Active Treatment of Depression

lntroduction

Introductions are written when books are completed. As I approach the end of this one, I suspect I understand one of the reasons why Freud never wrote his promised book on technique: It's a very difficult task. To propose rules about what to say when in psychotherapy can seem to be an exercise in either hubris or ignorance. How to respond to a given patient in a given hour depends on so many factors-tact and timing, the patient's diagnosis, the context of the relationship so far, short-term tactical needs vs. long-term strategic goals, the therapist's personality, the therapist's emotional reaction to the patient in the moment, and so on ad infinitum—that there are potentially thousands of "correct" or helpful interventions. In addition, one of the therapist's most powerful tools is his own unconscious; his associations to the patient's material can often advance the therapy even when he is uncertain exactly where they will lead. So it can seem like a forlorn hope to try to write a prescriptive book. But I am trying, despite all these caveats, because people with depression need a different approach to treatment than what standard practice is today.

This is a book for mental health professionals who treat patients with depression. I am a therapist who suffers from depression myself. I have tried to write something that will be practical and helpful to therapists, physicians, and pharmacologists who are trying to help patients who do not respond quickly or easily to the standard prescribed treatments. Unfortunately, research is confirming that these are the majority of people suffering from depression. As I did the literature review for this book, I found myself more and more concerned that most care for depression is superficial, inadequate, and based on false information. Many assumptions commonly held in the professional community—that newer antidepressants are reliably safe and effective, that short-term cognitive and interpersonal psychotherapy help most patients, that many people with depression can be effectively treated in primary care, that most patients can recover from an episode of depression without lasting damage—on close examination turn out not to be true at all. And practice based on these assumptions is not only inadequate for treatment of depression, it can actually exacerbate the disease.

Most therapists and psychopharmacologists can help a patient recover from a single episode of depression, but our relapse rate is far too high: Patients who have one episode of major depression are 50 percent likely to have another; patients who have three episodes are ninety percent likely to have more (Thase, 1999). And, if we are honest with ourselves, we will also admit that our batting average is not so good either; for every patient we can help, we probably see two whom we can't. Active Treatment of Depression suggests that we accept the idea that depression is a chronic disease, and that we help our patients plan their lives accordingly. Medications are usually helpful and often will be a part of the patient's life for some time to come, but rarely can they prevent future episodes and help the patient resolve the problems that led to trouble in the first place. Patients must learn, practice, and plan to reinforce more adaptive ways of functioning—they must change how they deal with emotions, they must identify and challenge depressed thinking habits, they must change how they work, play, take care of themselves, cope with stress and loss, and interact with others. And therapists must be ready to give hope, to reduce shame, to be mentor, coach, cheerleader, idealized object, playmate, nurturer, nudge—many different roles. In doing so, inevitably, we must challenge many of our assumptions about the use of the self in psychotherapy.

The ugly fact is that too much of treatment for depression only reinforces the disease. Any experienced therapist has encountered patients who have been damaged by previous treatment, sometimes by highly qualified practitioners. Analytic therapy has reinforced depression in some who become mired in rumination. Directive treatment has demoralized and shamed patients by sadistically attacking their defenses. Medication, even when effective, can reinforce passivity. ECT can do the same. Yet all of these approaches also can be beneficial, with the right patient at the right time. How do we understand this?

I urge the reader to accept the fact that no single theory can yet explain this complex condition that affects twenty percent of the population. In fact, trying to understand depression exclusively from a single perspective—for instance, a cognitive-behavioral, psychodynamic, or a biochemical point of view—will necessarily limit our understanding and our ability to help our patients. Rather, we must be willing to take the best knowledge from many different points of view and shape it into practice guidelines. In doing so, we must also practice "active treatment" because many of our customary ways of operating are counterproductive with depression. We must find ways of lending hope, of engaging the patient's emotions, of mitigating the effects of the patient's shame, of helping the patient see the connections between what happens in his life and how he feels inside. We must engage family members as helpers, advocate for medication, and actively plan for how the patient can continue to recover when treatment ends.

Our field is fragmented and divided. It would be foolish to try to write a book on a subject as broad as depression without creating disagreement and controversy. As a patient advocate, I want to challenge assumptions and shake up the way we normally do business. In doing so I have tried to be fair, complete, and objective, but it's quite possible that I have in places not presented a perfect understanding of why some people might hold a position I am in disagreement with. When this happens, I hope that the reader will not hold my error against me immoderately but judge it in the overall context of the message in this book. I think that this will be good for the reader; one of the most destructive problems in the mental health professions—probably in all professions—is that we tend only to read that which confirms our pre-existing beliefs.

I also hope that the reader will consider the nature of the problem we're trying to address. Depression is more difficult to treat than we want to acknowledge. Everyone believes that research has demonstrated that cognitive behavioral therapy, interpersonal psychotherapy, and medication are demonstrably and equally effective in treating depression. But that was at three months after treatment. At eighteen months, not a single one of the patients, no matter what treatment they'd received, were any better off than the control group (Shea et al., 1992). In order to truly help people who are suffering with this venomous and insidious condition, we have to be willing to challenge some of the assumptions we hold dear. I hope the reader will bring an open mind. I have attempted to present a reasonably thorough and objective review of the current state of knowledge, and I hope that the result is both reliable and provocative.

Much of what is to follow is rather prescriptive. I don't want to gloss over the individual differences between patients and between therapists. Any therapeutic dyad is a highly unique entity. Each therapist is—or should be—struggling with his own uncertainty, how to help this patient in this situation given the limits of his professional knowledge, his incomplete understanding of the patient, the constraints of the therapeutic relationship, and individual biases and anxieties. I'm trying to give advice to the therapist based on my own perspective about depression, advice that hopefully informs and enlightens without ignoring the uniqueness of the patient-therapist situation and without ignoring the complex, unfathomable, potential of human existence. I do not believe it is helpful for our profession to pursue the belief that there is one, and only one, technically correct intervention at any given point in time in a therapeutic relationship. Rather, there are infinite interventions, some more helpful than others. But even the most helpful interventions have the effect of constraining the future dialogue, of co-constructing a reality that will have an impact on the future that is impossible to predict with reliability. When the patient has depression, that new, constructed reality must provide a different perspective: hope, alternatives, openings, even wisdom and power. To settle for less is to sell the patient short.

The plan of the book is as follows: The next three chapters present three perspectives on what we know about depression. Chapter 1 describes what it's like to live with depression—the effects, the stigma, the difficulty getting treatment—which I think will unfortunately be new information to many therapists and psychiatrists. Chapter 2 introduces what I refer to as the "common-sense" model of depression, a model that emphasizes the multiple systems involved in the illness and the functional autonomy of the disease. Depression is, perhaps foremost among other things, a vicious circle that generates the conditions that sustain it, and the therapist and patient need to consider all the systems involved in this process if treatment is to be successful. Chapter 3 describes the "skills of depression"—the things we get good at that we should not be so good at, like stuffing feelings, depressed logic, victimizing, passive aggression, and recruiting accomplices. These are skills of depression in that we have learned them in a vain effort to save ourselves pain, by keeping us out of the feared situation—out of intimacy, or conflict, or the demand to perform. But they backfire on us and only reinforce the depressed state. Part of any therapy is to help the patient take these skills and reapply them in newer, more adaptive, ways.

The balance of the book is a review of principles of active treatment. Chapter 4, "A Biopsychosocial Assessment," presents a framework for conducting a systematic assessment of the individual patient who may be suffering from depression, an assessment that leads to a therapeutic focus. It also discusses issues involved in management of the suicidal patient. Chapter 5 focuses on the necessity of engaging the patient's emotions in the treatment process, a special problem with depressed patients, who are trying with all their might not to feel anything at all. Chapter 6, "Grief, Entitlement, Rage, and Hope," reviews psychodynamic thinking about depression, discusses the concept of "resistance" to treatment and what it means with this unique condition, and presents some of the reasons why depression manifests itself differently in men and women. Then, Chapter 7 reviews the appropriate use, limitations, and advantages of antidepressant medication.

