Feeling Good: The New Mood Therapy (2 page)

Based on these findings, Dr. Antonuccio and his coauthors concluded that psychotherapy should not be considered a second-rate treatment but should usually be the initial treatment for depression. In addition, they emphasized that cognitive therapy appears to be one of the most effective psychotherapies for depression, if not the most effective.

Of course, medications can be helpful for some individuals—even life-saving. Medications can be combined with psychotherapy for maximum effect as well, especially when the depression is severe. It is extremely important to know that we have powerful new weapons to fight depression, and that drug-free treatments such as cognitive therapy can be highly effective.

Recent studies indicate that psychotherapy can be helpful not only for mild depressions, but also for severe depressions as well. These findings are at odds with the popular belief that “talking therapy” can only help people with mild problems, and that if you have a serious depression you need to be treated with drugs.

Although we are taught that depression may result from an imbalance in brain chemistry, recent studies indicate that cognitive behavioral therapy may actually change brain chemistry. In these studies, Drs. Lewis R. Baxter, Jr., Jeffrey
M. Schwartz, Kenneth S. Bergman, and their colleagues at UCLA School of Medicine,” used positron emission tomography (PET scanning) to evaluate changes in brain metabolism in two groups of patients before and after treatment.
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One group received cognitive behavioral therapy and no drugs, and the other group received an antidepressant medication and no psychotherapy.

As one might expect, there were changes in brain chemistry in the patients in the drug therapy group who improved. These changes indicated that their brain metabolism had slowed down—in other words, the nerves in a certain region of the brain appeared to become more “relaxed.” What came as quite a surprise was there were similar changes in the brains of the patients successfully treated with cognitive behavioral therapy. However, these patients received no medications. Further, there were
no significant differences
in the brain changes in the drug therapy and psychotherapy groups, or in the effectiveness of the two treatments. Because of these and other similar studies, investigators are starting for the first time to entertain the possibility that cognitive behavior therapy—the methods described in this book—may actually help people by changing the chemistry and architecture of the human brain!

Although no one treatment will ever be a panacea, research studies indicate that cognitive therapy can be helpful for a variety of disorders in addition to depression. For example, in several studies patients with panic attacks have responded so well to cognitive therapy without any medications that many experts now consider cognitive therapy alone to be the best treatment for this disorder. Cognitive therapy can also be helpful in many other forms of anxiety (such as chronic worrying, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder), and is also being used with some success in the personality disorders, such as borderline personality disorder.

Cognitive therapy is gaining popularity in the treatment of many other disorders as well. At the 1998 Stanford Psychopharmacology Conference, I was intrigued by the presentation by a colleague from Stanford, Dr. Stuart Agras. Dr. Agras
is a renowned expert in eating disorders such as binge eating, anorexia nervosa, and bulimia. He presented the results of numerous recent studies on the treatment of eating disorders with antidepressant medications versus psychotherapy. These studies indicated that cognitive behavior therapy is the most effective treatment for eating disorders—better than any known drug or any other form of psychotherapy.
*

We are also beginning to learn more about
how
cognitive therapy works. One important discovery is that self-help seems to be a key to recovery whether or not you receive treatment. In a series of five remarkable studies published in the prestigious
Journal of Consulting and Clinical Psychology
and in
The Gerontologist
, Dr. Forest Scogin and his colleagues at the University of Alabama studied the effects of simply reading a good self-help book like
Feeling Good
—without any other therapy. The name of this new type of treatment is “bibliotherapy” (reading therapy). They discovered that
Feeling Good
bibliotherapy may be as effective as a full course of psychotherapy or treatment with the best antidepressant drugs.
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Given the tremendous pressures to cut health care costs, this is of considerable interest, since a paperback copy of the
Feeling Good
book costs less than two Prozac pills—and is presumably free of any troublesome side effects!

In a recent study, Dr. Scogin and his colleague, Dr. Christine Jamison, randomly assigned eighty individuals seeking treatment for a major depressive episode to one of two groups. The researchers gave the patients in the first group a copy of my
Feeling Good
and encouraged them to read it within four weeks. This group was called the Immediate Bibliotherapy Group. These patients also received a booklet containing blank copies of the self-help forms in the book in case they decided to do some of the suggested exercises in the book.

Patients in the second group were told they would be placed on a four-week waiting list before beginning treatment. This group was called the Delayed Bibliotherapy Group because these patients were not given a copy of
Feeling Good
until the second four weeks of the study. The patients in the Delayed Bibliotherapy Group served as a control group to make sure that any improvement in the Immediate Bibliotherapy was not just due to the passage of time.

