What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (19 page)

Treatments for Depression That Work

Most of the time, depression can be markedly shortened in duration and considerably relieved in intensity by treatment. There are four therapies that work: two biological, drugs and electroconvulsive shock (ECS); and two psychological, cognitive therapy (CT) and interpersonal therapy (IPT). All four have been subjected to rigorous testing involving tens of thousands of depressed people. They all work to about the same extent—moderately well.

Beware of any other form of treatment offered for unipolar depression.

Drugs
. The main kinds of drugs are tricyclics (for instance, Elavil, Tofranil, and Sinequan), MAO inhibitors (Marplan, Nardil, and Parnate), and serotonin-reuptake inhibitors (Prozac). All of these drugs take between ten days and three weeks to start working. When they do work, they relieve depression markedly about 65 percent of the time. That is the good news.

Here is the bad news: First, about a quarter of depressed people cannot or will not take drugs, usually because of side effects. Second, once you go off the drug, your risk for the relapse, or recurrence, of depression is considerable, probably just the same as your risk was before taking the drug. In order to prevent further depression or relapse, you should keep taking the drug—maybe for the rest of your life.
¹²

ECS
. Electroconvulsive shock is scary. It has worse press than it deserves, but it is far from innocuous. Most of the time it is rapid and highly effective. It relieves severe depression about 75 percent of the time, usually in a series of ECSs that take a few days. Many lives have undoubtedly been saved by its use, particularly the lives of acutely suicidal people.

The bad news is identical to that for drugs. Many people will not agree to ECS because of its considerable side effects—memory loss, cardiovascular changes, and confusion—and because it is a major medical procedure. Even more important, there is no evidence that it cuts down the recurrence of depression. Rather, it provides acute relief.
¹³

So both biological treatments bring quite effective relief. Both also have serious side effects, and both are only cosmetic—they don’t solve the underlying problems, and depression is likely to return unless you keep taking medication.

Cognitive therapy (CT)
. Cognitive therapy, which seeks to change the way the depressed person consciously thinks about failure, defeat, loss, and helplessness,
¹⁴
employs five basic tactics.

First, you learn to recognize the automatic thoughts—the very quick phrases, so well practiced as to be almost unnoticed and unchallenged—that flit through consciousness at the times you feel worst.

A mother of three children sometimes screams at them as she sends them off to school. She feels very depressed as a consequence. In CT, she learns to recognize that right after these screaming incidents she always says to herself “I’m a terrible mother—even worse than my own mother.” She learns to become aware of these automatic thoughts
.

Second, you learn to dispute the automatic thoughts by focusing on contrary evidence.

The mother reminds herself that when the kids come home from school, she plays football with them, tutors them in geometry, and talks to them sympathetically about their problems. She marshals this evidence and sees that it contradicts her first thought that she is a bad mother
.

Third, you learn to make different explanations, called
reattributions
, and to use them to dispute your automatic thoughts.

The mother learns to say: “I’m fine with the kids in the afternoon and terrible in the morning. Maybe I’m not a morning person.”

That is a much less permanent and pervasive explanation for screaming at the kids in the morning. As for the chain of negative explanations that goes “I’m a terrible mother, I’m not fit to have kids, therefore I don’t deserve to live,” she learns to interrupt it by inserting the new explanation: “It’s completely illogical to infer that I don’t deserve to live because I’m not a morning person.”

Fourth, you learn how to distract yourself from depressing thoughts. Rumination, particularly when one is under pressure to perform well, makes the situation even worse. Often, in order to do your best, it is better to put off thinking. You learn to control not only what you think but also when you think it.

Fifth, you learn to question the depression-sowing assumptions governing so much of what you do:

• “I can’t live without love.”
  

• “Unless everything I do is perfect, I’m a failure.”
  

• “Unless everybody likes me, I’m a failure.”
  

• “There is a perfect right solution for every problem. I must find it.”
  

These kinds of premises set you up for depression. If you choose to live by them—as so many of us do—your life will be filled with blue days and weeks. You can, however, choose a new set of more forgiving premises to live by:

• “Love is precious but rare.”
  

• “Success is doing my best.”
  

• “For every person who likes you, one person doesn’t like you.”
  

• “Life consists of putting my fingers in the biggest leaks in the dam.”
  

CT works quite well, bringing considerable relief to about 70 percent of depressed people. It is roughly as effective as the typically prescribed drugs, but somewhat less effective than ECS. It takes about a month to start working, and therapy is brief—usually a total of a few months, once or twice a week. In one way, CT is clearly superior to a single course of drugs or ECS: It lowers your future risk of depression by teaching you new skills of thinking that you can use the next time really bad things happen to you. While CT lowers future risk more than drugs, it does not lower your risk of recurrence even close to zero.
¹⁵

My main reservations about CT are, first, that it may work better on moderate depression than on severe depression—for which drugs should probably be tried first; second, cognitive therapy has mostly been used with educated people who are “psychologically minded”—aware of their thoughts and how thinking affects their emotions. Little is known about how well it works for less educated and less sophisticated people; third, there is so much recurrence of severe depression, even with CT, that there is a long way to go before anything more than “moderate relief” can be claimed.

