Feeling Good: The New Mood Therapy (85 page)

The patient may end up in a rather passive role as a kind of human test tube. You may think I am exaggerating, but I have seen numerous patients who were in just this position. They were taking lots of drugs with lots of side effects but were receiving very little benefit from any of them. I have treated many of these patients successfully with cognitive therapy and no drugs or cognitive therapy and only one antidepressant

I believe that some psychiatrists rely too much on drugs. Why is this? One problem is that most psychiatric training programs strongly emphasize biological theories about depression and stress the importance of drug treatments for depression and other disorders. In addition, a great many of the continuing education programs for psychiatrists in practice are sponsored by drug companies, and the focus of these conferences is nearly always on medications. The psychiatric journals, too, are filled with expensive drug company advertisements promoting the benefits of the latest medications for depression or anxiety, but I have never seen an ad promoting the latest psychotherapy technique. This is because there is simply no money to pay for such an ad! Drug companies also fund a great deal of the research on medications that appears in psychiatric journals, and concerns have been voiced about the potential conflict of interest inherent in such arrangements.

I do not mean to sound like a rabble-rouser! This is not a black-or-white issue. Clearly, the excellent research conducted by the pharmaceutical industry has been an enormous boon to the psychiatric profession and to individuals suffering from psychiatric disorders. My concern is that the emphasis on drugs sometimes seems excessive. Unfortunately, some psychiatrists do not have good training in the newer forms of psychotherapy, including cognitive behavioral therapy, which can be so helpful for individuals suffering from depression and anxiety. When a patient does not respond to medications, the main response of the psychiatrist may be to increase the dose or add another medication because this is what the psychiatrist has been trained to do. And when a patient complains of an adverse side effect, the psychiatrist may decide to add some other additional drug as an antidote—because that is what she or he has been trained to do. The result in some cases is that patients end up taking more and more drugs in larger and larger doses—without any real benefits. This is when polypharmacy can get out of hand.

When I was a psychiatric resident, I used to have the idea that if only I could find the right “magic bullet” (in other words, the right pill), I could help every patient. In those days, we treated our patients with pill after pill after pill but very little psychotherapy. My clinical experience taught me over and over again that this model was not sufficient—too many of my patients simply did not recover, no matter how many drugs I used, singly or in combinations.

To make things worse, most psychiatrists do not require patients to take mood tests, like the one in Chapter 2, between therapy sessions to track progress. As a result, the psychiatrist may conclude that the patient is being “helped” by a drug when the patient has not really improved substantially. To my way of thinking, treating patients without session-by-session assessments is anti-scientific and represents a barrier to good treatment and progress in the field.

Some psychiatrists and many patients are almost exclusively committed to these biological theories and treatments for depression. They may discount the value of other approaches, sometimes with a religious fervor. A number of well-known psychiatrists are quite outspoken in this regard. The intensity of these debates about psychotherapy versus drug therapy is sometimes more reminiscent of a power struggle for turf than an intellectual search for the truth. Fortunately, there is a growing and healthy trend to recognize that all of our current psychiatric drugs are limited in their effectiveness. In addition, there is an increasing recognition that a combination of medication with the newer forms of psychotherapy (including cognitive behavioral therapy and others) usually provides a more satisfactory outcome than does treatment with drugs alone.

It is clear that antidepressant drugs can help some individuals, but it is also clear that many patients do not respond adequately. When patients do not respond, I would prefer to switch into a different gear and use cognitive therapy or a combination of cognitive therapy and one antidepressant medication at a time. Most depressed people have real problems in their lives, and nearly all of us need a compassionate, healing relationship with another human being to talk things out at times. The idea that drugs alone should work to cure depression and anxiety may be appealing, but this approach is often ineffective.

To be fair, an exclusive focus on psychotherapy alone can be just as biased. I have seen patients who did not respond to many psychotherapeutic interventions that I personally administered—week after week their depression scores on the test in Chapter 2 did not change. Sometimes I prescribed an antidepressant while we continued working with a variety of psychotherapeutic strategies. Within several weeks, the depression and anxiety often began to improve, and the psychotherapy suddenly began to work better. In these cases, I was glad to have the medications available.

A final problem contributing to polypharmacy is that
many patients are unassertive. Even though they feel uncomfortable about all the drugs they are taking, they may sometimes assume that “the doctor knows best.” This is understandable. The doctor does have a great deal of training, and the patient’s knowledge is usually limited. In addition, the patient often admires the doctor and respects his or her advice. But in psychiatry and psychology, treatment approaches are far more subjective and varied than in internal medicine, where the treatments are far more precise and uniform. Your feelings about the treatment are important, and you have every right to share these feelings with your doctor.