Chapter 8, "Use Yourself Wisely," focuses on the role of the therapist's self in the treatment of depression. Treating patients with depression is hard work, and the therapist must make sure he is in good mental shape in order to bear the strain. At the same time, there are great rewards in our work, which if we appreciate them can contribute greatly toward keeping us fit. This chapter also talks about "the therapist's use of self" in the other sense of the phrase—use of the self as a therapeutic tool—specifically, playfulness and self-revelation. It concludes with a discussion of depression among therapists and what we can and should do about it.

The next chapter, "Maintain a Therapeutic Focus," presents some ideas about the concept of a central issue in depression—one that is manifested in the first episode, the immediate precipitant, and the transference. Chapter 10 discusses how the therapist understands and interacts with the patient's interpersonal world—too often a stable, dysfunctional world that reinforces the depressed state. It contains a review of interpersonal psychotherapy for depression, one of the newer widely accepted treatment methods. Chapter 11 focuses on the patient's cognitive processes, how they contribute to and in turn are affected by his emotional state. Principles of cognitive-behavioral therapy are reviewed, with a discussion of what it takes to be a good enough cognitive therapist.

Self-care is the topic of Chapter 12. Depression is an illness, and the patient has to learn to take adequate care of himself; not just physical and emotional care but also prevention of further damage to self and people he loves through impulsive or destructive activity. Chapter 13, "Practice, Practice, Practice," reviews a set of twelve "aphorisms of depression," which I suggest be introduced to the patient early in the treatment and reviewed frequently as treatment progresses. Some of these are rather bald confrontations of resistances ("There is a part of me that doesn't want to get well") that can disarm defenses when presented matter-of-factly as symptoms of the disease. Others are more simply reminders of the principles of recovery ("I need to practice detachment"). The final chapter discusses issues of termination with the depressed patient, including the likelihood of recurrence of the disease and the patient's need for continuing care. It ends with a model of a self-help group for depression which I have found popular with patients and personally rewarding.

This book does not address bipolar disorder, for two reasons. One is that I have not treated enough bipolar patients to talk intelligently about the subject; the other is that I tend to agree with the belief that bipolar disorder is a different species than simple depression. While major depression, dysthymia, and a depressed adjustment reaction may be points on a continuum, it seems most useful at present to view manic depression as inherently different. Much of what I have to say here may be useful for working with bipolar patients in a depressed state, but I make no claim to have any particular insight on this condition.

For reasons of space, I've also had to omit discussion of depression among the young and the old. This is a decision I've taken with regret, because if depression is an epidemic it seems to be most acutely so at the ends of the age spectrum. I am hopeful that better understanding of the genesis of depression among young people will result in changes in our social structure that can reduce the impact of the disease, but exploration of that subject will have to wait for another occasion. And it seems to me also that much of the rise in depression among the aging has to do with social change that has made it more difficult to find meaning and fulfillment in life, a process that begins far earlier and only becomes manifest as we age. But these topics will have to wait for another time.

The sensitive topics of gender and disability merit a few words. I have made a decision in this book to stick with the masculine pronoun rather than try to alternate he and she, him and her, or other strategies I've seen used to try to overcome a gender bias in language. I do this because all these other strategies, to my ear, end up sounding labored and distracting. I hope that the reader who is attuned to these issues will give me the benefit of the doubt and not assume I am unconsciously sexist.

I've used the word "patient" rather than "client" or "consumer" for much the same reason: just to be consistent and stick with generally accepted terminology. I certainly am aware that being considered a patient can convey all sorts of messages about one's competency, but I hope that the tone of the book conveys the great respect I feel for people who suffer with depression.

Even more of a problem is what to call someone who has depression. There is more than a suggestion of dismissal in some writing that uses the term "depressive" as a label, and I've tried to avoid that use. But sometimes it just gets too awkward to keep referring to "the depressed person," and I've used shorthand. Similarly with referring to the depressed person as a victim or sufferer; although the individual suffers, he's much more than those labels imply.

There is also the matter of my self-consciousness about my own depression. In some situations I'm afraid I will confuse the reader because I will use the word "we" to refer to the community of therapists, while at other times I use it to refer to people with depression. I hope it is clear from the context which usage is intended.

In Undoing Depression I wrote about my own experience with the disease in order to provide some guidelines for self-help and recovery to the millions of people who are unable to get adequate care. This is, on the surface, much less of a personal book; my story as someone with depression is not particularly interesting or relevant to the professional reader, except specifically in some areas where I have some experience about patients' reaction to the therapist's depression. Nevertheless, this book cannot not be personal, in that my opinions about what the depressed patient needs from the therapist are inevitably informed by my identification with the patient. I don't think I'm alone in this. I believe that most of the best theorists and therapists have a deeper understanding of the patient's needs because of their own experience with the same struggles. As I do workshops and consultations I am moved by the increasing number of professionals who are willing to acknowledge that they get depressed too. Unfortunately, these are still the minority. As professionals, we too often seem to be no more able than the general public to come to grips with the stigma of depression. I hope that this book will help change that.



Chapter 1. What is Depression?

Three months ago, 24-year-old Jessica was hospitalized after an abortive suicide attempt. Today, she sits in my office, the picture of despair. Tense and worried, she has intrusive thoughts of hurting herself or of other impulsive actions, which she tries desperately to control. She feels guilty and inadequate, hopeless and helpless. Despite medication, she wakes up every morning at 5 A.M. after a few hours of sleep. She's lost 20 pounds. She's had to reduce her responsibilities at work, where she cannot concentrate or make decisions. She constantly asks others for reassurance. Although she goes through the motions of living, she's unable to enjoy any activity. This all seemed to come out of the blue. Jessica had a fight with her mother and decided it was time to leave the nest. She confidently made plans to find her own place until early one morning the impulse to hurt herself—for no reason that she can understand—suddenly overcame her and she slashed her wrists.

Roger is a man in his fifties who works in an autobody shop. Roger joined AA and quit drinking about two years ago, and it's made his life smoother but not much happier. He works steadily and does everything he can to support his wife and children, but takes no pleasure in it. He never has any energy or shows any excitement. He's quiet and unassertive, and gets picked on at work. His rotten self-esteem is made worse by his virtual illiteracy, a result of undiagnosed dyslexia. This also makes him rely on his wife to make all the important decisions about the family. Roger has been unhappy and in the background almost all his life, since his mother died when he was nine. He started drinking and drugging in his early teens, but when he was a young man it was important to him to have a family and be a responsible adult; he's done the best he could, just never enjoyed it.

These are the two principal subtypes of depression. Jessica is diagnosed with major depression. The formal criteria as spelled out in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994) for her diagnosis include a depressed mood or a loss of interest or pleasure in ordinary activities most of the day and nearly every day for at least two weeks, accompanied by at least four of the following symptoms:

1. significant weight loss when not dieting, weight gain, or change in appetite
2. insomnia or hypersomnia nearly every day
3. psychomotor agitation or retardation (activity level slows down or increases)
4. fatigue or loss of energy
5. feelings of worthlessness or excessive guilt
6. diminished ability to think, concentrate, or make decisions
7. recurrent thoughts of death or suicide, suicidal ideation, or a suicidal plan or attempt.

