Depression Can Be Defeated
Dr. Bill Knaus
Depression is a serious state of mind and body that needs to be taken seriously now. The prevalence of depression has increased dramatically since the turn of the Twentieth Century. In any year about 10 percent, or 30 million, of the US population will suffer from a serious depression. Depression is currently the number one disability for women. By the year 2020, depression is expected to follow coronary heart disease as the second most common form of disability for both sexes.
The rate of depression for adolescents has increased about one-thousand fold since 1950, which is partly due to earlier pubescence, less exercise, and social changes. The elderly are four times more likely to experience a serious depression than they would at a younger age.
As the US demographic shifts toward a larger elderly population, the numbers of people depressed will increase. The time to consider prevention methods, is now. There are a variety of preventative methods to reduce the risk of future depression, including depression education courses and research-based psychology self-help books on depression.
A US Department of Mental Health report offers encouragement to those experiencing depression. About eighty-percent of those who suffer from depression can significantly improve or overcome this disability, while others can make lesser but still significant changes. Practically any gambler would take those odds. However, depression merges with pessimism, so the odds typically look bleak to the depressed perceiver. A shift in belief to thinking that a positive change is possible, can make a big difference.
Depression is a disability and not a choice. People do not normally choose to depress themselves. The choice comes in what to do to arrest depression. In this regard the old saying, “different strokes for different folks,” has merit.
Depression is more than the blues and blahs that temporarily come and go in life. When experiencing a persistently depressed mood, our psychology, biology, and social experiences are distorted.
People suffering from depression suffer from an intense melancholic mood, and typically experience a loss of pleasure and experience oppressive depressive thoughts that can negatively affect how they go about their day, interact with others, and perform work responsibilities. A persistently depressed mood is often accompanied by unpleasant physical symptoms such as fatigue, lower back pain, headache, sleep disturbances, and a problem appetite.
There are several different types and causes of depression. Persistent depressive distress often follows a trauma or a loss, a pattern of stressful inner dialogues, or can come out of the blue. This condition of mind and body affects people from all walks of life from Presidents to the person on the street.
Depression is nothing to take lightly. A lingering mild, moderate, or severe depression represents a serious disability. The personal cost is found in intense anguish and bodily distress. The current economic burden is estimated at $85 billion annually.
Depression is not a simple unitary condition. This psychological, biological, and social form of disability is often complicated with coexisting conditions such as anxiety, perfectionism, and substance abuse. Because of the different forms, causes, and complications of depression, any general formula to arrest depression is bound to fail as a universal remedy.
A BLACK BOX WARNING
The recent FDA announcement of a planned new “black box” warning for antidepressant medications, grabs attention. The proposed FDA black box warning involves extending a similar 2004 warning about elevated suicide risk following the use of antidepressants for adolescents and young adults. The warning encourages suitable precautions.
Rather than view the warning with alarm, the FDA announcement represents an opportunity for people to better education themselves about depression and how to address it with or without antidepressant pills.
ANTIDEPRESSANTS HAVE LIMITATIONS
Since the US Food and Drug Administration (FDA) allowed pharmaceutical companies to advertise their products directly to the consumer, the use of antidepressants has increased significantly. The companies take in about $10.9 billion in annual sales in the US alone; the sales charts continue to show an upward trend.
There has been a heavy reliance on antidepressants to stem the flow of depression. This represents a quick and initially inexpensive approach that had been favored by managed care insurance companies that have a strong voice in treatment decisions for addressing depression. But it seems like this emphasis has been too great for too long to the detriment of many who suffer from depression for whom a less costly or natural alternative might prove preferable. The long-term use of antidepressants is also proving more costly than many equally effective alternative approaches, and so the winds are beginning to shift.
The antidepressants are not panaceas for defeating depression and for preventing it from coming back. In controlled laboratory studies, about sixty-percent of antidepressant users start to improve in a two to six-week period. But the laboratory is different from the real world where the adherence and improvement rates are often lower.
