Shock! Horror! Psychotherapy Beats Anti-Depressants The most recent research has shown that treating only the symptoms of depression (i.e. with pills) does NOT give long-lasting effects. In healing, energy work, psychotherapy and alternative medicine circles in general, this latest scientific finding is not rocket science (I almost typed ‘brain science’!). But for the scientific community it is a far-reaching advance. Depression Statistics In The Netherlands (latest statistics are from 2003) about 850 000 people are affected with depression each year. A survey in the United States estimated that 13-14 million adults are affected there every year, with 32-35 million people predicted to experience depression at some stage in their lives (that translates to 16% of the population in the USA alone). Add into this, that depression often occurs with some other illness (e.g anxiety disorders, phobias, addictions) and you may start getting the idea that we have a huge problem (opportunity?) on our hands. Depression is at this moment in our history considered to be THE condition that is most responsible for health problems worldwide. Depression Characteristics Depression involves episodes of sadness, loss of interest, pessimism, negative beliefs about the self, decreased motivation, passivity, changes in sleep, changes in appetite, changes in social interest, and suicidal thoughts and impulses. Although most episodes of depression often resolve themselves without treatment, one-quarter (25%) of all patients suffer from chronic depression. Most of these people will also have repeated depressions. Current State of Affairs: Medication for Depression In medical circles, the goal of treatment for acute depression is symptom relief: get rid of the sadness/passivity/negative thoughts as quickly as possible. In terms of drug treatment, ‘response’ is defined as a noticeable improvement, and ‘remission’ is defined by the near absence of symptoms. Even when remission is achieved, patients have a high risk of relapse. It is for this reason that if you are prescribed antidepressants you will be advised to keep on taking them until at least 6 months after you have officially recovered. As a result, doctors are advised (‘practice guidelines’) to keep recovered patients on antidepressants indefinitely, especially if they have a history of recurrent (or chronic) depression. Current State of Affairs: Cognitive Therapy What science terms as ‘cognitive therapy’ gets translated into our more everyday language as ‘therapy’ or ‘psychotherapy’. This type of treatment is seen as a form during which inaccurate beliefs and negative thinking loops are corrected. Guidelines for the treatment of depression through cognitive therapy were developed in the 1960s and 70s, and were first bundled together in published form in 1979 by Aaron Beck and colleagues. According to their guidelines the patient is encouraged to identify the thoughts and images that accompany and proceed upsetting emotions. The person then learns to distance himself from the beliefs that are in these emotions, and then to question whether those beliefs are true and valid. Finally, the theme threading through the beliefs and thoughts is looked at across a range of situations in different aspects of the person’s life. Does this sound like the effects of healing, psychotherapy etc to you? It certainly does to me :=) Antidepressant Research To make quite a complex subject short, there are 4 main classes of antidepressants currently in use: MAOIs (monoamine oxidase inhibitors) TCAs (tricyclic antidepressants) SSRIs (selective serotonin-reuptake inhibitors) SNRIs (serotonin/noradrenaline-reuptake inhibitors). How these drugs work is to influence the actions of the neurotransmitter in the synapse between nerves. Some hinder the re-uptake of the neurotransmitter back into the neuron and its presence in the synapse allows the receptors to be triggered more/longer so that the nerve impulses are transmitted more. Others prevent the breakdown of the neurotransmitter so that it stays in the synapse longer and thus has the same effect as just explained.  And others work on certain receptors to affect how the nerve impulse is transmitted along the nerve pathways. The most shocking thing I ever learned about (neuro)pharmacology was that it is not yet understood HOW or WHY these drugs work….and yet their side effects can be just as debilitating as the depression itself. It is scary to think that antidepressants are prescribed so easily. But putting my personal judgements aside, the efficiency of antidepressants has been established through literally thousands of placebo-controlled clinical trials (references 5 & 6). About half of all patients will respond to any given antidepressant, and a large proportion of the remaining half will respond to another antidepressant or combination of them. However, science has now found that antidepressants seem to suppress symptoms rather than cure them! Antidepressants are certainly effective in the treatment of ACUTE depression – and they are preventative so long as their use is