Roger's diagnosis is dysthymia. In the DSM-IV, the essential criterion for this diagnosis is a depressed mood for most of the day, for more days than not, for a period of at least two years. In addition, there must be at least two of the following symptoms while feeling depressed:

1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness

Strictly speaking, almost all the new developments in psychopharmacology for depression apply to Jessica but not to Roger. Major depression has the advantage of being researchable. It is usually characterized by rapid onset, and most patients can be expected to get better within a reasonable amount of time. But we conveniently ignore the fact that most people like Jessica are permanently damaged by their experience with depression, and are likely to have more episodes as their life goes on. As far as Roger is concerned, no one wants to fund research lasting the amount of time to treat dysthymia adequately. But that doesn't stop Roger's doctor from prescribing the same type of antidepressants for him. In fact, they seem to be working better for Roger than for Jessica right now.

There is room for a great deal of discussion, some of which we will explore, about whether Roger and Jessica have two different but related diseases, or two manifestations of the same process. Whichever position we take, it's important to recognize that for both Roger and Jessica depression represents at least four things all at the same time: an adaptation, an illness, a communication, and a vicious circle. I make no apologies for this state of affairs; if light can be both a wave and a particle and an electron can be in two places at once, we can surely think of something as complex as depression as having several coexisting manifestations. In fact, we can avoid a lot of argument and misunderstanding about depression if we make it clear which aspect we are talking about. In order to treat depression successfully, we must keep all aspects in mind, but may want to emphasize one or another at any given time depending on the needs of the patient.

Depression as adaptation. When a hungry infant's cries elicit no response, eventually the child will retreat into a state that looks like depression: withdrawn, self-absorbed, and self-soothing. This state serves several purposes: The infant is saving his resources for another occasion when the environment may be more responsive, putting a limit on his own distress, and reducing the risk of alienating his environment.

Likewise, depression in an adult is an adaptation to a nonresponsive environment. When we lose someone who loves us, grief is the natural result. When we don't believe we can replace that love, we become depressed. We stop trying to achieve what we think is impossible. If we become severely depressed, we are likely to suffer further rejection and outright discrimination, to which ironically our only response seems to be adoption of a depressed identity. Depression becomes a solution to a problem for us. Instead of continuing to seek love, justice, or whatever we feel deprived of, we lower our expectations and focus on trying to prevent further disappointment and hurt.

Depression as illness. Depression is highly analogous to a systemic disease like a fever or an endocrine malfunction. It affects our entire being and experience. We don't merely have trouble sleeping or guilty thoughts or lack of energy or a feeling of pessimism and hopelessness, we have all at the same time; it's a predictable syndrome in which the symptoms accompany each other. We function at a less effective rate physically, intellectually, emotionally, socially. There is good reason to believe that something is going haywire in our brains that mediates all these effects, something that can often be helped by medication.
Recognizing that one is ill is the first step in recovery. When we know that we are sick, we start listening to professional advice, we take better care of ourselves, we give ourselves a moratorium from striving. Much of the difficulty with depression is that it is often very difficult for the patient to recognize his illness. Much of the hope for prevention and improved treatment comes from improved general awareness of the disease aspects of depression.

Depression as communication. Psychiatric symptoms can be understood as a disguised attempt at expressing feelings, a communication from the sufferer to others in his life. The disguise can be necessary for a variety of reasons—the nature of the relationship may make open expression of needs undesirable, or we may not want to consciously acknowledge our feelings. Our defense mechanisms work to keep the feeling out of conscious awareness, but the other person usually responds to the feeling. When someone close to us "forgets" our birthday, we feel justified in being angry because we assume that the forgetting is a communication.

Depression, at one time or another, can express all these messages and many more: Take care of me. Give me a little slack. You can't help me. Don't leave me. Give me some extra attention. No one understands me. I can't take it anymore. I hate myself. You don't really love me. Therapy can be directed toward twin goals: helping the patient become more aware of needs and feelings that he keeps out of awareness but nevertheless communicates to others, and helping him get those needs met in ways that are less likely to backfire and do not continue to reinforce the illness aspect of depression.

Depression as vicious circle. An acute illness will remit when the disease has run its course. We can leave behind a particular adaptation when the external stress is removed. But depression is a self-reinforcing cycle, a functional autonomy that does not end because the conditions that brought it about are removed. The neurochemistry in the brain doesn't reliably repair itself when good things happen to us. A continually depressed mood means that we only see things that confirm our depression. We think depressed thoughts and we act in self-destructive ways, and we do real damage to ourselves and those we love. All our experience confirms that we are right to be depressed. We cannot lift ourselves up by our bootstraps or snap out of it, because depression feeds itself.

The result is that depression is at the same time a disease and a social problem, an understandable reaction to stress and a self-destructive state. In this initial chapter I am going to focus on depression as a social problem: how our society conceives of it now, how we respond to it, how we try to treat it. As we then move on to discuss direct treatment, the rest of the book will speak to the other aspects of depression.

THE CRISIS IN CARE FOR DEPRESSION

Depression is second only to heart disease in its health impact worldwide. This surprising news comes not from any mental health advocacy group, but from the World Bank and World Health Organization (Murray & Lopez, 1996), which measured the lost years of healthy life due to disease. In the United States in 1990, the cost of treatment of depression, increased mortality, and loss of productivity was estimated at $44 billion a year, higher than any disease but heart disease, greater than the effect of cancer, of AIDS, of lung disease, MS, or any other single disease entity (Greenberg, Stiglin, Finkelstein, & Berndt, 1993). Nationally, there are approximately 30,000 suicides annually, as compared to 20,000 homicides (American Association of Suicidology, 1997). One person in five will suffer an episode of major depression during his or her lifetime, and one person in five is suffering from some form of depression at any given moment (Agency for Health Care Policy and Research [AHCPR], 1993). Health economists equate the disability caused by major depression with that of blindness or paraplegia (Murray & Lopez, 1996). And the impact will only get worse: For each group born since 1900, the age of onset of depression has gotten younger, and the lifetime risk has increased. If current trends continue, the average age of onset for children born in the year 2000 will be 20 years old (Thase, 1999).

If all this is true, if depression is indeed our second biggest public health problem, if it affects 20 percent of the population, costs us so much, and is only getting worse, you may be asking yourself, Where's the big national foundation leading the battle against depression? Where's Jerry Lewis and Ronald McDonald? But if you understand depression, these questions answer themselves. People with depression are ashamed of their disease. This is partly a reflection of public attitude, but also partly a manifestation of the disease itself; we blame ourselves for being weak or lacking character instead of accepting that we have an illness, instead of realizing that our self-blame is a symptom of the disease. And feeling that way, we don't step forward and challenge unthinking people who reinforce those negative stereotypes. So we stay hidden away, feeling miserable and blaming ourselves for our own misery.

This is a dirty little secret of mental health economics: If you're depressed, you don't think you're worth the cost of treatment. You feel guilty enough about being unproductive and unreliable; most likely your family members have been telling you to snap out of it and you believe you should. You're not likely to shell out a hundred dollars an hour to see a therapist, and if your insurance won't pay you're not likely to put up a fight. Yet your therapist wants to get paid, hospitals will bill you whether you get better or not, and HMOs require you to be very determined before they will pay their share. They will play on your own guilt about your condition to make it difficult for you to get anything more than the absolute minimum treatment. They count on discouraging you from pursuing your claims in order to save themselves money; and, in doing so, they reinforce your depression. Meanwhile, publicly funded mental health services dismiss the depressed as the "worried well," focusing their resources on patients with schizophrenia. And though there's a lot of talk about "parity" for mental health services, it's just talk. Most managed care plans find ways of drastically restricting coverage for outpatient care. The myth is that depression can be treated successfully by medication alone; but, as we shall see, that is only a myth, and a cruel one that reinforces patients' ideas that there is something wrong with them if they do not recover in the prescribed manner.

