just discovered that a dear friend of yours received psychotherapy for depression and found that the treatment was helpful. Ask yourself what you would say to your friend. Would you say: “Oh, the psychotherapy just shows what a weak and defective neurotic you are. You should have taken a drug instead. What you did was shameful.” If you would not say this to a friend, then why give yourself these messages? That’s the essence of the double-standard technique.

  Myth Number 11. “My problems are real, so psychotherapy couldn’t possibly help me.” Actually, cognitive therapy seems to work the best with depressed individuals with real problems in their lives, including catastrophic medical problems such as terminal cancer or an amputation, bankruptcy, or severe personal relationship problems. In many cases, I have seen individuals with problems like this who improved in a handful of cognitive therapy sessions. In contrast, chronically depressed individuals without any obvious problems that triggered their depressions are often more difficult to treat. Although the prognosis is excellent, they may require more intensive and prolonged treatment.

  Myth Number 12. “My problems are hopeless, so no psychotherapy or drug could possibly help me.” This is your depression talking, and not reality. Hopelessness is a common but horrible symptom of depression that is based on twisted thinking, just as the other symptoms are. One of the distortions is called “emotional reasoning.” The depressed individual may reason: I feel hopeless, therefore I must be hopeless. Another cognitive distortion that leads to feelings of hopeless is fortune-telling—you are making a negative prediction that you will never improve, and assuming this prediction is really a fact. Other distortions can lead to feelings of hopelessness as well. These include the following:

  • all-or-nothing thinking—you think of yourself as completely happy or completely depressed; shades of gray do not count, so if you are not completely happy or completely recovered, you assume you are completely depressed and hopeless;

  • overgeneralization—you see your current feelings of depression as a never-ending pattern of defeat and suffering;

  • mental filter—you selectively think of all the times you have been depressed, and end up thinking your whole life will be bad forever;

  • discounting the positive—you insist that the times you were not depressed don’t count;

  • “should” statements—you use up all your energy telling yourself you “shouldn’t” be depressed (or you “shouldn’t” have gotten depressed again) instead of systematically working to overcome the feelings;

  • labeling—you tell yourself you are hopelessly and irreversibly defective and conclude that you could never really feel whole, or happy, or worthwhile.

  Other cognitive distortions, such as magnification or personalization, can also lead to feelings of hopelessness. Although these feelings are not realistic, they can act like self-fulfilling prophecies. If you give up, nothing will change and you will conclude that you really were hopeless.

  Patients who feel hopeless usually cannot see that they are deceiving themselves. They are nearly always convinced these feelings are entirely valid. If I can persuade them to challenge these hopeless feelings and try to get better—even though they feel in their hearts that this is impossible—they usually do begin to improve, slowly at first and then more rapidly, until they feel a whole lot better.

  One of the most important tasks of any therapist is to help depressed patients find the courage and determination to resist and fight these hopeless feelings. This battle is often fierce and rarely easy, but nearly always rewarding in the long run.

  Chapter 19

  What You Need to Know about Commonly Prescribed Antidepressants

  (Notes and References appear on pages 682–687.)

  This chapter contains practical general information about the use of antidepressants. You will learn who is the most—and least—likely to benefit from an antidepressant, how you can tell whether an antidepressant drug is really working, how much mood elevation you can anticipate, how long you should stay on it, and what you can do if it doesn’t work. You will also learn how to monitor and minimize side effects and prevent potentially dangerous interactions between antidepressants and other drugs you may take, including prescription drugs as well as nonprescription (over-the-counter) drugs you can obtain at the drug store or grocery store. In the next chapter, I will provide specific information about each antidepressant and mood-stabilizing drug currently in use.

  When you read this chapter, keep in mind that the use of antidepressants is still a blend of art and science. Each practitioner has a slightly different philosophy, and your doctor’s approach may differ from mine. I will state my own biases up front.

  First, I am quite demanding in terms of what I expect from an antidepressant. I believe that any antidepressant medication should have a pretty profound and dramatic effect in order to justify its continued use. In addition, I firmly believe that every patient taking antidepressants should take a mood test like the one in Chapter 2 at least once a week. Your score on this test (or any other good depression test) is a highly reliable measure of how well your antidepressant is working. I do not encourage patients to continue taking drugs that have only modest or questionable beneficial effects on mood. When the score on the test goes down only a little bit (for example, a 30 percent or 40 percent improvement), I would be inclined to call this a placebo effect and not a real drug effect. This amount of improvement could be due to the passage of time, the psychotherapy, or the belief that the drug will work. If the improvement in mood is minimal, and assuming the patient has had a sufficient dose of the medication for a sufficient period of time, I would probably take the patient off the drug and try another medication, a combination of medication and psychotherapy, or psychotherapy alone.