This review of drug-prescribing practices obviously represents my own approach. Your physician’s ideas might differ. Psychiatry is still a blend of art and science. Perhaps some day the “art” will no longer be such a prominent ingredient. If you feel uncertain about your treatment, ask your physician questions. State your concerns and urge your doctor to explain the treatment in simple terms you understand. After all, it’s your brain and body that are at risk, not the doctor’s. The sense of teamwork and collaboration are important to successful treatment. As long as the two of you agree to a rational, understandable, and mutually acceptable strategy for your therapy, you will have an excellent chance of benefiting from your doctor’s efforts to help you.

The Feeling Good Handbook
(New York: Plume, 1990). Dr. Burns shows how you can use cognitive therapy to overcome a wide variety of mood problems such as depression, frustration, panic, chronic worry and phobias, as well as personal relationship problems such as marital conflict or difficulties at work.

Intimate Connections
(New York: Signet, 1985). Dr. Burns shows you how to flirt, how to handle people who give you the run-a-round, and how to get people of the opposite sex (or the same sex, if that is your preference) to pursue you.

Ten Days to Self-Esteem
and
Ten Days to Self-Esteem: The Leader’s Manual
(New York: Quill, 1993). In this ten-step program, Dr. Burns provides a practical, workable blueprint for breaking out of the bad moods that rob us of self-esteem. He provides you with clear, easy-to-understand instructions and specific tools gleaned from twenty years of systematic research and psychiatric practice. The
Leader’s Manual
shows you how to develop this program in hospitals, clinics, schools, and other institutional settings.

Dr. Burns offers workshops and lectures for mental health professionals and for general public audiences as well. For a list of dates and locations, you are invited to visit Dr. Burns’ Web site at www.FeelingGood.com

Burns,
The Perfectionist’s Script for Self-Defeat
.

Dr. Burns helps you identify perfectionistic tendencies and explains how they work against you. He shows you how to stop setting unrealistically high standards and increase productivity, creativity, and self-satisfaction.

Burns,
Feeling Good
.

Dr. Burns describes ten common self-defeating thinking patterns that lead to depression, anxiety, frustration, and anger. He explains how to replace them with more positive and realistic attitudes so you can break out of bad moods and enjoy greater self-esteem now and in the future.

Strategies for Therapeutic Success: My Twenty Most Effective Techniques—Volumes I and II
. 8 Cassettes

In this two-day intensive workshop, Dr. Burns illustrates the most valuable therapy techniques he has developed during two decades of clinical practice, training, and research.

Feeling Good: Fast & Effective Treatments for Depression, Anxiety, and Therapeutic Resistance
. 4 Cassettes

Dr. Burns describes the basic principles of CBT and illustrates state-of-the-art treatment methods for depression and anxiety disorders. He also illustrates how to deal with
difficult, angry patients who seem to sabotage the treatment because they feel mistrustful and unmotivated.

Feeling Good Together: Cognitive Interpersonal Therapy
4 Cassettes

In this workshop, Dr. Burns shows how to modify the attitudes that sabotage intimacy and lead to anger and mistrust. He also explains how to deal with patients who blame others for their personal relationship problems.

Rapid, Cost-Effective Treatments for Anxiety Disorders
4 Cassettes

In this workshop, Dr. David Burns shows you how to integrate three powerful models in the treatment of the entire spectrum of anxiety disorders, including generalized anxiety, panic disorder (with or without agoraphobia), phobias, social anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder (including victims of childhood sexual abuse).

You may order the audiotapes for professionals or for the general public by visiting Dr. Burns’ Web page at www.FeelingGood.com

Therapist’s Toolkit 2000

Includes hundreds of pages of state-of-the-art assessment and treatment tools for the mental health professional. Purchase includes licensure for unlimited reproduction in your clinical practice. Site licenses are available.

You are invited to visit Dr. Burns’ Web site at www.FeelingGood.com. This Web site contains information about:

The pagination of this electronic edition does not match the edition from which it was created. To locate a specific passage, please use the search feature of your e-book reader

Page numbers in
italics
refer to figures and tables. A small “n” following a page number refers to a note on that page.

accomplishments, self-esteem and, 327–30

  advantages of, 328

  disadvantages of, 328–29

  does work equal worth, 331–41

accurate empathy, 185–91

achievement

  DAS test score and, 285

  worth and, 327–41

achievement trap, 346–51

action, motivation and, 125–27

active death wish, 387

Adapin, 379

  side effects, 531

adaptive anger, 163–64

Adler, Alfred, 10n

adolescent rejection, 301–2

Agras, Stuart, xxii

air-traffic controllers, 409

alcohol, 330

all-or-nothing thinking, 32–33, 42

American Psychiatric Association, xxvi

amitriptyline (Elavil, Endep), 448–49,
518

  side effects, 499–500,
530

amoxapine (Asendin),
519

  side effects,
536

amphetamines, 330

Anafranil, 484, 518

  side effects,
530

anger, 149–97

  as adaptive, 163–65

  cognitive therapy and, 153

  Freud on, 153

  frustration and, 195–96

  internalized, 153

  irrational statements, 159–60

  labeling, 157