Suppose you had cancer and required regular chemotherapy, or kidney disease and required dialysis, or pulmonary disease and required oxygen and physical therapy; or that your child had an accident and required surgery—what would happen if there were an annual cap on benefits for these conditions? What would happen if there were a copay of 50 percent on these benefits? You know what would happen—we'd have a revolution. But we seem to take it for granted that there should be caps and copays on mental health services—which is our way of reinforcing the message that the victim is to blame for his own disease. We're begging for "parity" when we should be demanding equality.

While there seems to be greater recognition of depression as a public health problem, there is also more of an emphasis on treating it medically, and psychotherapy seems in danger of becoming obsolete. U.S. News recently ran a cover story on the continued increase and greater recognition of depression (Schrof & Schultz, 1999). The banner on the magazine cover reads "Depression is on the Rise, Despite Prozac and Other Drugs. But New Treatments Could Help Millions." When you look inside, you see that the new treatments are additional medications and magnetic stimulation of the brain. Psychotherapy isn't mentioned. Managed care has made adequate psychotherapy very difficult for most Americans to get, but no one seems to mind too much because the answer to our problems is expected to come from a pill, from lights, from magnets. If in the fifties America had a love affair with Freud, in the nineties we tossed him aside. Yet, though we keep pinning our hopes on medications, very few people who are actually taking the pills feel they're a panacea. "Prozac poop-out" (Slater, 1998) is in the news. The National Depressive and Manic-Depressive Association, surveying visitors to its Web site, found that a majority reported troublesome medication side effects and only modest improvement in their condition; more than two-thirds were not satisfied with their relationship with their provider (National Depressive and Manic-Depressive Association, 1999). The popular press (Fox, 1998) and serious research (e.g., Judd et al., 1998a; Keller & Hanks, 1994; Solomon et al., 2000; Thase, 1999) are increasingly recognizing that depression is a very debilitating, long-term illness that can't be treated successfully by a prescription or by a twelve-week psychotherapy trial, but serious discussion of alternatives is almost nonexistent.

In 1998, more than 130 million prescriptions for antidepressants were written in the United States, and Prozac, Paxil, and Zoloft were among the six best-selling drugs of any kind (Moore, 1999). By some estimates one out of ten Americans has tried one of the new antidepressants (Glenmullen, 2000). Seventy percent of antidepressant prescriptions are written by general practice MDs (Yapko, 1997a). This extraordinary popularity comes about chiefly because of marketing of the newer medications by the pharmaceutical industry, the economics of health care, and the stigma of depression (Kirkpatrick, 2000). Research shows that selective serotonin reuptake inhibitors (SSRIs) and other new medications are in fact no more effective than the older antidepressants, and despite their reputed lower side effect profile, the dropout rates are similar for both treatments (AHCPR, 1999a). MDs in general practice have been encouraged to believe that it's more acceptable to patients who present with depression to give them a pill rather than refer them to a specialist. Meanwhile, studies comparing the effectiveness of newer antidepressants with psychotherapy, or researching the effects of the two combined are few and far between (Keller et al., 2000). Only a few projects have studied the effects of combined psychotherapy and pharmacotherapy (see Thase et al., 1997, for a review). The Surgeon General's Report to the Nation on Mental Health apologizes for the brevity of its review of psychotherapy for mood disorders, noting that psychosocial interventions "are much less studied than the pharmacotherapies" (U.S. Department of Health and Human Services, 1999, p. 265). It's as if psychotherapy has become irrelevant. This is despite the fact that we have known for a long time that psychotherapy is more effective than medication alone at preventing relapse (Blackburn, Eunson, & Bishop, 1986; Evans et al., 1992; Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998).

It seems reasonable to ask, if the new antidepressants really are effective, shouldn't we see some decline in the suicide rate by now? Perhaps we are not because the actual effects of the drugs have been magnified by the way we conduct research. There are some serious problems with the generally accepted research that documents the efficacy of antidepressant medications, both the newer SSRIs and the older tricyclics (Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999; Moore, 1999). Pharmaceutical manufacturers support, authors submit, and journals publish articles that demonstrate a positive effect of treatment more readily than those that do not disprove the null hypothesis. Thus meta-analyses that report 19 of 21 studies show that medication X is more effective than a placebo may present a distorted picture; there may have been 15 studies which failed to show the effect of treatment but didn't get published. Further, placebo responses to depression are generally high; up to 60 percent of patients improve on placebo alone. Efforts to control for these effects bias the investigation in favor of the active agent, by including a pretreatment "washout" phase in which all patients are taken off their active medication and given a placebo; those who have a positive placebo response during this phase are then eliminated from the study (Brown, 1994). The sample is thus skewed from the outset by excluding those who are the most active placebo responders, but even so almost as many people in antidepressant trials respond to placebo as to the active agent (Talbot, 2000: Thase & Howland, 1995). Most studies also exclude from the data all subjects who drop out before the conclusion of treatment, skewing the sample further by eliminating many who may be dissatisfied or experiencing negative side effects. Finally, the double-blind procedure itself is open to question when patients and clinicians can generally determine whether the subject is receiving active treatment or a placebo on the basis of the side effects. There are relatively few studies that use an active placebo mimicking the side effects of medication.

Most troubling of all, perhaps, is the appearance of conflict of interest among researchers who receive financial support from pharmaceutical companies. For instance, it was recently disclosed that Dr. Martin Keller of Brown University, whose studies are cited several times in this book, received over $550,000 in consulting fees—not research support, but personal income—from drug companies in 1998 (Bass, 1999). Despite professional journals' expectation that authors disclose conflicts of interest, Dr. Keller did not disclose the extent of his financial ties to drug companies. Payments on that scale inevitably raise the suspicion of bias, and we can only regret that a respected researcher has put himself in a position where his results can be questioned. Dr. Keller is the principal author of a major new study (Keller, et al., 2000) demonstrating that combined treatment with Serzone and cognitive-behavioral analysis psychotherapy (McCullough, 2000) is markedly more effective than either alone, a result which supports a principle thesis of this book; unfortunately, as a result of drug industry influence, that support feels suspect to me.

Although for the purposes of conducting treatment with patients in the real world of today we need to assume that antidepressant medications can often be effective, these issues seem to me to introduce enough doubt to question whether the difference between the typical 40 percent improvement rate with placebo and 60 percent with the active agent is really meaningful. In any case it seems remarkable how easily and wholeheartedly our society has swallowed the idea of antidepressant efficacy. I think the only reason for this is that there is indeed an epidemic of depression, and the pills have come along at the right time to help reassure us all.

Misdirected Science

Market research suggests that most Americans, after decades of tobacco wars, marijuana scares, and debate about global warming, believe science is bought and paid for, so subject to the influence of the sponsors of the research that it has lost its objectivity (Lake Snell Perry & Assoc., 1999). If the public understood depression research, that same skepticism would only be reinforced. Politics, economics, turf, and the absence of independent thinking combine to prevent us from creative, meaningful work.

At the White House Conference on Mental Health in June 1999, Steven Hyman, the director of the National Institute of Mental Health, was interrupted twice with applause during his brief presentation. On both occasions he had alluded to the value of psychotherapy for the treatment of mental illness. The audience was moved to applause by surprise and relief. For far too long, NIMH has focused almost exclusively on research into the biochemical aspects of mental illness, ignoring other influences such as the well-known fact that the best single predictor of mental illness is poverty (Shore, 1994). This position has been politically popular: It supports the pharmaceutical industry, which has had a very close relationship with NIMH, and it is supported by the most vocal advocates for the mentally ill, who insist that these conditions are "no-fault brain diseases." But it has come at the cost of trivializing research, inhibiting research into effective psychotherapy, and making the idea of prevention a taboo subject.

