Stronger Medicine

It was mid-morning on the first day of the large psychotherapy conference when I first began noticing the small white buttons with their pithy little saying sprouting on the lapels of conference attendees: “DEPRESSION: IT’S AN ILLNESS, NOT A WEAKNESS.” By late afternoon, the buttons, dispensed at an exhibit booth for a large pharmaceutical company, were everywhere. I glimpsed them affixed to collars, pockets, belt loops, purses, backpacks, folders, any spare inch of apparel or appurtenance. It was startling to see how quickly a slogan could capture the allegiance of so many of my colleagues, especially when so many of them shared a common preference for brief, solution-oriented psychotherapies. Why were they so willing to make a public endorsement of the saying? For one thing, the slogan is catchy. It seems to suggest that we’ve moved beyond an era of superstitious belief and finally uncovered depression’s “true” nature. The idea that depression is a clear-cut illness, caused by a “chemical imbalance” that can be cleared up with a daily dose of Prozac or Zoloft, now threatens to become a widely accepted clinical mantra and a popular shibboleth, repeated in best-selling books, mass-circulation periodicals and morning TV talk shows.

Currently, the most common mental health disorder in America and one of the most costly, depression racks up a staggering $54 billion a year in costs from work absenteeism, reduced productivity, lost earnings and treatment expenses, according to a 1995 study by the National Institute of Mental Health. Depression is also among the most medicalized of psychiatric diagnoses; indeed, family doctors, not psychiatrists, write up to 70 percent of antidepressant prescriptions, with a wide array of meds to choose from. With the lion’s share of mental health research dollars going into psychopharmacology during the past 15 years, there are now five major classes of antidepressants on the market. Seven new medications have been introduced within the last 10 years alone, and about 15 more are now being tested by the pharmaceutical companies.

But does the wide prevalence of depression, the staggering popularity of drugs to treat it and the obvious zeal for medicalizing the whole problem constitute prima facie proof that it is a disease? Can we now reduce the complex phenomena of depression, with all its emotional, cognitive, relational, social and biological elements, to a simple neuro-chemical mistake? Or is it possible that most depressed people are not “sick,” and that biology only represents one component in the reasons for their depression and the way they experience it?

While the symptoms of depression, at least as officially described in the Diagnostic and Statistical Manual, may seem to many to be fairly clear-cut and predictable, its origins and antecedents are not. Genetics, childhood trauma, unconscious guilt, neurochemical imbalance, poor interpersonal skills, learned helplessness are all potential “ground zeroes” by one school of therapy or another. In fact, the way therapists regard and treat depression might be considered as a kind of professional Rorschach test, revealing far more about their theoretical allegiance than about the true condition of their depressed clients. Analysts are trained to think of depression as the consequence of unresolved childhood developmental losses; cognitive therapists look for errors in thinking and belief that reinforce negative emotions; behaviorists help clients extinguish habits that contribute to depression; and family therapists study systemic or interpersonal triggers for depressive symptoms. However different the methods and the philosophies of their proponents, all these models provide valuable insights into the hydra-headed entity of depression, and none can stand as the final, defining word. But of all of the methods for treating depressed clients, biological psychiatry is today in the ascendancy, due largely to the proliferation during the last 15 years of effective medications for treating depressive symptoms with fewer side effects than ever before.

The rising fascination with evolutionary psychology and biological determination has led some experts to proclaim, without much evidence, that all emotional states (including depression) are ultimately based on biology.

One study published in Psychological Science in 1990 by Robert Plomin, Robin Corley, John DeFries and David Fulker, for example, suggests that one’s amount of television viewing may be genetically determined. A 1992 study in the same journal by Matt McGue and David Lykken indicates that the tendency to divorce is also biologically determined. Do we really have genes for TV and divorce? Where and how in human history would we have acquired such genes (that only seem to have been activated in the last 30 or so years)? Indeed, as psychologist Stanton Peele writes in Diseasing of America, it is currently fashionable to view all kinds of self-defeating personal behaviors, including eating disorders, excessive shopping and too much sex, as evidence of disease.

The push to redefine depression as a disease is aided and abetted by the managed care industry, which encourages the use of antidepressant medication as a treatment approach. According to psychiatrist Matthew Dumont, “It seems that if we so much as inquire whether a depression might be related to the stresses or losses of life before blasting it with a chemical, we are virtually guilty of malpractice.”

