Act to relieve depression

One of my colleagues is married to a man who suffers from severe depression. “Sometimes I get so frustrated,” she told me recently. “I know this is an illness, but when he becomes depressed he doesn’t want to leave the house. But I think he’d feel better if he did.”

Depression is a complex illness, which develops and manifests in a multitude of ways. But for some people, at least one study suggests that taking some type of action, such as maintaining a routine, may indeed relieve depression.

The study, conducted at the University of Washington and involving nearly 250 people, compared standard cognitive behavioral therapy with an expanded version of behavioral therapy called behavioral activation therapy.

Cognitive therapy targets persistent self-defeating thoughts. Cognitive behavioral therapy, a version that includes behavioral training and homework, has become one of the most widely used treatments for depression. But some researchers have questioned how much work the cognitive part of the therapy really does.

Behavioral activation therapy, the alternative used in the study, is based on the idea that depressed people withdraw from the routine activities and demands of daily life to avoid emotional pain. As a result, they receive fewer rewards and become more depressed.

For example, a depressed person in the midst of a conflict with a coworker stays home for several days. Withdrawing from feeling as well as action, she avoids immediate conflict but deprives herself of the satisfying knowledge that she is completing tasks and earning money, while doing nothing to address the original problem. What would help her in the long run is temporarily difficult and unpleasant. As depression progresses and deepens, that may come to include getting out of bed in the morning.

In behavioral activation therapy, the therapist is interested in the function of negative thinking — the way it promotes withdrawal — rather than its rightness or wrongness, as in conventional cognitive behavioral therapy. Patients are shown how to find out and record what gives them a feeling of accomplishment, then do it more.

Patients are taught, for example, to maintain regular routines and schedules while exploring alternative behavior by role-playing. They also learn to avoid pessimism and gloomy rumination by directing their attention to the immediate experience of their senses. In this respect, behavioral activation therapy resembles the newer mindfulness-based cognitive therapies.

In the University of Washington study, people with major depression were divided into four groups that received behavioral activation therapy, cognitive behavioral therapy, an antidepressant medication, or a sugar pill (placebo). Treatment continued for 24 sessions over four months while standard questionnaires measured changes in the symptoms. Results were tracked separately for mildly depressed and severely depressed patients.

Patients in all four groups improved, and all treatments were equally effective for the mildly depressed patients. For the severely depressed, behavioral activation and the antidepressant drug were equal, and both were superior to cognitive behavioral therapy and the placebo.

But patients taking the medication or placebo were much more likely to drop out than those receiving psychotherapy. So, overall, behavioral activation therapy was the most successful treatment. When depressed people were prodded into action, it seemed, their thoughts followed — and in a positive direction.

Of course, this is just one study. But it suggests that for some people who are severely depressed, taking action is therapeutic.

Do you know someone who is severely depressed, who withdraws from day-to-day activities? It’s not easy to prod someone without it feeling like nagging. To push and support at the same time is challenging. In your experience, what has helped?

Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.

Depression
Nearly 1 in 10 adults will suffer from some form of depression in a given year, affecting not only them, but also their friends and family. Thankfully, years of research and recent breakthroughs have made this serious illness easier to treat. With Understanding Depression, a special health report from Harvard Medical School, you can stay up-to-date on the latest information on depression symptoms and treatments to improve your life—or the life of someone close to you.

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