NIMH, of course, is only a reflection of our society. There is a gee-whiz mentality about American culture that seems to favor technology over people. A recent lead editorial in Archives of General Psychiatry—an AMA publication—proudly trumpets that we are "beginning to see the light" in light therapy for seasonal affective disorder (Wirz-Justice, 1998). In other words, some researchers have finally published articles that seem to establish that light therapy is more effective than a placebo. From reading the popular press, you would never have suspected that there was any question about the effectiveness of light therapy, but apparently researchers have never been able to demonstrate its efficacy. When you read the first article (Eastman, Young, Fogg, Liu, & Meaden, 1998), on first blush it's hard to see the heralded effects. Members of both treated and placebo groups report less depression as time goes on; the mean scores on a depression rating scale for both groups over time (only four weeks in this study) are substantially the same. But the eager researchers do some number crunching and discover that of those who had the greatest improvement, substantially more were in the treated group. Of course if the mean scores were the same this implies that the treated group also had substantially more who had little or no improvement, as is indeed the case, though the authors gloss over that fact. In the second study, there are two placebo conditions, and light therapy proves to be better than one of them (Terman, Terman, & Ross, 1998). I leave it up to the reader and to further research to determine if these studies will ever have an impact on actually helping patients, but I do note that this seems to be the best technology can do, after at least fifteen years and millions of American research dollars, trying to show that light therapy does something for depression.

Meanwhile, in almost the same month, the British Journal of Psychiatry published studies demonstrating that sending an interested and well-meaning volunteer out to visit the depressed in their homes once a week for an hour helps them feel significantly less depressed (Harris, Brown, & Robinson, 1999a, 1999b). No fancy statistical analysis—the results are obvious. In the treated group, 65 percent attained remission of symptoms, as opposed to 39 percent of the control group. But no one is investigating such ideas in the United States You couldn't get that paper published here. Maybe it's because no one can make a buck off volunteers.

At the same time, there is growing evidence that the distinctions drawn in the DSM-IV between major depression, dysthymia, and "depressive disorder not otherwise specified" (a wastebasket diagnosis with an estimated prevalence of 14 percent of the population at any given time) distort our understanding of what is in reality a single disease that has different manifestations at different points in our lives. A twelve-year follow-up of 431 patients who had sought treatment for a major depressive episode found that although subsequent episodes occupied only about 15 percent of the patients' lives, still only 41 percent of their time was spent symptom-free (Judd et al., 1998a). The rest of the time was spent in states comparable to dysthymia (27 percent) and in subthreshold depression (17 percent). This is despite the fact that patients were being treated with medication or psychotherapy in 62 percent of the weeks. Remaining in subthreshold depression was a powerful predictor of relapse into major depression (Judd et al., 1998b), suggesting that simply no longer meeting all the criteria for major depression is a very poor definition of recovery. Patients who had presented with their first lifetime episode of major depression had a higher proportion of time (54 percent) symptom-free, suggesting that adequate treatment early in the illness can prevent some suffering. We need to be preparing the public and the health insurance industry for the idea that depression is a chronic disease that waxes and wanes over a lifetime, especially if inadequately treated.

Assuming that dysthymia and major depression are distinct diseases leads to some strange conclusions. In an outstanding application of circular reasoning, some researchers argue with a straight face that the fact that dysthymia in children has an earlier onset than major depression means it is a distinct entity (Kovacs, Akiskal, Gatsonis, & Parrone, 1994) apparently without considering that it's simply easier to meet the criteria for dysthymia; the diagnosis is less restrictive. Symptoms develop gradually, and a child is more likely to "qualify" for dysthymia earlier in development than for major depression, just as some children's bronchial infections develop into pneumonia while others do not. Still other researchers advocate for the concept of "double" depression (Keller, Hirschfeld, & Hanks, 1997)—dysthymia and major depression—giving the idea that there are separate disease processes at work and an individual has been unlucky enough to catch both, rather than simply stating that a person who has been depressed for some time has recently gotten worse.

In all this flurry of research, we rarely mention that most patients who suffer from depression have poor outcomes in the long run. Clinical trials generally run for two to three months, with "recovery" measured at the end of treatment and little if any follow-up conducted; but this is like arguing that ice is a cure for fever. Adequate treatment for depression increases the likelihood of complete recovery, but most patients still remain vulnerable. The best predictor of chronic outcome is the duration of the initial episode, from before treatment begins until the patient recovers; thus early detection and effective treatment should be a priority (Angst, 1999). Recurrence becomes more likely over time; three-quarters of patients can expect to have another episode within five years (Lavori, Keller, Mueller, & Scheftner, 1994). The major risk factors for recurrence are psychosocial: the patient's level of neuroticism and lack of self-confidence, areas that are much more likely to be improved by psychotherapy than by medication (Angst, 1999).

The very limited amount of research on psychotherapy still being conducted largely focuses on applications of interpersonal psychotherapy or cognitive-behavioral therapy (see chapters 10 and 11), which have the reputation of having been demonstrated to be effective treatments for depression. Little research is going into investigating the question of what makes these approaches effective, although their theoretical base is limited and certainly needs greater elucidation (cf. Jacobson & Gortner, 2000). Generally what research there is shows that psychotherapy and medication have different effects on the course of treatment of depression (Klerman, 1993; Klerman, Weissman, & Markowitz, 1994). Medication reduces symptoms, and therapy helps improve social functioning and interpersonal relations. Medication has its effect within a few weeks, while psychotherapy usually takes months. There has been virtually no evidence that psychotherapy and medication have any negative effect on each other, despite the fears of many practitioners on both sides; but partly because of the polarity in the field, there has been little systematic attempt to understand how they complement each other.

No one seems to be working on an integrative model that would attempt to describe how to use pharmacology and psychotherapy most effectively together, despite some promising clinical applications (e.g., Schuchter, Downs, & Zisook, 1996). "Separatist tendencies and fragmentation of the field have occurred throughout the history of psychiatry and are largely reflective of a complex evolution of disparate belief systems, social trends, and hidden biases about the nature of man, the origin of his psychopathology, and how he can be healed" (Karasu, 1993, p. 11). The separatist tendencies continue, driven by prestige, turf, money, and closed-system thinking; practitioners who seek a holistic model to help their depressed patients are left to their own devices. Luhrmann (2000), after a thoughtful, observant analysis of the development of the split between the biomedical and psychodynamic camps in psychiatry, presents a devastating vision of the future in which patients are reduced to chemistry and knowledge about such things as personality, stress, or how to get the patient to take the pill, will be lost to psychiatry forever.

Likewise, there is precious little research going on about how we can prevent depression or other serious mental illnesses. British research shows the effects of childhood experience on development of adult depression. In a study of 1142 children who were followed from birth to age 33, it was found that factors like poor mothering, poor physical care, parental conflict, overcrowding, and social dependence were all highly linked with development of adult depression (Sadowski, Ugarte, Kolvin, Kaplan, & Barnes, 1999). Findings like these are unpopular in the United States; the emphasis on mental illness as "brain disease" suggests that developmental factors and the social environment are not to be looked into. At a recent conference, the director of a major national mental health foundation told me she does not believe mental illness can be prevented. Yet adult patients keep coming into our offices, telling us that their depression feels as if it's related to past experiences of trauma and deprivation. Are we not to believe them? Are there not ways to help people improve their parenting so that their children will be less vulnerable to depression? Or ways to structure our society so that we all have less chance of becoming depressed?

Meaningless Research = Bad Policy

From the "Medicare Provider News":

Patients with Major depressive disorders . . . require treatment with medications with or without psychotherapy. . . . Providers who's [sic] license does not allow them to prescribe medications . . . must refer the patient to a psychiatrist for evaluation and treatment with medication before continuing any further psychotherapy. . . . Psychotherapy is not a treatment that is required or rendered on an ongoing basis or indefinitely in every patient. . . . severe depression or schizophrenic conditions (while being treated with medications) may require 15 to 20 sessions (Health Care Financing Administration, 1999).