Antidepressants do seem to have a medicative effect for a subgroup of people with certain forms of depression. The majority of people who use antidepressants do not suffer major side effects. However, for others, the drugs have side-effects that can be worse than the depression.
Antidepressants can be a productive way to help alleviate depression but the pills have limitations:
- For some, antidepressants have side effects that are serious enough to warrant stopping their use immediately.
- The relapse rate following the use of antidepressants is significant. Following the termination of an antidepressant, about fifty- to eighty-percent get depressed again. The current drug company solution is to encourage switching antidepressant drugs. If one doesn’t work, try another. Although the switch over approach can be profitable to the drug companies, it detracts from the use of other methods that can initially be equally or more effective and have the added benefits of preventing depression from coming back.
- Depression comes in different forms including major depression, bipolar depression, and atypical depression. Some suffer from forms of depression that can get worse following the use of antidepressants.
- Adherence is a problem. An estimated twenty-five to fifty-percent on antidepressants stop taking the antidepressant pills within a month.
- The elderly who use SSRI antidepressants (Zoloft, Prozac), show reduced bone mineral density in their hips and higher risk for fractures following falls. Such falls may occur due to low blood pressure and dizziness associated with antidepressant use.
- It’s a fact that pharmaceutical companies have held back negative results from their own antidepressant studies. This very serious omission cannot ethically be justified. If the scientific findings are open to question, then this information flashes a warning signal to the consumer that is as loud as the FDA warning.
- Some experience increased suicidal urges.
When antidepressants fail, alternatives are sometime sought. However, reframing the question from “what can one do if antidepressants fail” to “what can one do before antidepressants are used,” can cause a radical--and needed--shift in perspective.
The reframed question suggests the importance of prevention, and prevention programs do work. It also suggests that there are equally or better and often less costly ways to defeat depression and to defend against depression relapses. Armed with such information, an informed consumer is likely to make better choices.
ALTERNATIVE METHODS FOR DEFEATING DEPRESSION
If one assumes that the first line of defense against depression is the antidepressant drugs, then antidepressants will typically be used first. Alternatives may be sought in cases where the pills don’t work. But if you operate on the assumption that there are evidence-based alternatives to arrest depression, you might consider those approaches first. That is the approach taken here. Cognitive forms of therapy, exercise, structured routines, and the use of the herb, St. Johns wort, represent priority alternatives.
The following describes a sample of alternative methods that have been found effective in addressing depression:
- 1. Antidepressants can be effective when the user believes that the drugs will help. A significant part of an antidepressive’s effectiveness can be attributed to a placebo effect where depressed persons come believe they will get over depression. This effect suggests that overcoming depressive thinking--especially the hopelessness variety--can lead to relief from depression. This change in thought also can be accomplished through recognizing and challenging depressive irrational belief systems. Recognizing and challenging depressive beliefs can give the person a sense of individual control that does not depend upon “placebo magic.”
Can the known power of a placebo be economically harnessed without antidepressants? Definitely yes! Learning and practicing positive critical thinking techniques can have a placebo effect. But more than that, developing and applying rational skills to overcome depressive thinking, can have a durable effect in stopping depression and preventing it from coming back.
- Decreasing depressive thinking is associated with an improved mood and reduction in physical symptoms. Cognitive methods used to help eliminate distorted depressive thinking are significantly more effective than antidepressants in preventing depression from coming back. That added benefit is especially important for people with a history of repeat bouts of depression. The Cognitive Therapy method has strong research support. Multi Modal Therapy holds promise as a comprehensive approach for dealing with multiple tiers of depression.
Rational Emotive Behavioral Therapy (REBT) methods can be beneficially directed toward addressing both irrationalities in depressive thinking but also conditions that commonly coexist with depression such as anxiety, anger, panic, and an inappropriately low tolerance for frustration. Effectively dealing with depressive thinking and these coexisting conditions can open opportunities for fulfillment as well as for preventing depression from coming back. Among the various cognitive methods for arresting depression, the REBT method would seem to be the more comprehensive approach for defeating both depressive thinking and the sort of negative thoughts that are part of those conditions of mind that so often coexist with depression.