At the initial evaluation, the researchers administered two depression tests to all the patients. One was the Beck Depression Inventory (BDI), a time-honored self-assessment test that patients fill out on their own, and the second was the Hamilton Rating Scale for Depression (HRSD), which is administered by trained depression researchers. As you can see in Figure 1, there was no difference in the depression levels in the two groups at the initial evaluation. You can also see that the average scores for the patients in the Immediate Bibliotherapy Group and the Delayed Bibliotherapy group at the initial evaluation were both around 20 or above on the BDI and on the HRSD. These scores indicate that the depression levels in both groups were similar to the depression levels in most published studies of antidepressants or psychotherapy. In fact, the BDI score was nearly identical to the average BDI scores of approximately five hundred patients seeking treatment at my clinic in Philadelphia during the late 1980s.

Every week a research assistant called the patients in both groups and administered the BDI by telephone. The assistant also answered any questions patients had about the study and encouraged the patients in the Immediate Bibliotherapy Group to try to complete the book within four weeks. These calls were limited to ten minutes and no counseling was offered.

At the end of the four weeks, the two groups were compared. You can sec in Figure 1 that the patients in the Immediate Bibliotherapy Group improved considerably. In fact, the average scores on both the BDI and HRSD were around 10 or below, scores in the range considered normal.

Figure 1
. The patients in the Immediate Bibliotherapy Group (top Chart) received
Feeling Good
at the intake evaluation. The patients in the Delayed Bibliotherapy Group (bottom chart) received
Feeling
Good at the four-week evaluation. BDI-Beck Depression Inventory. HRSD=Hamilton Rating Scat for Depression.

These changes in depression were very significant. You can also see that the patients maintained their gains at the three-month evaluation and did not relapse. In fact, there was a tendency for continued improvement following the completion of the bibliotherapy treatment; the scores on both depression tests were actually lower at the three-month evaluation.

In contrast, you can see in Figure 1 that the patients in the Delayed Bibliotherapy Group barely changed and were still around 20 at the four-week evaluation. This showed that the improvement from
Feeling Good
was not just due to the passage of time. Then Drs. Jamison and Scogin gave the patients in the Delayed Bibliotherapy Group a copy of
Feeling Good
and asked them to read it during the second four weeks of the study. Their improvement in the next four weeks was similar to the improvement in the Immediate Bibliotherapy Group during the first four weeks of the study. You can also see in Figure 1 that the patients in both groups did not relapse but maintained their gains at the three-month evaluation.

The results of this study indicated that
Feeling Good
appeared to have substantial antidepressant effects. At the end of the first four-week Bibliotherapy period, 70 percent of the patients in the Immediate Bibliotherapy Group no longer met the criteria for a major depressive episode, according to the diagnostic criteria for a major depressive episode that are outlined in the American Psychiatric Association’s official
Diagnostic and Statistical Manual
(
DSM
). In fact, the improvement was so great most of these patients did not need any further treatment at the medical center. To the best of my knowledge, these are the first published scientific studies showing that a self-help book can actually have significant antidepressant effects in patients suffering from episodes of major depression.

In contrast, only 3 percent of the patients in the Delayed Bibliotherapy Group recovered during the first four weeks. In other words, the patients who did not read
Feeling Good
failed to improve. However, at the three-month evaluation, when both groups had read
Feeling Good
, 75 percent of the patients in the Immediate Bibliotherapy Group and 73 percent of the patients in the Delayed Bibliotherapy Group no longer qualified for a diagnosis of major depressive episode according to DSM criteria.

The researchers compared the magnitude of the improvement in these groups with the amount of improvement in
published outcome studies using antidepressant medications or psychotherapy or both. In the large National Institute of Mental Health Collaborative Depression study, there was an average reduction of 11.6 points on the HRSD in patients who received cognitive therapy from highly trained therapists for twelve weeks. This was very similar to the 10.6-point change in the HRSD observed in the patients who read
Feeling Good
after just four weeks. However, the bibliotherapy treatment seemed to work significantly faster. My own clinical experience confirms this. In my private practice, very few patients have recovered during the first four weeks of treatment.

The percentage of patients who dropped out of the bibliotherapy therapy was also very small, around 10 percent. This is less than most published outcome studies using drugs or psychotherapy, which typically have dropout rates from 15 percent to over 50 percent. Finally, the patients developed significantly more positive attitudes and thinking patterns after reading
Feeling Good
. This was consistent with the premise of the book; namely, that you can defeat depression by changing the negative thinking patterns that cause it.

The researchers concluded that the bibliotherapy was effective for patients suffering from depression and might also have a significant role in public education and in depression prevention programs. They speculated that
Feeling Good
bibliotherapy might help prevent serious episodes of depression among individuals with a tendency toward negative thinking.