The implications of this sort of policy being applied to all Medicare patients boggle the mind. What if the patient doesn't want medication? What if medications have had significant side effects with this patient? What if this patient is among those who do not respond to medication? What if the patient is anxious or suspicious and referring him to a psychiatrist means he will drop out of treatment? What if severe depression does not remit after 15 to 20 sessions? And what does it mean to put severe depression and schizophrenic conditions on the same footing?

A policy like this sends a clear message to patients that there is something wrong with them if they don't want to take medication, or if they do not respond. It reinforces the guilt and self-blame that people with depression suffer from already. It is clearly discriminatory and should be illegal.

Depression rarely occurs alone. There is enormous overlap with other emotional problems, but this ugly fact gets in the way of "clean" research. The NIMH Epidemiologic Catchment Area study found that 75 percent of people who have had a major depressive episode also had a history of some other psychiatric disorder (Robins & Regier, 1991). Analysis of data from the National Comorbidity Study (Kessler et al., 1994; Kessler, et al. 1996) revealed that major depression developed secondarily to other psychiatric disorders in 62 percent of all cases. Among those who had suffered a major depressive episode within the past year, 51 percent had also suffered an anxiety disorder during the same time, 4 percent had experienced dysthymia, and 18.5 percent had also suffered a substance abuse disorder. Co-occurring anxiety disorder and dysthymia were both predictive of poor outcome for major depressive disorder. The WHO study (Goldberg, 1996) found a remarkably similar comorbidity between depression and anxiety: 68 percent.

Yet FDA trials require pharmaceutical manufacturers to focus on the effects on a single "disease" at a time. Researchers know, but clinicians, insurers, and legislators forget, that there are several equally respectable explanations for the co-occurrence of depression and other mental illnesses. It could be that when a person has been excessively anxious for some time, feeling unable to cope with life, depression is a natural result. It could also be that vulnerable people react to stress differently, and that what our diagnostic systems classify as anxiety and depression are manifestations of the same process. It could be that alcoholism leads to depression, or that depression leads to alcoholism, or that both drinking excessively and depression are the same person's unsuccessful attempts to cope with life. If we have a diagnostic system that allows 26 different kinds of depression, as the ICD-9 does, we will observe 26 different kinds of depression, and we may think they are all different animals, but we would be foolish to do so. If we want to study "pure" depression and not measure the impact of our treatment on the patient's anxiety, substance abuse, or problems in living, we may be tempted to do so because it's easier to draw statistical conclusions, but we won't be helping patients much.

In the end, we must keep in mind some simple facts. People often want psychotherapy. Life is hard and we need all the help we can get. But training in psychotherapy rarely benefits from the results of empirical research, because the research isn't being focused on real-world issues. Turf, money, and politics have driven American science away from a meaningful investigation of how best to help our patients cope with real problems. People with depression can't overcome their symptoms without solving their problems; in my experience, most of them don't even want to. Let's try to help them.

LIVING WITH DEPRESSION IN THE REAL WORLD

Stigma

Look for a minute at how we think about chronic fatigue syndrome, a complex illness for which no physiological basis has yet been found, but which seems to be on the increase and certainly captures much media attention (see chapter 12 for a more thorough discussion of this condition). Though most scientific studies of chronic fatigue syndrome refer to psychological causes, most news accounts refer to physiological causes. Many news stories are slanted in such a way that the scientist who talks about psychology is painted as dismissive, patronizing, or protecting his turf, wasting time and research funds while the magic bullet for chronic fatigue syndrome is out there somewhere waiting to be found. Patients feel like an oppressed minority. And too many physicians reinforce the idea that it insults the patient to suggest that his problems are in his head. "Professor Arthur Kleinman, from the departments of anthropology and social medicine at Harvard . . . believes that chronic fatigue syndrome should be treated by a physician, not a psychiatrist, to maintain the patient's self-respect" (Showalter, 1997). These reactions and attitudes reflect the values of our culture, that psychological distress is less real than physical distress, that to be told your symptoms are due to stress is to be told you're weak or malingering. The implication at the bottom, which many of us still believe, is that you should be able to pull yourself out of mental illness if you really want to. The patient with chronic fatigue syndrome believes he's being insulted when perhaps his doctors are really trying to help him.

We can see the effects of stigma operating in managed care. Expecting patients to get a referral for mental health services from a "gatekeeper"—a primary care physician—is an effective way of limiting access. When patients are switched from a gatekeeper plan to a "carve-out" plan, wherein they call a special telephone number to get a referral, the change has the effect of doubling utilization of mental health and substance abuse services (Sturm, 1997). In other words, people find it much easier to ask for help when they don't have to go through their family doctor. Most people know that what they are feeling—depression, anxiety, confusion, conflict—is about what is happening in their lives, not about their biochemistry, and they do not particularly wish to confide in their physician in order to get the help they need.

Another subtle manifestation of stigma is the continuing enthusiasm among personality researchers for the diagnosis of "depressive personality disorder," or DPD (Millon & Kotik-Harper, 1995), which is in the DSM-IV as a classification requiring further study. This diagnosis refers to people who suffer from a chronic low-grade depression that is difficult to treat, with the implication that something in their personality causes them to get into situations of rejection or punishment. A careful study (Klein & Shih, 1998) of DPD among 400 patients with mood disorders and their first-degree relatives found a high degree of overlap with dysthymia (80 percent of participants with DPD had dysthymia, and 73 percent of those with dysthymia had DPD). Further, only 49 percent of participants initially diagnosed with DPD retained it at a 31-month follow-up. Of course, in order to have real meaning, a construct such as DPD should be independent of diagnoses like dysthymia, and should be stable over time. Another recent study—which most clearly succeeds in demonstrating the ability of researchers to apply muddy reasoning under the pressure to publish or perish—compared a small group of patients who tested positive for this supposed disorder to others who had similar histories of longstanding depression without the hypothesized personality traits (Lyoo, Gunderson, & Phillips, 1998). It was found, not surprisingly, that those who fit the profile for DPD scored higher on measures for harm avoidance and neuroticism, and lower on scales of novelty seeking and extraversion, than the other depressed patients. That this is not surprising is because those with DPD are by definition expected to be inhibited and constricted. This kind of finding could be dismissed as an irrelevant academic exercise except for the familiar reification process in science. If depressive personality disorder does become an accepted diagnosis, health insurance won't pay for treating it, and thousands of depressed individuals will be unable to get help.

Here's why: The rigorous and respected experts who organized the DSM-III and DSM-IV took a strictly phenomenological approach to classification; while they hoped that use of their very objective definitions for different syndromes would lead eventually to identification of underlying mechanisms, they never intended that the manual would be interpreted to suggest that one disorder is more treatable, or is due to different causes, than another. Imagine their surprise to find that Congress has legislated that major depressive disorder is a biologically based mental illness and dysthymia is not. Thus major depression is covered by our existing "parity" law, while insurance companies remain free to restrict coverage to patients suffering from dysthymia, as if the two entities are as distinct as reconstruction of a cleft palate or a nose job. And if dysthymia is discriminated against, what will happen to depressive personality disorder? As it is now, no insurance company will pay for treatment of any personality disorder. Many patients with depression who do not respond quickly to standard treatment are likely to get dismissed as having a personality disorder—in other words, told they're both beyond help and that it's their own character that's to blame.