Fascinating new brain scan research shows that applying cognitive procedures to reduce depressive thinking commonly results in measurable changes in the brain that are associated with a significantly lower relapse rate. Following the use of cognitive methods, brain wave studies show more normalized wave patterns. Following cognitive interventions, brain imaging shows a shift from the color of a depressed brain toward the color of a “normal” brain. These physical measures, coupled with reports of feeling better, make a compelling case for using cognitively oriented methods for defeating depressive thinking.
- One of the best antidepressant methods is exercise. A Duke University study found exercise to be initially as effective as the antidepressant Zoloft. Over a longer period, compared to Zoloft users, exercise was associated with a lower relapse rate. Exercise has strong research support.
- The herb, St. Johns wort, is an effective antidepressant with strong research support. It has few side effects. The herb is significantly less expensive than antidepressant medication products. It is more widely used in Europe and Canada than in the US and equals the drug company antidepressants in its overall effectiveness.
- Does combining antidepressant medications with cognitive approaches more rapidly reduce depression and prevent it from coming back? There is modest evidence that combining cognitive methods with antidepressant medications may prove more effective than either approach alone. It is the direction of this combined approach that is intriguing. Adding a cognitive therapy to an already existing antidepressant medication approach increases the rate of improvement for the medication group. Adding antidepressants to an ongoing cognitive therapy program, adds little to nothing. One might consider adding a cognitive component to an antidepressant drug approach to help speed recovery and to reduce the risk of a relapse.
- Stressful relationships can increase the risk for a depressive outlook and a depressive outlook can act as a catalyst for stressful relationships. Interpersonal Therapy or Cognitive Behavioral Therapy interventions can effectively help reduce interpersonal stresses and improve the quality of relationships for a subgroup of people suffering from depression, and correlate with the reduction of depression. Isolation, especially during “senior years,” is associated with depression. Planned social experiences can reduce a sense of loneliness and the risk for depression among the elderly. Social support groups can be beneficial for this subgroup.
- Activity is a time-proven remedy for depression. Creating and following through on a predictable scheduled set of activities of daily living, can help create a forward momentum against depression. The schedule can involve a simple and basic routine that includes awakening at a set time, dressing at a set time, eating breakfast at a local restaurant, and retiring to sleep at an anointed hour. It can include weeding a garden daily. The idea is to work a basic routine that is realistic under depressive circumstances, and manageable.
- Can reading a professionally written cognitive behavioral psychology self-help manual for defeating depression prove effective? This bibliotherapy approach is effective for a subgroup of depressed people who believe that if they had the tools to address their depression, they’d consider using them. The research strongly supports this approach. The Cognitive Behavioral Workbook for Depression, cited below, describes a comprehensive approach for dealing with depression that has a heavy loading of REBT methods. This easily read book contains many innovative techniques including the application of procrastination technology for defeating depression.
- People with histories of recurrent depression can improve their chances for reducing the risk of future depressions through psychological health maintenance efforts. These efforts can involve scheduled rereading of appropriate self-help sections of bibliotherapy references, prophylactic meetings with a qualified psychotherapist, maintaining exercise or diet programs, and so forth.
As a public service, New Harbinger Publications posted a guide to depression research and practice that I wrote. The report describes a broad range of methods that are effective in addressing depression. This information can be found at: http://www.newharbinger.com/client/client_images/NHpdfs/CBTAppendix.pdf
Those who want to learn about techniques to quell a winter depression can get information at: http://www.rebtnetwork.org/essays/depression.html
About the Author
Bill Knaus, Ed.D. — One of the original Directors of Training, REBT. Fellow, REBT. Training Faculty, REBT. Originator of Rational Emotive Education. Taught at City University of New York: Queens College, Springfield College, & American International College. Former president, Advocacy Network. He is the author of twelve books including The Cognitive Behavioral Workbook for Depression. New Harbinger, November 2006.