But this devaluation of therapy that inevitably accompanies the new emphasis on biological approaches is wrong-headed on two fronts. In the first place, epidemiological, social and cultural data indicate that, for most people, depression is not a disease of biological origin. Increasing in prevalence among all age groups, it is growing most rapidly among late adolescents and young adults. The average age of onset for a first major depressive episode has been steadily decreasing and is now the mid-twenties. Since gene pools and biochemistry do not tend to change so markedly in so short a time, the evidence supports an argument for social and cultural causes for depression in most cases. Since 1945, when the first of the baby boomers, who suffer disproportionately from depression, were born, our cultural mores have changed profoundly. The breakup of the family, explosive technological growth, dwindling resources, violence, terrorism and the threat of nuclear disaster have undermined our sense of social stability and cast deep shadows over future expectations. Writing in the Archives of General Psychiatry in July 1985, psychiatrist Gerald Klerman and his colleagues identified some of the social stresses they believe account for the higher rates of depression. These include urbanization, changes in family structure, new gender roles and occupational shifts. All of these trends unsettle people, uproot them from traditional mores and meanings, confuse them about who they are and what is expected of them and create many new opportunities for experiencing inadequacy and failure. Psychology researcher Martin Seligman suggests that, as a people, we tend to be more self-absorbed than our forebears, and thus more hypersensitive to each transient mood. Seligman thinks that we may also have unrealistically high expectations of ourselves and others, even as we increasingly feel both more helpless and hopeless about controlling our lives.

This dichotomy is even more confounding for our own emotional well-being, Rates of depression and symptomatology vary widely from culture to culture and between genders, also lending support to the theory that the interplay of social, cultural and psychological factors is generally more important than biology. The Amish, for example, have considerably lower rates of depression than do other Americans. Their lower incidence of depression presumably relates to cultural factors, including vital religious beliefs, close-knit community ties and a reliance on their own labor rather than technology. Women in this country are two or three times more likely to be diagnosed as depressed than men, in part for biological reasons (reproductive events like postpartum depression and possibly premenstrual syndrome), but more likely because of systemic social inequities and cultural conditions.

There is no question that genetics and biochemistry play a part in depression, but the best data from identical-and fraternal-twin studies indicate that genetics can be identified as a cause of unipolar depression less than 20 percent of the time. But, if, as the evidence now shows, cultural and social forces contribute more to the onset of depression than does biology, medication is only a partial solution.

More important, there is now abundant evidence that therapy is as effective or more effective than drugs are for treating depression, with lower rates of relapse. In the January 1994 issue of American Psychologist, Ricardo Munoz, Steven Hollon et al. reviewed guidelines for treatment of depression developed by the Agency for Health Care Policy and Research (AHCPR) that compared thousands of treatment outcome studies using drugs alone, psychotherapy alone or a combination. Evaluating the guidelines, the authors concluded that psychotherapy was at least as efficient as drugs for relieving depression. And, on many measures, including treatment-dropout rate, social adjustment, symptomimprovement and relapse rate, psychotherapy performed better than meds. Several metanalyses of many controlled studies involving thousands of patients have reached the same conclusion. One is a recent review by David Antonuccio et al. of numerous studies comparing drugs to therapy and the value of both approaches combined, published in the December 1995 issue of Professional Psychology: Research and Practice, which reports substantial evidence for the superior effectiveness of therapy. There is “no stronger medicine” for depression than psychotherapy, writes Antonuccio in a recent issue of the American Psychologist. So, while medications can help relieve symptoms, and possibly help clients take better advantage of therapy, the reputation of Prozac or Zoloft as miracle cures for depression, rendering therapy obsolete, is simply not supported by research.

Late last year, the position of therapy was buttressed even more by the largest survey ever conducted of people who had undergone outpatient psychotherapy treatment, published in the November 1995 issue of Consumer Reports (See Around the Network, January/February 1996 Networker) and based on extensive reader-response questionnaires submitted by 4,000 subscribers. Unlike standard efficacy studies, with their random assignments of clients meeting rigid eligibility requirements to standardized treatments, the Consumer Reports survey caught the experience of therapy as it really is for most people with therapists who typically offer an eclectic mix of approaches and adjust their work to individual clients.

Of respondents to the survey, 87 percent said they felt better after treatment. There was no significant difference between psychotherapy alone and in combination with medication for any disorder, including depression. And social workers, psychologists and psychiatrists all had roughly the same rates of success. Most surprising, perhaps, to a field giving increased emphasis to brief therapy, respondents reported better results for longer treatment. Among those with similar levels of emotional difficulty, those who stayed in therapy more than six months said they made greater progress than those who left earlier. Not surprisingly, people whose choice of therapist or whose length of treatment was dictated by insurance coverage improved less than those who freely chose the clinician and modality.