Health Insurance Reimbursement

Many years ago psychotherapists made a devil's bargain with the health insurance industry, and today the chickens have come home to roost. In an effort to get health insurance reimbursement for our patients, we agreed that they had to have a specific disease, like major depression or anxiety disorder. But our treatment was generally not addressed at the disease, it was directed at the whole person; that's how psychotherapy works. And we swept under the carpet the difficult issues of just how much care is legitimate to expect a third party to pay for, just how much of our work with a particular patient is directed at self-improvement rather than fixing a specific problem, and at what point self-improvement becomes elective. We all could afford to ignore these issues until the health care system started to go bankrupt. Then, the insurance industry stepped in to control costs through various means we refer to collectively as managed care, and psychotherapists have been on the defensive ever since, as if we got caught with our hands in the cookie jar.

After all, the purpose of health insurance is to pay the cost of treatment if you get sick. In most cases, sickness can be objectively determined through blood tests, X rays, MRIs, and the like. If you have an infection, there are germs; if you have cancer, there are mutated cells; if you have heart disease, your blood pressure and cholesterol change. There is usually an empirically validated or at least consensus-based treatment for such sicknesses. And—most important from the insurer's point of view—there is a predictable course to the sickness, with proof that treatment alters the course. If it couldn't be shown that treatment alters the course of the illness or at least diminishes the symptoms, no one would expect insurance to pay for treatment. This is the doctrine of medical necessity (Bennett, 1996).

But these elements—an objectively verifiable disease, with a predictable course and an empirically validated treatment—are hard to establish when it comes to mental illness. Even schizophrenia and manic depression, widely accepted as having a "biological" basis, still can't be verified by any objective test, although there is a course and a treatment. With depression and anxiety disorders, when so much of the diagnosis is based on the patient's own subjective experience, the diagnostic picture is less clear still, the course is unpredictable, and we are just beginning to have empirically validated treatments.

So why should I expect my insurance company to pay for my therapy? I've been seeing my present therapist for four years, usually every other week. What proof do I have that it's helping my depression? Indeed, could I even prove to my insurance company that I have depression? I go to work every day, I'm not suicidal, I'm productive, I vote, I even have fun sometimes. In fact, sometimes I even have fun in my psychotherapy. Should Blue Cross pay for me to have fun?

The image of Woody Allen whining on the couch, narcissistic and self-righteous, comes to mind. Did health insurance really pay for everyone to have analysis four or five times a week for years? No wonder there's a backlash. We can't have that.

Actually, we never did have that. Insurance paid for very few analyses. Where health insurance was abused was in inpatient treatment, which until 1989 accounted for more than 80 percent of all mental health care expense (Borenstein, 1996). When insurance paid for 28 days of hospital stay per year, hospitals planned their programs around a 28-day stay, regardless of whether it was in the patient's best interests or not. For example, in 1981 all employees covered by the Blue Cross federal employee plan who were treated as inpatients stayed an average of 27.5 days; an amazing coincidence, or an example of "fiscogenic" treatment (Fiedler & Wight, 1989).

My answer to Blue Cross is that it should pay for my outpatient mental health care, within limits that we should be able to negotiate like rational people. To destigmatize mental illness and encourage people to get help before problems become unmanageable, some level of outpatient care should be available to everyone without oversight of any sort. We can negotiate around copayments, caps, frequency of treatment, etc. if treatment lasts longer than the eight sessions that most people find sufficient. We need much greater awareness that mental disorders are real. The doctrine of medical necessity is misapplied; treatment may not be necessary but advisable, both for the individual patient and for society as a whole.

At the same time, I think any honest psychotherapist will admit that many of his patients are in the position where treatment is optional. Yes, they would probably be worse off without it, but could we prove that to the insurance company? We need to get off the defensive. It doesn't help matters much to have serious researchers demonstrate that both medication and psychotherapy are more effective in treating depression than standard medical practice, yet apologize that they cost more (Lave, Frank, Shulberg, & Kamlet, 1998; Von Korff et al., 1998). Of course they cost more! Treating anything costs more than not treating it. That's why we have health insurance.

The now-famous Consumer Reports survey (1995) of readers' experience with psychotherapy and the mental health system, while it has its methodological drawbacks (Seligman, 1995), demonstrated several important points:

* Most patients who saw a mental health professional reported significant improvement and a high degree of satisfaction.
* Patients who were seen by psychiatrists, social workers, and psychologists all improved equally.
* There were no differences between specific modalities of therapy.
* Long-term therapy was more effective than short-term therapy.
* People whose choice of therapists or length of treatment was limited by managed care did worse.
* People who went to AA improved even more than the patients in psychotherapy.

While this is strong evidence for the value and utility of psychotherapy and self-help, unfortunately it has little to say about the impact of treatment on specific diseases, the issue we are forced to address by the medical model. It's very difficult to prove the efficacy of psychotherapy with a specific disease to the degree of precision and control that the FDA, the medical profession, and the general public expects. The reason is that what I do with patient A is going to be very different from what I do with patient B, even though they have the same diagnoses—and what therapist X does with these two patients is going to be different from what I do. So if we want to study the effects of psychotherapy on a group of 200 patients with depression (and the more patients the better so that our results can achieve statistical significance), we quickly find that we're comparing apples to oranges to bananas, because the course of therapy of each of these 200 patients is unique. And in fact, over all 200, maybe no more get better than if they were not treated at all; but the effect of therapy may be that some of them get a lot better. The near-impossibility of conducting studies assessing the effectiveness of long-term treatment gets twisted and used by the managed care industry to conclude that long-term therapy is not effective or necessary.

That is precisely why cognitive-behavioral therapy and interpersonal psychotherapy are usually touted as the treatments of choice for depression. The approaches are so specific that they give the practitioner a guidebook for what to do, so that they are researchable, and have been demonstrated to have some impact. As I hope to make clear, though any good practitioner should be familiar with both of these approaches and prepared to use their methods when appropriate, in my belief they don't go far enough to be of lasting benefit to most patients. Their research base, though deep, is narrow, because they are generally unwilling to examine aspects of successful treatment that don't fit their theoretical model.

Let's look more closely at how the present system reinforces the patient's tendency to blame himself. Managed care is touted as a "free-market" institution. If a plan does not provide quality care, so the argument goes, it will lose customers and eventually either have to improve its services or go under. The competitive forces of the marketplace, in other words, are thought to ensure continual improvement in quality. But people with depression may lack the energy and assertive skills needed to advocate for themselves, to go to the time and trouble of complaining or switching plans; they may just assume that there is nothing they can do about their dissatisfaction. A study by Druss, Schlesinger, Thomas, and Allen (1999) seems to support this. Analysis of data from a survey of 20,000 employees at major corporations, who did have the capability of switching plans without penalty, found that enrollees who had a high level of depressive symptoms were significantly less likely to switch plans. A high level of symptoms of any kind—physical or psychological—was associated with greater dissatisfaction; but the enrollees whose complaints were primarily physical were much more likely to actually make the change to a different plan.

Another study, by Druss and Rosenheck (1998), suggests that people with mental disorders may actually be correct in assuming that they are powerless to change their situation vis-ý-vis managed care. A survey of over 75,000 individuals found that, while people with mental disorders were no more likely to be uninsured or to go without a primary provider than those without mental disorders, those with mental disorders were twice as likely to report having been denied coverage because of a preexisting condition, or to report staying in a job because of fear of losing benefits.

Is it going too far to argue that, if the industry counts on factors like stigma, ignorance, and poverty to prevent people from getting their needs met, that is discrimination? We've all known for years that mental health consumers are poor advocates for themselves. In the National Comorbidity Study, only one in five respondents who had had a mental health need in the past year had gotten any help at all, and only one in nine had gained access to mental health services (Kessler et al., 1994). The managed care industry uses low utilization and the low rate of complaints about mental health care to rationalize cuts in services and to suggest that professionals who advocate for their clients are only motivated by self-interest (Goleman, 1996). It's rather like the schoolyard bully who can count on his victims not to defend themselves.

