Psychiatry and Mental Healthiness – Part 3: Depression

For the context of this current series, Psychiatry and Mental Healthiness, please read my previous post Healthcare and the Human Experience.

During my last year of residency, one of the electives I participated in was the Interpersonal Psychotherapy Clinic, one of the teaching clinics offered at UCLA for both Psychiatry residents as well as graduate students in the Department of Psychology. Interpersonal Psychotherapy or IPT, is a research supported psychotherapy that has been demonstrated to be as effective as taking antidepressants for the treatment of Major Depressive Disorder. In other words, this counseling technique is a treatment for clinical depression that works as well as taking medication. Unlike Cognitive Behavioral Therapy (CBT) for depression (another well researched form of therapy) which focuses on correcting false beliefs and encouraging positive behaviors with a focus on symptom resolution, IPT focuses on relationships. In fact, it doesn’t focus on symptoms at all. Just relationships. The theory behind IPT is that there is a cause and effect between relationship impairments and clinical depression, and in addressing the cause, the depression would resolve. In research and in practice, this has been demonstrated to be true.

One of the invaluable experiences I had during my year in this clinic was to follow the advice of one of the instructors Dr. Resnick (also a Psychiatrist) to not prescribe any antidepressants to the patients in the clinic, even though we could. He wanted us to have the experience of treating someone’s depression successfully without using what had been our go to strategy up until that point in our training. He knew that even though all of us had learned through lectures and textbooks that certain psychotherapies had been studied in head to head clinical trials with antidepressants and shown to be as effective – we wouldn’t really believe it unless we experienced it ourselves. Why? Because it’s our human nature to only believe things that make sense and feel right to us. Making sense of it was easy enough. These were well done studies published in highly regarded peer reviewed journals and have since been replicated many times (see the Value of Truth – Part 1 and Part 2). Feeling right about it was the challenge because as a Psychiatry resident it was uncomfortable to not prescribe an antidepressant and try this therapy only approach, especially while feeling reasonably competent in our medication management skills and feeling totally inadequate as a still-just-learning therapist. But regardless of my amateur status, I did my best with the support of my instructors and peers, and as we focused on resolving conflicts, helped process grief, managed role transitions, or helped someone develop their people skills, things got better. And better. And better until our patients were no longer depressed. I didn’t prescribe any medication. We didn’t focus on thought distortions or negative depressive behaviors or symptoms. Even though I was originally skeptical and tentative, my own experience had demonstrated that by focusing on and improving relationships, a person’s depression could be cured.

Looking back, after 10 years in practice as a therapist, I also recognize that in addition to the specifics of the IPT strategies, another relationship component that contributed to my patients’ recovery was the relationship I had with them. When looking at large studies comparing the effectiveness of different forms of psychotherapy, the factors that are always at the top of the list that determine the best outcomes are relationship oriented factors – rapport between therapist and client, and the consistency of sessions. Essentially, it’s the time spent building a healthy working relationship.

Another factor high on the list that is not relationship oriented but is also consistent with mental healthiness principles is the therapist’s belief that psychotherapy will work. In other words, the therapist’s growth mindset and grit (see How Do We Grow? – Part 4). One of the reason’s I’m so grateful for experiencing the effectiveness of therapy alone is that it allowed me to have this belief – that therapy as a treatment works. Well how about the patient’s mindset? A study out of Duke University demonstrated that when comparing taking an antidepressant alone, exercise and taking an antidepressant, and exercising alone, all were good treatments for depression. For some, this may be surprising in itself that the exercise alone group did about as well as the other two. However, the more surprising outcome was when these three groups were followed six months later. In the two groups that took antidepressants and had fully recovered, about a third were depressed again by the time the researchers had caught up to them. For the exercise alone group, only about 8% had become depressed again. At first glance the conclusion seems to be that exercise is the best long term treatment for depression, but confounding this interpretation is the fact that the middle group, medication plus exercise, fared about as poorly as the medication alone group. What seems to be going on here is not the effect of just exercise, but rather something akin to my own experience of gaining a belief of the effectiveness of therapy because I couldn’t attribute the success to prescribing medication. Those that exercised alone also could not attribute their recovery to medication, and so could only conclude that it was something that was within their control, in this case their consistent exercise despite being depressed. As anyone familiar with depression would know, this would take extraordinary effort, determination, and persistence despite a lack of immediate gratification – once again, grit. In the months that followed their initial recovery, I believe that the positive experience of having been successful in this way reinforced a belief of self-efficacy and self-empowerment. In the same way that my own experience made me a grittier therapist, I believe that this study demonstrates the effect of self-determination (grit) and self-belief (a growth mindset) as a superior long term strategy for depression over medication.

Looking at health as a spectrum, with illness on the low end, and healthiness at the high end, it makes sense that when we are healthy, we are far from getting ill, and when we are unhealthy, we are vulnerable to getting sick. It also makes sense that when we are sick, that restoring healthy mindsets and behaviors can move us back towards wellness. This can also be demonstrated to be true through clinical experience. I briefly mentioned Cognitive Behavioral Therapy (CBT) as another therapy form that works as well as taking medication. This is true for depression along with a variety of other psychiatric conditions including all anxiety conditions, substance abuse, and for some of the more chronic symptoms of schizophrenia (see here). The goals of CBT are exactly what I just described – restoring healthy mindsets, promoting and practicing healthy behaviors. And of course, being a therapy practice, it also has the benefits of the relationship between therapist and client.

Integrating all of these ideas together, we can see that mental healthiness principles can not only be effectively implemented to “treat” depression, but done so in ways that are more authentic and growth promoting than the present standard of care, medication management. Through IPT we see that it can resolve depressive symptoms and restore relationships and build self-efficacy. Growth mindsets of both therapist and patient and the development of grit contribute to the independent effectiveness of therapy as well as the long term stability of those vulnerable to getting depressed. Restoring accurate authentic beliefs and healthy behaviors can move a person from illness back towards healthiness. Therapy itself promotes the development and practice of a healthy relationship that is collaborative, trusting, respectful, and giving. As I’ve mentioned before, I believe that a mental healthiness focus striving for growth and wellbeing is superior to a mental illness one that settles for lesser goals of being no longer sick or stability. Looking at these alternative treatment options supports that belief, without compromising the obvious goal of resolving depressive symptoms.

Next in this series, we’ll learn about how therapy done with compassion, collaboration, and grit in a nonjudgmental fashion, while focusing on mindfulness, emotional and social intelligence, and personal growth can resolve the previously believed “worst” of the personality disorders at efficacy rates (>90%) that drug companies can only dream about.