Becoming Unblued

Move over Prozac. Try cognitive therapy for a drug-free way to treat depression.

With this issue, Mother Jones inaugurates a new health column by contributing writer Michael Castleman. He is the author of eight books, including Nature's Cures, which investigates the science behind 33 alternative therapies.

What should you do if you feel persistently blue? These days, people with depression are more likely than ever to be given antidepressant medication. But for those with mild to moderate depression, there's an equally effective alternative: cognitive therapy. Cognitive therapy is a deceptively simple, do-it-yourself approach based on the idea that depression is often triggered by distorted thinking -- and relieved by correcting it.

Unfortunately, cognitive therapy is ultra-low-tech, and Americans love high-tech -- as do the pharmaceutical companies that spend millions marketing high-tech, high-profit antidepressant drugs. In 1989, they developed a very good one, Prozac, which has hogged the depression spotlight ever since. Within two years, it was the nation's most widely prescribed antidepressant. And for good reason: It was as effective as other drugs, but with fewer side effects.

Prozac's release coincided with a profound shift in scientific thinking about depression. Instead of the traditional belief that the condition resulted from psychological conflicts treatable only through long-term psychotherapy, an insurgent group of biological psychiatrists said depression was caused by a chemical imbalance in the brain and could be cured by medication that normalized brain chemistry. Because pills are so much cheaper than weekly therapy sessions, managed care has enthusiastically embraced Prozac and its newer cousins -- Paxil, Zoloft, Serzone, Effexor, and Wellbutrin -- all chemically known as selective serotonin reuptake inhibitors, or SSRIs. An estimated 17.6 million Americans suffer from depression each year, and last year pharmaceutical companies sold U.S. drugstores $3.5 billion worth of SSRIs.

The real value of antidepressant drugs is in treating serious, or clinical, depression, whose most tragic consequence, suicide, claims more than 30,000 lives a year. But these days doctors prescribe Prozac & Co. for an enormous number of people who have mild to moderate depression and are not at risk for suicide. These people feel persistently sad, lethargic, irritable, and indecisive, and they express helplessness and hopelessness frequently enough to worry -- and irritate -- those around them, but they continue to function in the world.

God knows, mild to moderate depression is no picnic; for some, drugs might really help. But in the rush to elevate mood with medication, we've overlooked two important issues. Antidepressants -- particularly SSRIs -- are notorious for causing sex problems (see "Getting in the Mood"). And they promote the subtle but very real message that people need drugs to regulate their moods, itself a depressing thought.

Many people with mild to moderate depression don't need drugs. Some can successfully rebalance their brain chemistry -- and get off antidepressant medication -- using other approaches. These include acupuncture and aerobic exercise, which increase natural mood-elevating brain chemicals (neurotransmitters), and companionship, which has equally powerful, though less biochemically elucidated, mood-lifting effects on inherently social animals such as ourselves. And because these approaches are personally empowering, they also are much better for the soul.

Cognitive therapy has several advantages over even these approaches in treating mild to moderate depression. Unlike acupuncture, there's no practitioner. You do it entirely on your own. And unlike aerobic exercise, you don't have to join a gym or work up a sweat. Cognitive therapy is quick, easy, available anywhere, and, once you get the hang of it, free.

In analyzing 28 studies comparing how people fared after using different treatments for depression, psychologist Keith Dobson of the University of British Columbia in Vancouver found that those using cognitive therapy fared better. In those studies specifically comparing the method with drug treatments, those using cognitive therapy did better than 70 percent of those who used antidepressants.

Developed some 30 years ago by Philadelphia psychiatrist Aaron Beck, cognitive therapy has gained popularity through two books by Dr. David Burns: Feeling Good: The New Mood Therapy (1980) and The Feeling Good Handbook (1989).

"Most people with mild to moderate depression," says Brooklyn, New York, psychologist Mark Sisti, who specializes in cognitive therapy, "don't have to take drugs or spend a great deal of time understanding their past to improve how they react to potentially depressing situations in the present."

As simplistic as it sounds, cognitive therapy focuses on recognizing -- and correcting -- the thought traps that trigger emotional tailspins, those interior soundtracks that lead to self-belittlement and keep people feeling despondent.

For example:

  • All-or-nothing thinking. You see things as black or white. If you're not perfect, you assume you're a total failure.

  • Labeling. You make a mistake, but instead of thinking, "I made a mistake," you label yourself: "I'm an idiot."

  • Overgeneralization. The tip-off is using the words "always" or "never." You hurt someone's feelings and think, "I'm always insensitive." You make a mistake and think, "I never get things right."

  • Mental filtering. In situations with both positive and negative aspects, you dwell on the latter. Your mother compliments you on her birthday dinner, but says the cake was a bit dry. You filter out her positive comments and whip yourself for being a lousy baker.

  • Discounting the positive. You often react by putting yourself down. Your co-workers praise your work, and you think, "It wasn't good enough," or "Anyone could have done it."

  • Mind reading. Without evidence, you jump to the conclusion that people are reacting negatively to you. As you approach the coffeemaker, two co-workers fall silent. You decide they hate you.

  • Fortune-telling. You predict bad outcomes. The boss asks you to do something new. You decide you can't do it, that you're bound to fail.

  • Magnification. You exaggerate problems. Your toilet backs up, and you believe your entire plumbing system must be replaced.

  • Emotional reasoning. You mistake emotions for reality: "I feel nervous about flying, therefore it must be dangerous."

  • Personalizing. You blame yourself for things beyond your control. Your child misbehaves at school. You think, "I'm a terrible parent."

Shakespeare captured the essence of cognitive therapy in Hamlet: "There is nothing either good or bad, but thinking makes it so." Here's a quick way to put cognitive therapy to work for you. The next time something happens that triggers a negative, potentially depressing thought, imagine it happened to a friend, who then asks your advice. Most people are much harder on themselves than on others. Imagine your friend's son misbehaved at school. Would you say, "You're a terrible parent"? Of course not. You'd do your best to provide comforting perspective. With cognitive therapy, you give the same gift to yourself.

Beyond recommending that you befriend yourself, therapists who teach cognitive therapy suggest this process:

  • Write it down. Writing automatically provides perspective and helps reveal distorted thinking.

  • Identify the distressing event. What's really bothering you? Is it simply that you got a flat tire? Or is it that you got your outfit dirty changing it? Or that you knew you needed a new tire but didn't replace it? Or that the flat made you late for your daughter's soccer game?

  • Identify your negative emotions. You might feel annoyed about the flat, frustrated that replacing it dirtied your clothes, angry for not replacing it sooner, or guilty for being late to the game.

  • Identify the negative thoughts tied to your emotions. You may have these thoughts about failing to replace the tire: "I never take care of things in time. I always procrastinate."

  • Identify distortions and substitute the truth. Instead of blaming yourself, here's another way to reason: "I don't always procrastinate. That's an overgeneralization. I usually juggle the many demands of my job and family quite successfully. I would have replaced the tire sooner, but an emergency came up at work. The tire just got by me."

Cognitive therapy's major strength is its simplicity. Frequently, that's precisely what puts skeptics off. But when pernicious thoughts threaten to overwhelm you, an organized, step-by-step program helps.

Cognitive therapy is also cheap -- less than $30 for Burns' books. Or, if you prefer some one-on-one coaching from a therapist who teaches it, you can learn cognitive therapy in a few sessions, which is all most managed care plans pay for these days. Many psychotherapists teach cognitive therapy. Ask around. Or write the Beck Institute for Cognitive Therapy (www.beckinstitute.org), GSB Building, Number 1 Belmont Ave., Bala Cynwyd, PA 19004.