UNIPOLAR DEPRESSIONS: Beyond the Medical Model …
By Mickey Skidmore, ACSW
Depression is the most common disorder affecting Americans, a problem that is still growing steadily across all age groups (Yapko, 1999). Depression is growing at a pace where it is likely to be the world’s second-most disabling disease after heart disease by the year 2020. In the United States, depression affects 18 million people at any given time. It will affect 1 in 5 people over the course of a lifetime, and cost over $40 billion a year in lost work and in healthcare (Schrof & Schultz, 1999).
Without a doubt, depression is the most prevalent emotional disorder in the USA. If any other physical disease were to grow as rapidly as depression, it would be considered nothing short of an epidemic. Pharmaceutical companies have convinced physicians, therapists, and the general public that (unipolar) depression is “a bio-chemical imbalance of the brain.” However, our knowledge of depression has greatly improved in recent years, and many might be surprised to learn that our own scientific research does not support this statement. So why do so many turn to this view?
There has been a cultural shift in our awareness regarding healthcare delivery. Drug companies routinely market ads for their products directly to the consumers. Last year, one drug company had a $5 billion advertising budget for antidepressants. It would seem that the emphasis on medication has in fact contributed to the advance of depression. Managed Care companies in their zeal to contain cost have further reinforced this position. Books such as Peter Kramer’s “Listening to Prozac” (70 weeks on the best seller list) seduced millions of readers into this overly simplistic view about this affliction which torments millions of people. Unfortunately, this view leads people to underestimate the complexity of this condition. Interventions for this condition need to be as multi-dimensional as the problem. Despite this, the USA, which comprises roughly 5% of the world population, consumes 75% of the worlds antidepressants.
More than ten years ago, everyone thought Prozac would be the miracle drug for melancholy. Not only were these new generation of drugs touted to have fewer side effects, they were also supposedly non-addictive. Yet recent research in the Journal of Clinical Psychiatry (1997) discusses emerging information regarding withdrawal from SSRI’s. If Prozac, and other SSRI’s, were indeed to be the magic bullet against depression, why is the problem worse now than ever? These factors have contributed to a reductionistic individual focus, and a casual attitude toward depression, which is clearly a complex weave of biology an environment. The short-sightedness of emphasizing medications as the sole treatment intervention for depression is tantamount to bailing water out of the boat while the holes go unplugged.
So what does empirical science suggest? In short, depression is a multi-dimensional complex of biology and environment. Overall, it is an affliction that is under-diagnosed, and mis/undertreated. It has been estimated by some that only 1 out of 4 persons ever receive appropriate treatment for depression. Moreover, the face of depression is changing – and sadly becoming younger and younger. Beyond the overly simplistic and reductionistic view of medication we should be exploring family interactional patterns (family traits) – or depressogenic family systems and the learning patterns within them. (There is a three times higher risk of depression in children of depressed parents [Yapko, 1999]). LEARNING is a significant variable in prevalence of depression. The interactional sequences between parent and child may indeed be more a relevant variable than genetics.
What follows is further information which the research bears our about depression:
* Insomnia: is perhaps the single greatest risk factor for a major depressive relapse.
* Anxiety: is the most common co-morbid condition associated with major depression.
* Death/Suicidal Thoughts: the greatest risk factor for this is hopelessness. Moreover, there is a 15% increased risk than normal if the client has impulsive tendencies.
* Many depressed individuals operate out of a Global Cognitive Style – which is predominantly or all negative. People mistakenly accept their projections as truth. The problem isn’t that they’re thinking negatively – it’s that they’re listening! (Everyone has an inner critic).
* Remuneration works against the recovery of depression.
* Gender Considerations:
– Depression affects 2X as many women as men & 2X as many teenagers as boys.
– 25% of women will be affected be depression at some point in their lives.
– Women experience 50% chance of mood & somatic changes premenstrually.
– Women experience 50-80% chance of mild post-partum depression.
– Women experience 10-20% chance of severe post-partum depression.
– Married women are the least susceptible — single women the most to depression.
– The most common triggers for depression in men: job failure / loss of status.
– The most common triggers for women: disruption / cut off from close
Beyond the family there is additional research emerging which reflects how technology adversely contributes to the complexities of depression. For example, greater use of the internet leads to shrinking social support and happiness, and an increase in depression and loneliness (American Psychologist, Sept. 1993). (As of June 1998, approximately 60-70 million Americans use the internet). Furthermore, TV requires the same Global Cognitive Style mentioned earlier found in depression, rather than critical thinking. When people lose contact with those around them – they suffer. People need to be connected to something greater than themselves.
So, where do people learn relevant skills for problem solving? … Conflict resolution? … Impulse control? … And how to think (critical thinking)? Many of today’s family’s struggling with being single parents, day care, blended, or otherwise stressed fall far short of this task. The institution of the Church no longer holds the same place in our culture as it once did. Social systems are increasingly inadequate to meet this challenge. Even therapy which could make a tremendous impact on this issue finds professionals in the field ununited about this. Furthermore, managed care and insurance companies when the use therapy at all, use it to mop up people’s problems rather than in a preventative way.
ACTION APRROACHES FOR DEPRESSION…
In December of 1989, Federal Public Law 101-239 reached significant conclusions after an expansive review of the professional literature on depression, the intent of which was to offer clinical practice guidelines. Among the more compelling were:
* Cognitive, Behavioral & Interpersonal therapies were determined to be the most effective psychotherapy treatments for depression.
* No one antidepressant was found to be more clearly effective than another.
* Brief dynamic oriented psychotherapy is the weakest / least effective.
* Psychotherapy is most effective when it is active, time-limited, focuses on current problems and/or symptom resolution – not personality change.
In conclusion then, the following is a suggested list of approaches for therapist to utilize in their treatment approaches of depression:
Psychoeducation: Medication requires the client to assume a passive postion in their treatment – they only need to take the medication on time.
Reframing: (it isn’t YOU – it’s the way you go about it). This aspect of therapy values strategic thinking; depersonalizes the circumstances; and orients the client towards a need to build skills.
Avoid alcohol & caffine: these agents disrupt the same neural pathways as depression, and when metabolized in the body often result in anxiety.
Encourage Problem-Solving Time: (separate and distinct from sleep) > other than bedtime.
Physical Exercise: (it takes energy to make energy); will increase seratonin levels.
Tape Sessions: (this increases any gains received from therapy); encourage clients to review, outline, transcribe, or highlight these gains.
“Me Manual” (or journaling): an opportunity to learn about yourself; what you are learning about your depression, i.e. triggers, vulnerabilities, etc.
Record a Sleep Tape: (Hypnosis)
Hypnotically Building Expectancy: manipulating the efficacy of the Self-Fulfilling Prophecy.
1) American Psychologist, Sept. 1993
2) Federal Public Law 101-239, (Dec., 1989)
3) Journal of Clinical Psychiatry 1997; 58:291-297
4) Schrof, Joannie M. & Schultz, Stacey. “Meloncholy” US News & World Report, March 8, 1999.
5) Yapko, PhD, Michael. “Breaking the Patterns of Depression” North Carolina Society of Clinical Hypnosis Annual Conference, 4/9-10/99.