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The illness of depression and how psychotherapy may help

by Douglas Berger

One of the most common issues that comes up in sessions with patients at our clinic in Tokyo is depression, and one of the most frequently asked questions is “How can psychotherapy help people with depression?”

This is a complex question that depends on what we mean by both “help” and “depression.” Let’s start with the types of conditions we might consider as depression in a general sense, and from there we can discuss how clinicians and researchers define “help.”

Some people use the word “depression” when what they are actually describing is boredom or apathy. Boredom or apathy can be situational — as in a boring job — or it can be due to loneliness. It may be a symptom of a medical condition, such as stroke, or a psychiatric condition, such as attention deficit hyperactivity disorder, where an individual may need constant stimulation in a topic they are interested in to alleviate the boredom of everyday life. In these cases, any treatment would be geared at correcting the underlying situation or condition, and by definition the problem they have is not depression to begin with.

Depression in terms of a low mood can be part of a transient depressive state due to some kind of stressful situation (often a disappointment), but this is not an illness, and it resolves itself when the situation is corrected. Stress at work, with romantic partners, having a medical condition or a death in one’s family are common examples. Supportive psychotherapy to coach the person through a complex or tough situation, or cognitive interventions — i.e., making sure the person does not exaggerate their thoughts in bad ways — may be very helpful in navigating through the stress.

Depression may also be related to personality. Individuals with deeper or a greater number of deficits in their personality or self-identity (i.e., having core issues or mental schemata of feeling unloved, belittled, invalidated, incompetent, etc.) may have a more pervasive low mood related to these core issues. This low mood may be worsened by situations that stimulate these deficits (like being ignored, rejected, etc.), leading to what are known as secondary depressed states. The real problem is the underlying personality issue, not the depressed mood, and this would not be considered a manifestation of an illness of depression unless it worsens as described below.

Usually a mixture of various approaches, including psychodynamic psychotherapy, which uses a core issue-defense paradigm, or that based on cognitive therapy, which involves changing one’s maladaptive thinking patterns, will help such people function better. For example, a person with a core issue of feeling unloved may be sensitive to perceived rejection by others and become needy in relationships. Pointing this out to them may help them find more adaptive ways of seeking love, i.e., to move on from relationships that are not satisfying instead of clinging to them. Those who have cognitive patterns such as always looking at the negative may be helped by being trained to see the positive side to things.

But because the person does not have an “illness” of depression to begin with, the therapy would only be helping the individual function better.

Those who have an illness of depression, which is known as major depression or clinical depression, have more physical symptoms, e.g., an inability to enjoy things, low mood, decreased appetite, disturbed sleep, low energy, etc. The more a depression is chronic or recurrent, if there is a family history of depression or another mood disorder, and if there was no specific stressful event leading up to the depression, the more likely the depression is a naturally occurring internal derangement of the chemical function in those brain areas that control mood. (This article does not have the space to review all the genetic and neurophysiological data that suggest that those with major depression have a brain illness.)

So how can psychotherapy help individuals with major depression? Depression is made up of two parts: one is the actual suffering the person has from the symptoms of depression described above, which is due to an imbalance in brain chemicals, and on top of that, these persons often have a psychological reaction of worry and despair. Most kinds of psychotherapy can help alleviate this secondary reaction, especially if the person can be made to see that this is an unnecessary reaction. These individuals are also likely to need to take medication in addition to psychotherapy to relieve most or all of their symptoms.

What about how clinicians and researchers define “help”? Recovery is often defined as 50 percent improvement based on a questionnaire that rates severity of depression, so someone can be said to have been helped even though they still have many depressive symptoms. In addition, depression studies often include people with the stress- or personality-induced depressive mood states described above that are not really attributable to the illness of depression, and these tend to improve over time even without treatment. The subjects in psychotherapy studies are also not blind to the type of therapy they receive (ie., there is no sugar pill placebo given like in a drug study), so that bias can affect the way the subjects report improvement.

While this article does not have the space to discuss all the problems in studying if psychotherapy works, we can say in a nutshell that there is some evidence to say it is helpful, but that it is not really proven in the same way that, for example, penicillin cures a sore throat.

Douglas Berger, M.D., Ph.D, is an American psychiatrist and director of the Meguro Counseling Center (www.megurocounseling.com). This article is provided as general information only. Persons in need should contact a mental health professional. Send questions you would like Dr. Berger to address in a future column to lifelines@japantimes.co.jp .