  Now some readers may think, “but a 40-percent improvement in my mood sounds pretty good. This sounds like real improvement. I’m almost half better.” Certainly, any improvement is desirable, but research studies indicate that inactive placebos can also have large antidepressant effects. A 40-percent improvement has been shown to be a typical placebo response. The only justification for taking any antidepressant drug is this: Is the drug doing its job? To my way of thinking, the goal of treatment is to recover from depression. Most patients want complete recovery, not just a slight or moderate improvement in their mood. If an antidepressant is not accomplishing this goal after a reasonable trial, then I would recommend switching to another drug or treatment approach.

  Second, I never treat patients with medications alone. If I prescribe an antidepressant for a patient, I always combine the medication treatment with psychotherapy as well. Although I tried the medication-only approach with large numbers of patients early in my career, I almost never found this approach to be satisfactory.

  For example, when I was a postdoctoral fellow following my residency training at the University of Pennsylvania, I ran the lithium clinic at the Philadelphia VA Hospital. I treated many depressed veterans suffering from bipolar manic-depressive illness with a combination of lithium and other antidepressant drugs. Although the medications appeared to be helpful, the results were not very encouraging. Most of these poor veterans were going in and out of the hospital almost constantly, and few were leading productive, joyous, stable lives. Later in my career, when I learned cognitive therapy, I treated all my manic-depressive patients with a combination of medications plus psychotherapy. The results were much better. From that point on, I can recall only one manic-depressive patient I treated who required hospitalization for an episode of mania.

  The results with depressed pati
ents were similar. Early in my career, I treated depressed patients with the drugs alone or drugs combined with traditional supportive psychotherapy. I administered a depression test like the one in Chapter 2 to every patient every session. I could see very clearly that while some patients were helped a lot by antidepressants, many were not. A lot of patients improved only slightly, and some did not improve at all. Later in my career, I began to combine antidepressant drugs with the new cognitive therapy techniques I was learning, and saw much better results. Eventually, I gave up treating patients with drugs alone.

  Third, I usually use one medication at a time, rather than a combination of many different kinds of drugs, although there are certainly many exceptions to this or any rule. The idea behind polypharmacy is that if one drug is good, two, three, or more will be even better. Some doctors also use additional drugs to try to combat the side effects of other drugs the patient is taking. The potential drawbacks to poly-pharmacy are many, including more side effects and more possible adverse drug interactions. I discuss polypharmacy in detail at the end of Chapter 20 and describe a number of specific situations in which the use of more than one drug may be justified.

  Finally, I have usually not kept patients on antidepressant drugs indefinitely following recovery. Instead, I slowly taper patients off their antidepressants after they have been feeling really good for several months. I have found that in most cases, patients who have recovered can continue to remain undepressed without medications. Keep in mind that all my patients have received cognitive therapy, whether or not they also received an antidepressant. The cognitive therapy is probably responsible for the good long-term results, because patients learn tools they can use for the rest of their lives whenever they are feeling upset.

  Many doctors practice very differently. They tell their patients that they must continue taking their antidepressants indefinitely to correct a “chemical imbalance in the brain” and to prevent relapses into depression. While relapse is an important issue, I have found that training patients to use their cognitive therapy tools whenever they need them seems to maintain improvement following recovery. In fact, a number of well-controlled long-term follow-up studies have confirmed that this works better than drugs to prevent relapses.

  While this is my philosophy in a nutshell, remember that there is no single “correct” approach, and your doctor’s philosophy might differ from mine. In addition, there are many exceptions to any rule, and your own diagnosis or personal history may mandate a different approach from the one I have just outlined. If you have questions about your treatment, discuss your concerns with your physician. In my experience, the sense of teamwork and mutual respect is still the most important ingredient in any successful treatment.

  If I Am Depressed, Does It Mean that I Have a “Chemical Imbalance” in My Brain?

  There is an almost superstitious belief in our culture that depression results from a chemical or hormonal imbalance of some type in the brain. But this is an unproven theory and not a fact. As discussed in Chapter 17, we still do not know the cause of depression and we do not know how or why antidepressant drugs work. The theory that depression results from a chemical imbalance has been around for at least two thousand years, but there is still no proof of this, so we really do not know for sure. Furthermore, there is no test or clinical symptom that could demonstrate that a particular patient or group of patients has a “chemical imbalance” that is causing the depression.

  If I Am Depressed, Does It Mean that I Should Take an Antidepressant?