Although the Consumer Reports study is not without problems low response rate to the questionnaire, lack of specificity to the depression diagnosis and other possibly distorting factors it broke new ground. By going directly to the mental health consumer, it produced the most naturalistic view of the actual experience of therapy of any study of the field ever conducted. According to psychology researcher Martin Seligman, principal consultant on the survey, writing in the December 1995 American Psychologist, “[The survey] is large-scale; it samples treatment as it is actually delivered in the field; it samples without obvious bias those who seek out treatment; it measures multiple outcomes…; it is statistically stringent and finds clinically meaningful results…Its major advantage over the efficacy method for studying the effectiveness of psychotherapy and medications is that it captures how mid to whom treatment is actually delivered and toward what end…It provides a powerful addition to what we know about the effectiveness of psychotherapy and a pioneering way of finding out more.”

While medications are often invaluable for symptom relief of depression, their effectiveness is not evidence for an underlying physical pathology. Medications work because they have a relevant chemical effect, indicating a correlation between their impact on specific neurotransmitters and mood. But while there are some cases in which medications may help depression sufferers without additional treatment, the consensus among most depression experts is that only prescribing medications is generally a disservice to the client. Most people require much more substantial psychotherapeutic help to learn the skills necessary for solving problems and avoiding future difficulties, if their medication-improved mood is to endure.

What is it about psychotherapy that makes it so vital to treatment, that gives depressed clients something they cannot obtain from medications? People become and stay depressed partly because they tend to explain life’s ordinary defeats and disappointments in terms of their personal inadequacies and failures, and then believe their own negative opinion of themselves. Others have deeply pessimistic worldviews that influence their mood states and tend to engender self-fulfilling prophecies. A healing relationship with a therapist can provide the kind of personal support and teaching that can clear up the misperceptions that contribute to the negativistic view of life typical of depressed people. Therapy can help clients see life events from different perspectives and reattribute experience by assigning alternative explanations for life events that are less damaging to themselves than the typical depressive worldview. The ability to see and interpret events from new perspectives is critical to mental health.

As we become increasingly a nation of wanderers, our lack of steady and sustained social connections and consequent lack of competence in relationship skills provokes even higher rates of depression. Our ethos of extreme individuality and personal rights over collective responsibility and social accommodation increases the likelihood that we will be lonely and depressed, without the deep ties to family and friends that can immunize us against alienation and despair. But there is no disease here, just a way of responding to life that is proving ever more toxic to our individual and collective psyches.

As therapists, what can we do in the face of this rising tide of depression, which deeply implicates not the faulty biology of millions of people but the depressing nature of our civilization? And how can we counter the myth of pharmaceutical omnipotence that undermines our own confidence in therapy and our appreciation for its irreplaceable role? We must be aware that therapy works with depressed people because it draws on the clinical skills and adaptability required to understand a complex disorder skills no pill can mimic. Therapists also need to emphasize active, solution-oriented treatments over pathology-based passive ones. Rather than search the dim past for causes of presumed deficits, we need to actively teach clients the specific skills they need to manage their feelings and develop what author Daniel Goleman calls their “emotional intelligence.”

Martin Seligman, in his book, The Optimistic Child, writes that antidepressant skills for interpreting and responding intelligently to life events can be taught at a young age. We can prevent later misery by teaching children to be more flexible in their interactions and empower them to solve problems before they lead to entrenched, self-destructive patterns of behavior. Similarly, Robert Ornstein and Paul Ehrlich, in their book New World, New Mind, argue cogently that learning to think preventively acquiring a refined sense of the relationship between “this” course of action and “that” predictable consequence helps people avoid being sucked under by their own moods and emotional reactions. In short, therapists are badly needed to help people learn the tried-and-true skills that used to be considered the hallmark of adulthood. They include the ability to think ahead, critically consider alternatives, anticipate consequences, recognize when to give precedence to the heart or the head and, perhaps most of all, create and maintain solid and satisfying personal connections to other people.

Just as there is no single cause for depression, which is the personal and idiosyncratic response of individuals to a multitude of biological, psychological and social factors, so there can be no all-purpose panacea, like the simple act of taking a pill, that resolves life’s difficulties. The idea that depression is a disease reflects, in part, the benign intention to destigmatize the suffering it causes and, less benevolently, the economic pressures to find a cheaper cure. Americans have a history of valuing quick-fix solutions to difficult problems. But this simplistic approach to depressive disorders underestimates the remarkable human capacity for self-transformation. We have the ability to use imagination and intelligence to change our life circumstances, our attitudes and emotions, even, to some extent, our personalities. It is the privilege of our profession to be able to help troubled people along this path, and though medications may make this journey less arduous, in the long run, therapists are indispensable for getting their clients to this destination.

So, for the sake of your profession and your integrity, watch out for facile explanations of depression and pluck off those buttons that reduce complex issues to catchy slogans. Your clients will thank you, and you’ll feel better about your vital role in treatment.