Treating depression – a case for psychotherapy

Close-up of Dandelion on background green grass - an image symbolic of treating depressionFeeling down and sad for a long time, feeling hopeless and worthless, finding it difficult to enjoy anything in life including that you used to enjoy before, struggling to make up your mind even about minor things, feeling fatigued a lot, having a low sex drive, feeling too miserable to make contact with your friends very often? You may be suffering from depression.

If you do, you are not alone. Every year almost one in ten adults will at some point suffer from depressive symptoms for a period of time that usually lasts for several weeks. Which symptoms they experience, how severe they are, and how long they last depends on the individual, but some of the symptoms that often show up with depression are the ones mentioned above.

What causes a person to develop depressive symptoms and depression is different from one person to the next, and the idea that depression is caused by a chemical imbalance in the brain is not universally accepted. Certainly, MRIs often show that the brain’s neurotransmitters – the chemicals that brain cells use to communicate – seem to be out of balance in depressed people. But these MRIs do not explain what caused this imbalance to occur, and the imbalance may not be the original cause of the depression itself.

Disregarding this dilemma, the first-line medical approach to treating depression is to prescribe anti-depressants. But anti-depressants actually have very little effect with regard to treating depression – no more than “sugar pills” in fact. But at least with sugar pills you don’t have to suffer the, sometimes horrendous, side effects that you may experience when treating depression with anti-depressants. You can read more about this subject in the article “Anti-depressants for depression? A critical question.

Fortunately anti-depressants are not the only methods for treating depression, and not even the most suitable for many people. For a great majority of people suffering from depression, psychotherapy would most likely be a much better option for treating depression.

When depression shows up

When depression is caused by organic brain dysfunction, e.g. as a result of head trauma, it makes sense to consider the possibility of restoring the chemical imbalance by use of pharmaceutical substances. But for most of the people you have known, who have suffered from depression – and that must be a few, considering how common depression is – it is likely to, at least in part, have had emotional-psychological and/or social causes. The depression has been the final(?) outcome of experiences that the person has not been able to process successfully, and that have eventually manifested as depression.

There are many, many examples of “conditions” that may very well look like depression, and can even turn into depression, but that nevertheless are better addressed with counselling and/or psychotherapy than with anti-depressants. Grief after losing a loved one may be diagnosed as depression if it lasts for a long time, but the process of grieving is very individual, and can be supported and facilitated with the aid of good counselling or psychotherapy. Bad relationships, abusive home environments, and unfulfilling jobs can precipitate depression. Poor self-esteem, inability to stand up for oneself, unhappiness with one’s life situation generally, there is an almost endless variation on the theme of what can end up as a diagnosis of depression, yet would be more sensible to see as an issue in itself, and addressed with psychotherapy rather than with medication.

We may even consider some (probably most) depressive episodes as normal, natural events that we experience as at times as part of human existence. Just like sadness, joy, excitement, anger, fear, jealousy, worry, and other emotions, depression can be a normal human emotion with an important role to play for our emotional-psychological wellbeing. Depression may serve us by drawing attention to some of the perhaps-not-so-good decisions we have made and actions that we have taken, which have influenced the direction our life has gone. Treating depression of this kind with the aid of psychotherapy may allow us to identify and make critical course corrections in life, that may lead us to a place of a lot more happiness than otherwise.

Depression is also often the result of letting other unprocessed emotions and life issues build up over time. In order for emotions to run their course and dissolve, we must first acknowledge their presence, recognise how they influence our functioning, and learn how we come to feel this way. Psychotherapy can support us in this process and help us grow and develop as human beings, rather than be medicated into “feelinglessness.”

Treating depression with psychotherapy

That psychotherapy is an effective method for treating depression is beyond doubt. A vast number of research studies, meta-analyses (combining data from several separate research projects) and review articles have demonstrated the importance and effectiveness of psychotherapy and psychological interventions for treating depression [1, 2]. But not only does psychotherapy produce good outcomes for people who experience depressive symptoms, it also tends to do so quite rapidly; half of the people diagnosed with depression can expect to see positive, lasting results from treating depression with psychotherapy, in ten sessions or less [3].