continued…..However, there are NO PUBLISHED FINDINGS which suggest that antidepressants reduce the future risk of depression once their use is discontinued. It is this fact alone that suggests that the mechanism of depression is left unchanged by the medicines, and that the person is left at risk of further episodes if they no longer lake their pills. The fact that not all patients experience a return of depression after they stop taking the antidepressants is thought that the stability given during the medication enables the person to cope with the negative life situations. This then holds off further episodes of depression. Cognitive Therapy Research In contrast to the lack of evidence for long-lasting effects of antidepressants, there are considerable studies that cognitive therapy provides protection against relapse and maybe recurrence (ref. 7). The first studies that looked at cognitive therapy were conducted in the 1970s and 1980s. They found that cognitive therapy is as effective at reducing acute distress as antidepressants – and that its effects were more enduring (reference 9). Then, in true scientific fashion, the results got questioned (reference 10). Cognitive therapy was suggested to be less effective than antidepressants, and not much better than placebos. It turned out that the ‘problem’ here –and therefore why cognitive therapy fared less well – was that there was a great variation in the therapist’s experience! (reference 11) Finally Putting Debate to Rest: Cognitive Therapy versus Antidepressants In 2005 a large scale, well-controlled study was carried out with 240 severely depressed patients (reference 12). 120 received antidepressants, 60 had cognitive therapy and 60 had placebos. The cognitive therapy and antidepressant providers were experienced practitioners who received feedback and supervision throughout the study. At the 8-week assessment point both the cognitive therapy and antidepressants outperformed the placebo. At this point the placebo was discontinued. At the 16-week treatment phase, there were no differences in the outcome between the antidepressant and cognitive therapy groups: 58% of patients met the criteria for ‘response.’ In the continuation phase, patients who responded to 16 weeks of antidepressants were randomly assigned to either continue treatment or change to a (pill) placebo (reference 13). Patients who responded to 16 weeks of cognitive therapy were withdrawn from treatment and allowed no more than 3 booster sessions during the 1st year of the follow-up period (and never more than one per month). 76% of the antidepressant responders relapsed following medication withdrawal, compared with only 31% of the cognitive therapy responders. Patients continuing with antidepressants fared better than patients who were assigned the placebo (with a relapse rate of 47%, this classed as comparable to the cognitive therapy relapse rate). After the continuation phase had ended, the patients who had not relapsed while on antidepressants were taken off their medication. Of these patients, 54% experienced a recurrence and a new depressive episode. Only 17% of the patients who had had cognitive therapy experienced a recurrence. These findings – together with previous studies - firmly show that cognitive therapy has an enduring effect that is not found with antidepressants. This suggests in terms of mechanisms that cognitive therapy produces changes that antidepressants do not. So What Happens in The Brain? In coping with depression, two main areas are thought to play a key role: the amygdala, and the prefrontal cortex (see picture further down). Increased Amygdala Activity The amygdala is found in the limbic region of the brain. It is important for processing emotional aspects of information and for generating emotional reactions. It is linked by brain pathways to the hippocampus, which creates and maintains emotional memory. Many studies have found that the amygdala is very active in depressed people. As a result, when the amygdala is more active more repeated negative associations are formed. Decreased Activity in Prefrontal Cortex The prefrontal cortex is responsible for control and planning. It has also been found to have a ‘damping’ effect on the amygdala. In depressed people, it has been found that their prefrontal cortex is often less active than non-depressed people. As a result, the damping control is less present, meaning that the overactive amygala can then start to run riot…..The result is the symptoms associated with depression. Brain Differences in Cognitive Therapy and Antidepressants A series of functional Magnetic Resonance Imaging (fMRI) studies have nicely shown what happens in cognitive therapy and with antidepressants. In the picture here ADM is antidepressant medication, and CT is cognitive therapy. The amygdala is the smaller ‘blob’; the prefrontal cortex is the much larger region. Red is for increased activity, blue is for decreased activity. In cognitive therapies (healing, psychotherapy etc) the therapist helps the person to understand their triggers, and to start to be able to deal with them.  