  Many people also believe that if you are depressed you should be on an antidepressant. However, I do not insist that every depressed patient must take an antidepressant. Large numbers of well-controlled studies published in respected scientific journals indicate that the newer forms of psychotherapy can be just as effective as, and sometimes more effective than, antidepressants.

  Certainly many depressed people have been treated successfully with antidepressants and swear by them. They are valuable tools and I am glad to have them available in my treatment arsenal. Sometimes antidepressants are helpful, but they are rarely total answers, and often they are not necessary.

  How Can I Decide Whether or Not to Take an Antidepressant?

  I always ask my patients during their initial evaluations whether or not they would prefer to take an antidepressant. If a patient strongly feels that she or he would prefer to be treated without an antidepressant, I treat with cognitive therapy alone, and this is usually successful. However, if the patient has been working hard in therapy for six to ten weeks without any improvement, I sometimes suggest we try to add an antidepressant to put some “high octane” in the tank, so to speak. In some cases, this makes the psychotherapy more effective.

  If a patient feels strongly that she or he would like to receive an antidepressant at the initial evaluation, I treat with a combination of an antidepressant medication and psychotherapy right away. However, I almost never treat patients with antidepressant medications alone, as noted previously. In my experience, the drugs-only approach has not been satisfactory. The combination of medications with psychotherapy seems to produce better results in the short term and in the long term than treating patients with drugs alone.

  It may sound unscientific to base the medication decision on the patient’s preferences, and certainly there are exceptional cases where I feel I have to make a recommendation that differs from my patient’s wishes. But the majority of time, I have found that patients do well when treated with the approach they are most comfortable with.

  So if you are depressed and you have strong positive feelings that an antidepressant drug will help you, this increases the likelihood that you will be helped by one of these medications. And if you feel strongly that you would prefer to be treated with a drug-free form of therapy, the likelihood of a successful outcome is also good. But I would urge flexibility in your thinking. If you are receiving a medication, I strongly believe that cognitive or interpersonal psychotherapy can enhance your recovery. If you are receiving psychotherapy and your progress is slow, an antidepressant might accelerate your recovery.

  Can Anyone Take an Antidepressant?

  Most people can, but competent medical supervision is a must. For example, special precautions are indicated if you have a history of epilepsy, heart, liver, or kidney disease, high blood pressure, or certain other disorders. For the very young and elderly, some medications should be avoided, and smaller dosages may be indicated. And, as noted above, if you are taking medicines in addition to an antidepressant, special precautions are sometimes required. Properly administered, an antidepressant is safe and may be lifesaving. But don’t try to regulate it or administer it on your own. Medical supervision is a must.

  Should a pregnant woman use an antidepressant? This sensitive question often requires consultation between the psychiatrist and the obstetrician. Since fetal abnormalities might occur, the potential benefit, the severity of the depression, and the stage of pregnancy must all be taken into account. Other treatment approaches should usually be employed first, and an active self-help program of the type described in this book might eliminate the need for a medication. This would give optimal protection to the developing child, of course. On the other hand, if the depression is very severe, there may be cases where it makes sense to use an antidepressant.

  Who Is Most—and Least—Likely to Benefit from an Antidepressant Drug?

  Your chance of responding to an appropriate drug may be enhanced:

  1. If you are unable to carry on with your day-to-day activities because of your depression.

  2. If your depression is characterized by many organic symptoms, such as insomnia, agitation, retardation, a worsening of symptoms in the morning, or an inability to feel cheered up by positive events.

  3. If your depression is severe.

  4. If your depression had a reasonably clear-cut beginning.

  5. If your symptoms are substantially different from the way you norma
lly feel.

  6. If you have a family history of depression.

  7. If you have had a beneficial response to antidepressant drugs in the past.

  8. If you strongly feel that you would like to take an antidepressant drug.

  9. If you are strongly motivated to recover.

  10. If you are married.

  Your chance of responding to an appropriate drug may be diminished:

  1. If you are very angry.

  2. If you have a tendency to complain and to blame others.

  3. If you have a history of an exaggerated sensitivity to drug side effects.

  4. If you have a history of multiple physical complaints that your doctor has been unable to diagnose, such as tiredness, stomach ache, headache, or pains in your chest, stomach, arms, or legs.

  5. If you have a long history of another psychiatric disorder or hallucinations preceding your depression.

  6. If you feel strongly that you do not want to take an antidepressant drug.

  7. If you are abusing drugs or alcohol and you are unwilling to go into a recovery program.

  8. If you are receiving financial compensation for your depression, or if you hope to receive financial compensation. For example, if you receive disability payments for depression, or if you are involved in a lawsuit and hope to receive financial compensation because of your depression, then any form of treatment is going to be difficult. This is because if you recover, you will lose money. This is a conflict of interest.