Several meta-analyses have found that psychotherapy is at least as effective for treating depression as anti-depressants [4, 5, 6], and in the case of mild depression psychotherapy is the recommended first-line method for treating depression [7]. However, for clients with severe depression (or treatment resistant depression) the recommendation is to combine psychotherapy and anti-depressant medication [1, 7], since complementing anti-depressant medication with psychotherapy treatment in many cases leads to better outcomes than can be achieved with medication alone [8, 9, 10, 11].

In psychotherapy as in any other field of knowledge there are many different schools of thought, and many different treatment approaches. While some approaches may have been exposed to more research than others, for a variety of reasons, several authors have nevertheless shown that there is little difference in effectiveness between different therapeutic approaches for treating depression [12, 13]. One of the possible reasons for this could be the well-established fact that, in psychotherapy the quality of the therapeutic relationship that develops between client and therapist is far more important for a positive therapy outcome, than is the therapist’s theoretical orientation or which therapeutic technique is being used [3].

Unfortunately, most people who experience an episode of depression will at some point or another in their life experience one or more relapse episodes [14]. A positive development in this regard, then, is that when mindfulness practices have been provided as an addition to treatment-as-usual, the relapse rate has been found to significantly decrease [15].

References

  1. American Psychiatric Association. (2000). Practice guidelines for the treatment of patients with major depressive disorder (2nd ed.). Retrieved 28th of October, 2008, from http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx.
  2. Ekers, D., Richards, D., & Gildbody, S. (2008). A meta-analysis of randomized trials of behavioural treatment of depression. Psychological Medicine, 38, 611-623.
  3. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart & soul of change: What works in therapy. Washington, DC: American Psychological Association.
  4. Bortolotti, B., Menchetti, M., Belini, F., Montaguti, M. B., & Berardi, D. (2008). Psychological interventions for major depression in primary care: A meta- analytic review of randomized controlled trials. General Hospital Psychiatry, 30, 293-302.
  5. Pinquart, M., Duberstein, P. R., & Lyness, J. M. (2006). Treatments for late-life depressive conditions: A meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry, 163, 1493-1501.
  6. De Maat, S., Dekker, J., Schoevers, R., & De Jonghe, F. (2006). Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: A meta- analysis. Psychotherapy Research, 16, 562-572.
  7. National Institute for Clinical Excellence (2004). Depression: Management of depression in primary and secondary care. National Practice Guideline Number 23. Retrieved 28th of October, 2008, from http://www.nice.org.uk/guidance/CG23.
  8. Burnand, Y., Andreoli, A., Kolatte, E., Venturini, A., & Rosset, N. (2002). Psychodynamic psychotherapy and clomipramine in the treatment of major depression. Psychiatric Services, 53, 585-590.
  9. De Jonghe, F., Kool, S., van Aalst, G., Dekker, J., & Peen, J. (2001). Combining psychotherapy and antidepressants in the treatment of depression. Journal of Affective Disorders, 64, 217-229.
  10. De Maat, S., Dekker, J., Schoevers, R., van Aalst, G., Gijsbers-van Wijk, C., Hendriksen, M., et al. (2008). Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: A meta-analysis based on three randomized clinical trials. Depression and Anxiety, 25, 565-574.
  11. Pampallona, S., Bollini, P., Tibalidi, G., Kupelnick, B., & Munizza, C. (2004). Combined pharmacotherapy and psychological treatment for depression. A systematic review. Archives of General Psychiatry, 61, 714-719.
  12. Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76, 909-922.
  13. Wilson, K. C. M., Mottram, P. G., & Vassilas, C. A. (2008). Psychotherapeutic treatments for older depressed people. Cochrane Database of Systematic Reviews, 1. Art. No.: CD004853. DOI: 10.1002/14651858.CD004853.pub2.
  14. Brodaty, H., Luscombe, G., Peisah, C., Anstey, K., & Andrews, G. (2001). A 25-year longitudinal, comparison study of the outcome of depression. Psychological Medicine, 31, 1347-1359.
  15. 1Teasdale, J. D., Segal, Z. V., Williams, J. M G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623.