Can you think your way out of the depression box?

depressed person creative commons
Credit: Creative Commons

No one escapes a touch of the blues. Maybe you’ve been jilted, maybe the cat died, maybe England didn’t make it through the first round of the World Cup. Any one of these events could damper a mood. Of course, there is a wealth of pithy advice to cure such mild misery: “Get out and do some exercise!” or “Think positive!” or the simple-but-effective “Move on.”

These positivity pills taste a bit bitter if I’m in a sour mood, but I have to admit that most of them work for me. Exercising or socializing take me out of my head altogether; focusing my thoughts on something happy and positive makes me feel … happy and positive.

But could this approach work for clinical depression, a disease with roots much deeper than a simple bad mood?

There is a lot of evidence it does. Cognitive Behavioral Therapy (CBT) is a form of therapy that aims to help people to identify negative or destructive thought patterns and change their thinking, behavior, or both in order to craft a more constructive and harmonious mental environment. Although at first glance it might seem like glorified self-help, or just plain Pollyanna-ish, it provides so much more. Its track record at treating depression is highly promising.

Antidepressant drugs, typically the first-line treatment for depression, only resolve the symptoms of 22–40% of patients whereas after a course of CBT 42-66% of patients no longer met the criteria for depression, according to a meta-analysis published this year. Moreover, if patients stop taking anti-depressants they typically lapse back into depression but the patients who’ve received CBT continue to reap the benefits long after the course of therapy ends.

So CBT would seem to be the most positive treatment for depression so far — only it’s not quite that simple. Scientists don’t quite know why, and how, CBT works and so it can prove difficult to investigate its effectiveness.

To understand exactly what makes CBT difficult to analyze and understand, you have to look to the nature of the therapy itself. While CBT also addresses the thoughts that undermine a person’s confidence and moods it also focuses on encouraging behavioral changes as well. For some people, changing their thoughts by sheer willpower doesn’t work; they need to change their behaviors first and rely on the feedback loops between thoughts and actions to eventually break negative thought patterns.

Identifying Thought Example
An example of identifying negative thoughts (Credit: A therapist’s guide to brief CBT manual)

So CBT focuses on the two-way street between cognition and behavior. How much a therapist focuses on thought, and how much they focus on behavior can vary by therapist, by patient and by the degree of depressive symptoms.

To illustrate this variation, consider another condition that CBT apparently works well for: insomnia. A study published in 2009 looked at the effectiveness of CBT alone and CBT in conjunction with zolpidem, a popular sleep drug. The study found that patients who used both therapy and zolpidem fared better during the first six weeks of the study. But by the six-month mark, subjects who relied on CBT alone made the most progress.

A close inspection of CBT for insomnia, called CBT-I, shows it differs greatly from the CBT administered for depression. The six-week CBT-I courses focuses almost totally on behavioral changes around sleeping patterns such as maintaining set sleep and awake times, keeping the bedroom only for sleep, and restricting the amount of time allowed for sleep. Only one of the six weeks focuses on building cognitive skills—in that week patients are taught to, “not worry about the fact that they are getting no sleep.”

The relationship bewteen thoughts and feelings
A therapist illustrates the relationship between thoughts and mood (Credit: A therapist’s guide to brief CBT manual)

As it turns out, CBT-I has a wonderful effect on depression.

A study presented in November 2013 found that curing insomnia in people with depression using CBT-I also doubled their chance of a full recovery from the depression. A New York Times editorial said:

If the figures continue to hold up, the advance will be the most significant in the treatment of depression since the introduction of Prozac in 1987.

The study’s lead author Colleen Carney, a professor at Ryerson University in Toronto, Canada, was quoted in the New York Times article as saying:

The way this story is unfolding, I think we need to start augmenting standard depression treatment with therapy focused on insomnia.

The two versions of CBT differ in their emphasis: CBT for depression typically focuses on the cognitive portion, and CBT-I focuses on behavior — yet both are effective. It’s very difficult to pin down exactly what is, and isn’t working about CBT when treating depression. Yet it does work, and this demonstrates something vital about our understanding of the disease.

Depression in patients, however it may have started out, is clearly a multi-faceted disease. It has a cognitive components such as the warped beliefs (“things can never get better”), behavioral components ranging lethargy to full-on mania, social components such as isolation., often by virtue of a depressed person being removed from the workings of everyday life and biochemical components that may sometimes simply be bought on by the other components combined.

Depression requires a multi-faceted treatment plan. A better understanding of the mechanisms behind CBT promise to unleash the full potential of technique uniquely suited to combat a mind-body disease as pernicious as depression.

Jane Palmer is Gene-ius editor for the Genetic Literacy Project and a freelance science writer and radio journalist based near Boulder, Colorado. Follow Jane Palmer on @JanePalmerComms.

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