A popular response to the difficulty of funding treatment for depression by specialists has been to attempt to treat it in primary care. The NIMH Depression Awareness, Recognition, and Treatment (D/ART) campaign, begun in 1988, was a highly visible effort to educate the public and health care providers about the incidence and treatability of depression. Incredibly enough, no study of the campaign's effectiveness was ever completed (Magruder & Norquist, 1999). NIMH has also sponsored extensive research to investigate how depression can be treated more effectively by the primary care physician. "Enhanced acute-phase treatment," consisting of physician training, patient education, and consultation between physicians and mental health specialists, has been shown to improve compliance with medication regimes and better outcomes shortly after treatment (Katon et al., 1995; Katon et al., 1996). However, at 19 months the effects disappeared; both the treated and untreated groups scored the same on several measures of depression, and were likewise indistinguishable on continuation of medication (Lin et al., 1999). Another study of physicians who participated in a special four-hour training seminar on practice guidelines for depression found that their sensitivity to depressive symptoms was no better than a control group, despite the participants' belief that the seminar was effective in changing their practice (Thompson, 2000). Most primary care physicians have minimal training in providing mental health care and very limited time to work with each patient; those who participate in research studies like these are likely to be a self-selected subgroup with a special interest in mental health; yet their results are no better than this.

Parity

The issue of "parity" for mental health benefits, which many people thought was settled at least for the eight "biologically-based" conditions, hasn't gone away at all. In several states and in Medicare regulations, eight conditions including major depression were declared to be "biologically-based" mental illnesses, therefore to be treated exactly the same as physical illnesses—no higher deductibles or copayments. But as of 1999, the Clinton administration hadn't issued the regulations required to enforce the law passed the previous year, and seemed to be waffling on whether it intended to enforce the law at all. Meanwhile, the insurance companies found that they could get around the law by placing no restrictions on cost, but by limiting the number of outpatient sessions or inpatient days. It strains credulity to think that Congress, if it really wanted to guarantee parity, could have overlooked that loophole.

A woman contacted the nonprofit clinic where I worked to arrange follow-up care for her adolescent daughter, who was being discharged from a psychiatric hospital after a bizarre runaway episode. But let's focus now on the mother, not the child.

Sheila is a witty, sensitive, intelligent woman in her 30s. If she were your neighbor you would like her. She works hard, pays her bills, in general is an upstanding citizen. She is a single mother, having been divorced from her husband a few years ago.

She is the daughter of alcoholic parents. Her father was physically and emotionally abusive to her; Sheila was beaten frequently, and made to feel that she was ugly, bad, useless, incompetent, and to blame for all the family problems. You would not have known any of this if you lived next door to them. The family was successful economically, liked and respected in the community. Sheila got out of the home as soon as she could by marrying the first man who asked her.

But by the time their child was born, Sheila's husband had begun beating her. She became an example of the cycle of abuse, which is hard to understand but is seen a lot, where women who have been abused as children find themselves in abusive marriages. She put up with it for a few years, then got away with her daughter She made good use of women's services, and seemed to land on her feet.

However, by the time she contacted us there was more trouble. Her daughter was out of control. As we explored, we found that not only did the daughter run away from home repeatedly, but she was defiant, belligerent, and physically aggressive toward her mother. Sheila was intimidated and felt helpless to do anything about it. In fact, she had a major depression: She couldn't sleep or eat, felt hopeless, guilty, and ashamed all the time, couldn't concentrate, had thoughts of suicide—all the symptoms. She was surprised to hear that, from our point of view, she had an illness; her state felt normal to her. But depression is a disease that often goes unrecognized, even by those who have it.

So here we are: abused by her father, her husband, now by her child. Our patient was aware of the irony; it was another stick she would beat herself up with. "Why can't I just snap out of it?" she asked. "Why can't I just take charge of my life?" Our answer—that she had a disease called depression which she can't cure by herself—didn't entirely satisfy her. Like most of those who suffer with the disease, Sheila agreed with the conventional wisdom that depression is a sign of moral weakness or lack of character.

This is another aspect of Sheila's problems. Imagine that every time you went to the doctor you were made to feel guilty. Imagine that we as a society assumed that there is a state called "health," which is "normal" and that being ill is deviant, weak, shameful, or your own fault. Because that is exactly how Sheila, and in fact all our patients, are made to feel. Wouldn't it be crazy if you had to feel that you were somehow to blame if you caught pneumonia, or broke a leg, or developed a degenerative disease? Isn't it crazy now that people with depression or post-traumatic stress disorder or schizophrenia, have to feel that way?

Now let's ask: How could Sheila pay for getting the help she needs?

First of all, it's necessary to recognize that she had to pay for it. The agency had a state grant that helped us pay for services to her children, but there was no state grant for adult mental health services. If Sheila had a substance abuse problem, or were chronically mentally ill, there would also be state funds to help her out, but states have cut back on subsidies for people with acute mental health needs, who are dismissed as "the worried well." So Sheila was on her own.

Now, Sheila's employer was using a managed care plan. This meant they would reimburse the agency following their usual practice for mental health services: 50 percent of the cost of each office visit, to a maximum of $1000 annually. This is a rather standard benefit plan. At the commercial rate of $120 per hour for individual psychotherapy, they would pay $60 per visit. At that rate her benefits for the year would be exhausted after 17 treatment hours, four months of once-a-week treatment. Plus, she was expected to pay the copay of $60 per visit.

We worked out a plan with Sheila for psychotherapy every other week, and attendance at our free self-help group on depression. She paid the minimum fee out of pocket, and the agency accepted what her insurance paid. The agency continued to treat her after her insurance benefits were exhausted, relying on it's own fundraising to do so. It would have been preferable for her to be seen weekly until she was better, but she didn't want to do that, even when we offered to reduce her fee further. In addition, she saw our psychiatrist about every other month. Her medication cost $8 a day—$3,000 a year—thank God her insurance only required a copay of $10 on each prescription. She made about $15 an hour on her job—that's a gross of $30,000 per year—could anyone expect her to pay 10 percent of her gross pay for medication?

Sheila paid the clinic about $900 a year for her counseling, and her insurance paid another $1,000. But it cost something like $3,800 to provide her with the group weekly and individual counseling every other week and her psychiatrist visit. The agency did its best to be efficient and cost-effective, but realistically Sheila would require perhaps a year or two of professional help before she can recover.

Sheila was very fortunate to live in a community that made it possible for a clinic like ours to come up with the $1,900 in additional funds that it took to help her get back on her feet. Most people in the United States don't have that kind of resource.

But, personally, I had become burned out with organizing fundraisers, coaxing our board members to ask their friends for contributions, and going hat in hand to the United Way year after year. They were all tired of hearing from me, too. Isn't it time we face up to the problem? Can anyone provide an argument on any ground—economic, moral, therapeutic—to explain why we don't embrace Sheila's problems as part of the social contract? Even in the crassest financial terms, it just makes sense to help keep Sheila working so that she continues to pay into Social Security rather than draw on it, help her function as a mother to keep her daughter in school and out of trouble and the hospital again.

How did we get into a situation where "parity" is even a subject of discussion?

Among all the other things that depression is, it is a perfectly reasonable response to the way our society treats the individual who has it. People with mental illnesses are discriminated against by our healthcare system. People with depression have their feelings of guilt and inadequacy reinforced by this discrimination. Touting medication as a panacea for what are actually reactions to complex living problems reinforces the stigma when the medication doesn't live up to expectations. Any improvement we want to make in direct treatment of depression must take these harsh realities into consideration. We need to advocate for our patient and we need to help him understand what the system is doing to him. And we have a responsibility as citizens and as professionals to address these issues on a larger scale as well. Our failure to do so puts us in an indefensible position when we are trying to help an individual patient recover.