The official scientific term for this is ‘helping individuals to increase their emotion-regulation skills’.  As a result the activity of the prefrontal cortex increases, giving the person more of a feeling of responsibility and influence-ability. The prefrontal cortex gets exercised as it were, and the damping effect on the amygdala (emotions, fears etc) increases. Through this learning, and the new life experience that happens, the patient’s amygdala activity also starts to decrease.  With antidepressants, the increased amygdala activity is targetted directly and reduces it. The person feels less depressed. However, in targetting amygdala activity directly nothing is done with the prefrontal cortex to help the person understand their feelings, emotions and triggers (prefrontal cortex). This is why once the person stops taking antidepressants that their depression can return. Cognitive therapy helps the person apply strategies they have learned during their therapy each time they experience their normal tendency to process a situation in a negative way. Repeated application of these skills starts to alter how the person thinks about themselves over time – and about their beliefs in life itself. Just hitting the amygdala with medication doesn’t provide long-lasting relief from depression in many cases, because it doesn’t teach the severely depressed person to deal with the underlying causes. Enough said! Happy New Year to you all – go out and enjoy life :=) References: 1. Depressie in de Bevolking  http://www.rivm.nl/vtv/object_document/o1275n17537.html 2. Moussavi, S. et al. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370, 851–858 (2007). 3. Frank, E. et al. Conceptualization and rationale for consensus definitions of terms in major depressive disorder: remission, recovery, relapse, and recurrence. Arch. Gen. Psychiatry 48, 851–855 (1991). 4. Beck, A. T., Rush, A. J., Shaw, B. F. & Emery, G. Cognitive therapy of depression (Guilford, New York, 1979). 5. Depression Guideline Panel. Depression in Primary Care Vol. 2: Treatment of Major Depression (Clinical Practice Guideline No 5; AHCPR Publ. No 93-0551. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Rockville, Maryland, 1993. 6. Agency for Health Care Policy and Research. Treatment of depression – newer pharmacotherapies. Summary; Evidence report/technology assessment: number 7. US Department of Health and Human Services  http://www.ahrq.gov/clinic/epcsums/deprsumm.htm (1999). 7. Hollon, S. D., Thase, M. E. & Markowitz, J. C. Treatment and prevention of depression. Psychol. Sci. Public Interest 3, 39–77 (2002). 8. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am. J. Psychiatry 157 (suppl. 4), 1–45 (2000). 9. Cognitive Research references: *Rush, A. J., Beck, A. T., Kovacs, M. & Hollon, S. D. Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognit. Ther. Res. 1, 17–38 (1977). *Blackburn, I. M., Bishop, S., Glen, A. I. M., Whalley, L. J. & Christie, J. E. The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br. J. Psychiatry 139, 181–189 (1981). *Murphy, G. E., Simons, A. D., Wetzel, R. D. & Lustman, P. J. Cognitive therapy and pharmacotherapy, singly and together, in the treatment of depression. Arch. Gen. Psychiatry 41, 33–41 (1984). *Hollon, S. D. et al. Cognitive therapy, pharmacotherapy and combined cognitive-pharmacotherapy in the treatment of depression. Arch. Gen. Psychiatry 49, 774–781 (1992). *Kovacs, M., Rush, A. T., Beck, A. T. & Hollon, S. D. Depressed outpatients treated with cognitive therapy or pharmacotherapy: a one-year follow-up. Arch. Gen. Psychiatry 38, 33–39 (1981). *Blackburn, I. M., Eunson, K. M. & Bishop, S. A two year naturalistic follow up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. J. Affect. Disord. 10, 67–75 (1986). *Simons, A. D., Murphy, G. E., Levine, J. L. & Wetzel, R. D. Cognitive therapy and pharmacotherapy for depression: sustained improvement over one year. Arch. Gen. Psychiatry 43, 43–48 (1986). *Evans, M. D. et al. Differential relapse following cognitive therapy, pharmacotherapy, and combined cognitive-pharmacotherapy for depression. Arch. Gen. Psychiatry 49, 802–808 (1992). 10. Elkin, I. et al. Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J. Consult. Clin. Psychol. 63, 841–847 (1995). *Shea, M. T. et al. Course of depressive symptoms over follow-up: findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Arch. Gen. Psychiatry 49, 782–787 (1992). 11. Jacobson, N. S. & Hollon, S. D. Prospects for future comparisons between drugs and psychotherapy: lessons from the CBT-versus-pharmacotherapy exchange. J. Consult. Clin. Psychol. 64, 104–108 (1996). *DeRubeis, R. J., Gelfand, L. A., Tang, T. Z. & Simons, A. D. Medications versus cognitive behavioral therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am. J. Psychiatry 156, 1007–1013 (1999). 12. DeRubeis, R. J. et al. Cognitive therapy vs. medications in the treatment of moderate to severe depression. Arch. Gen. Psychiatry 62, 409–416 (2005). 13. Hollon, S. D. et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch. Gen. Psychiatry 62, 417–422 (2005).