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Treatment: Therapy
CBS CARES: If genetics and upbringing/childhood experiences are the root causes of depression, how can medications be effective in treating the underlying causes? Isn't psychoanalysis essential to effectively treat depression? In other words, without psychoanalysis or psychotherapy, won't the depression return if the patient is weaned off medication?
DR. ROOSE: It used to be believed that the roots of depression were in childhood experiences. According to this belief, medication could serve only as a band-aid, and it was necessary to undergo extensive psychotherapy to correct the underlying causes of depression. Depressed mood and anxiety were also considered to be the results of intra-psychic conflict, and therefore it was seen as necessary to resolve the conflict in order to truly treat the depression and anxiety.
Much of this thinking has been revised over the past 20 years. We now consider that depressed mood and anxiety can create events. For example, traditionally one might have seen the absence of a relationship as causing a depression. But now we understand that a person who is chronically depressed may have difficulty establishing a relationship. Currently, it is common to sequence treatments, i.e. to treat patients for depression and then after the depression is resolved to initiate psychotherapy to address some of the life problems that have resulted from the chronic depressive illness. There are also a number of studies showing that the combination of medication and psychotherapy may be the best treatment for people with chronic depression.
CBS CARES: How effective is psychotherapy in treating people with depression?
DR. WEISSMAN: The evidence for the efficacy of some of the new psychotherapies that have been developed for depression is pretty strong. There is cognitive therapy, for which there have been many trials. And there are studies of interpersonal psychotherapy that show efficacy if it's compared to no treatment or even compared to medication.
CBS CARES: What is cognitive-behavioral therapy?
DR. KAHN: Cognitive-behavioral therapy, or CBT, is a structured, short-term form of psychotherapy designed to root out self-critical thoughts that people think to themselves automatically. Making a person aware of these thoughts by keeping lists and consciously thinking of alternatives can lead to substantial relief of mild to moderate depression, in some studies as effectively as medication.
CBS CARES: What is interpersonal psychotherapy?
DR. WEISSMAN: I developed interpersonal psychotherapy along with my late husband Gerald Klerman, and it's been tested in numerous clinical trials. Like cognitive therapy, it's a time-limited therapy that's been described in a manual. We know there's a strong biological vulnerability to depression but that depression usually occurs in an interpersonal context. So with interpersonal psychotherapy, you try to understand what was going on in the patient's life in association with the onset of the symptoms. The four very general categories that have been identified as often occurring in association with an onset of depression are grief, a dispute, a role transition (moving, retiring, promotion, children leaving home) and an interpersonal deficit (problems in loneliness and boredom and making and sustaining relationships). The therapist helps the patients first to make a diagnosis, then to identify the problem area and deal with it.
CBS CARES: What is the difference between psychoanalysis and psychotherapy?
DR. KAHN: Psychotherapy refers to any treatment that relies on talking about a problem. It takes many forms, some of which are more open-ended, and others of which are highly structured, following textbooks and manuals. Some of the more structured approaches, such as cognitive-behavioral therapy and interpersonal therapy, have been developed and research-tested to achieve quick results in depression, usually in a matter of weeks to months. In contrast, psychoanalysis is a multi-year, in-depth exploration of how a person experiences themselves and other people, relying on detailed understanding of early life experiences and examination of unconscious thoughts and feelings as revealed in free association, dreams, and other avenues. While it can be effective in helping people develop stronger and more mature personalities and making better decisions in life, it is not a treatment for depression.
CBS CARES: Do people who feel better from psychotherapy or psychoanalysis undergo the same chemical changes as those who feel better from medication?
DR. ROOSE: Initial studies have been conducted using advanced imaging techniques to look at brain function. They appear to show that patients with depression may have the same changes in certain critical areas of the brain whether they respond to medications, psychotherapy or placebo treatment.
CBS CARES: Why aren't psychiatrists required to undergo psychoanalysis or psychotherapy to qualify? Should this be a requirement and wouldn't it enhance their abilities to diagnose patients?
DR. SILBERSWEIG: No. The question may reflect an older way, or a subset, of thinking. While there are those in the area of psychoanalysis who think that psychoanalysis is an important part of training in that area, psychiatry and psychotherapy is now much broader. A good therapist should have a good understanding of him/herself, and should be knowledgeable and experienced in the relevant area of practice (which may not always include psychotherapy). Psychiatrists need to be highly trained in the pathophysiology, psychology, differential diagnosis and treatment of the conditions they treat, like any physician-- though with specialized training in the understanding of the human mind/brain in health and disease.
CBS CARES: Judge Jerome Frank, the father of the jurisprudence school of American Realism, once wrote that all Judges should be required to undergo psycho-analysis, because - despite being clothed in legalise - their judgments are mainly influenced by their personal subliminal and psychological factors…for example, childhood and adult experiences and relationships. Do you think that the judicial process would be enhanced if judges were able to benefit from the personal awareness provided by psychoanalysis?
DR. SILBERSWEIG: Psychoanalysis is a brilliant and powerful approach to understanding the human mind, and could therefore be very helpful to judges and others. However, it is one (very important) school of thought, and does not have the monopoly on the route to personal awareness.
CBS CARES: What is the difference between the role of psychiatrist and psychologist?
DR. KAHN: Psychiatrists are best equipped to conduct an overall evaluation of a problem and to consider the role of general medical problems, psychiatric history, and psychological stresses. Psychiatrists are fully trained medical doctors and can coordinate care with other physicians to conduct exams and tests, and can prescribe medication. Many psychiatrists are also excellent psychotherapists and can conduct that aspect of treatment, while others prefer only to focus on medication (psychopharmacology) and work with a clinical psychologist, who provides psychotherapy. Psychologists are sometimes better trained than psychiatrists in specific forms of psychotherapy such as interpersonal therapy or cognitive-behavior therapy, or in group or family therapies. Dividing the work among the psychiatrist and psychologist (or other trained therapist, such as a social worker) is also often required by insurance considerations.
CBS CARES: What's the best way to find the right psychiatrist or psychologist?
DR. KAHN: By asking other physicians, talking to friends who have sought help themselves and who have had a good experience with a specific psychiatrist or psychologist, or contacting a local medical school department of psychiatry. The American Psychiatric Association also maintains referral lists. Psychiatrists can often recommend, or work directly with, psychologists.
CBS CARES: If your psychologist or psychiatrist is smart, but you don't like him/her, should you change? How important is it to like and be liked by your doctor?
DR. KAHN: It is very important to feel personally comfortable with your psychiatrist or psychologist. You're going to trust this person with your thoughts and feelings, and your health, so if you don't click personally, bring it up and discuss whether a change is in order.
CBS CARES: How do you know when your psychiatrist is wrong for you?
DR. KAHN: If he or she doesn't explain your diagnosis and treatment options; doesn't return phone calls or renew medications promptly; doesn't address side effects when they come up; changes medications frequently without explanation, or doesn't change when you're not responding.
CBS CARES: And then, what are the signs that you have the wrong psychologist?
DR. KAHN: If you or the psychologist are very late for or forget appointments; if your therapist is defensive about your comments or questions; you don't have anything to say, or the psychologist doesn't seem to offer any helpful insights or advice. Not getting better can sometimes just be the nature of the illness, but not making any changes or exploring why there is no improvement is also a sign of not having the right psychologist.
CBS CARES: How do you know when you've been in therapy too long?
DR. KAHN: If you feel better and the visits begin to feel more social, or you don't feel better and there is no acknowledgement of the need for a fresh approach. In the latter case, it's not that you've been in therapy too long, but that you've been in therapy with the wrong psychologist too long.
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