Interpersonal therapy (IPT)
. Interpersonal therapy focuses on social relations. It has become important because in the major NIMH-sponsored outcome study of depression, it was intended to be a placebo treatment but proved just as effective as tricyclics and at least as effective as CT in relieving depression.
¹⁶

This therapy has its origins in the long-term psychoanalytic treatments devised by Harry Stack Sullivan and Frieda Fromm-Reichmann. But IPT is decidedly not psychoanalytic. In contrast, it does not deal with the childhood underpinnings, the decades-old defenses. IPT is also not long-term; rather, it consists of twelve to sixteen sessions, usually once a week.
¹⁷

IPT sees depression in a medical model, asserting that depression has many causes, biological as well as environmental. Salient among the causes are interpersonal problems. IPT hones in on the here-and-now problems of getting along with other people. Current disputes, frustrations, anxieties, and disappointments are the main material of this therapy. IPT looks at four problem areas in the current life of the patient: grief, fights, role transitions, and social deficits.

When dealing with grief, IPT looks for abnormal grief reactions. It brings out the delayed mourning process and helps the patient find new social relationships that can substitute for the loss. When dealing with fights, the IPT practitioner helps determine where the disrupted relationship is going: Does it need renegotiation? Is it at an impasse? Is it irretrievably lost? Communication, negotiation, and assertive skills are taught. Role transitions include retirement, divorce, and leaving home. When dealing with these, the IPT practitioner gets the patient to reevaluate the lost role, to express emotions about the loss, to develop social skills suitable for the new role, and to establish new social supports. When dealing with social deficits, the IPT practitioner looks for recurrent patterns in past relationships. Emotional expression is encouraged. Both abiding social strengths and weaknesses are uncovered. When weaknesses are found, role playing and enhanced communication skills are encouraged.

The main virtues of IPT are that it is brief (a few months) and inexpensive, it has no known adverse side effects, and it has been shown to be quite effective against depression, bringing relief in approximately 70 percent of cases. Its main drawback is that it is not very widely practiced (it is very hard to find an IPT practitioner outside of New York City). This means that little research has been done to find its active ingredients and to replicate its benefits for depression.

The Right Treatment

UNIPOLAR DEPRESSION SUMMARY TABLE

Everyday Depression

Your score on the depression test was probably below the moderate-to-severe range; most people score between 5 and 15. If that is true for you, you are probably not in need of therapy for depression. It may be true that you are sad quite a bit, that most of your life is not filled with gusto, that you get fatigued pretty easily, that setbacks hit you pretty hard, that you suck up energy from social gatherings rather than adding life, and that you are not optimistic about your future. But you probably do not have a depressive disorder.

If the last paragraph describes your state, you should try to do something to change this state of affairs, for even mild depression poisons everyday life. The same four groups of symptoms—sadness, pessimism, passivity, and muted physical appetites—occur when depression is mild, only with less force. When mild depression has become a life-style, it is pointless, and it should be changed.

Mild depression is usually caused by pessimistic habits of thinking. The pessimist sees the causes of failure and rejection as permanent (“It’s going to last forever”), pervasive (“It’s going to ruin everything”), and personal (“It’s my fault”). These habitual beliefs are just that, mere beliefs. They are often false, and they are often inaccurate catastrophizings. The main lesson of cognitive therapy is that this way of thinking can be permanently changed—even in severe depressions. Mild depressives can usually change it without therapy.

The main skill of optimistic thinking is disputing. This is a skill everyone has, but we normally use it only when
others
accuse us wrongly. If a jealous friend tells you what a lousy executive or bad mother you are, you can marshal evidence against the accusation and spit it back in his or her face. Mild depressives make the same sorts of accusations to themselves,
about
themselves, many times a day. You walk into a party and you say to yourself, “I have nothing to say. No one is going to like me. I look terrible.” When these accusations issue from inside, you treat them as if they were unimpeachable. But the automatic pessimistic thoughts you have are just as motivated and irrational as the ravings of a jealous rival. They originate not in hard fact but in the criticisms your parents made of you in anger, your big sister’s jealous mocking, and your priest’s unbending rules, all absorbed passively when you were much younger.

You can, with some discipline, learn to become a superb disputer of pessimistic thoughts. I wrote a book about this,
Learned Optimism
(1991). It has exercises in it that should prove useful to you. This is not the place to repeat its contents, but I commend it to you. Once you acquire the skills of optimism, they stay. This regimen is not like dieting, which, as we shall see in
chapter 12
, almost always undoes itself after a time. Staying on a diet, continuing to refuse the food you love, is no fun. Disputing your own negative thoughts, in contrast,
is
fun. Once you are good at it, it makes you feel better instantly. Once you start doing it well, you want to keep doing it. If you have a low mood almost every day, you can choose to change the way you think. When you do so, you will find that your life is more worth living.

9

The Angry Person

For some of the large indignities of life, the best remedy is direct action. For the small indignities, the best remedy is a Charlie Chaplin movie. The hard part is knowing the difference.