The Why Files The Why Files --

Depression: Bluer than blue


Making them whole
If depression is the leading cause of suicide, and a top cause of disability, what can we do to treat it? One key to treating -- even preventing -- depression sounds simple enough: sleeping well, eating well and getting enough exercise.  In an old portrait, a bearded man sits in a chair wearing a black jacket and waistcoat.According to psychologist Jon Allen of the Menninger Clinic, "I believe that healthy living is as important or more important than treatment." Depression, he says, seems to occur after a "stress pile-up. If you take seriously the idea that depression is a response to overwhelming stress, what will make you resilient to stress is fundamentally your bodily health. Medications and therapy are important, but what is the point of treatment if you drink [lots of alcohol] or don't get enough sleep?"

"Abraham Lincoln fought clinical depression all his life," according to The Atlantic Monthly. Photo: National Archives

There is plenty of evidence that exercise helps treat and prevent depression. For example, a 2004 study of middle-schoolers by Rod Dishman of the University of Georgia showed that "A naturally occurring change in physical activity across time was inversely associated with a change in levels of depressive symptoms across time."

But while physical activity is especially helpful for warding off depression, once the condition arises, the medical and psychological prescriptions typically include other approaches:

Anti-depressants medicines, including the older tricyclic antidepressants and the newer selective serotonin reuptake inhibitors, such as Prozac.

Cognitive-behavioral therapy, which tries to help patients "concretely deal with negative thoughts and problematic behavior, and avoid situations and conflicts that can trigger episodes," says Kenneth Wells, a professor of psychiatry and health services at UCLA, who also studies depression at the Rand Corporation.

Interpersonal psychotherapy, which focuses on dealing with grief or conflicts with a spouse or boss.

All of these strategies can work, but is there room for improvement? Yes, according to a 2005 study by Wells and colleagues that combined education for adolescent patients and doctors with case-management and evidence-based medicine. To disenjargonate:Mousey woman with alert eyes and close-cropped hair wears a large dark dress In case management, managers guide patients through the medical system to prevent patients from getting lost in the system. (Case management, says Wells, "is increasingly suggested for chronic disease management.") The techniques of evidence-based medicine are based on scientific studies, rather than a therapist's intuition or experience. Thus the cognitive-behavioral therapy used in the experiment relied on a general "script" that had already proven itself.

Many have speculated that reclusive American poet Emily Dickinson (1830-1886) was a depressive, but it's impossible to know for sure. Image: Library of Congress

After 12 to 16 weeks of treatment, the structured approach to recruitment, training and therapy proved superior to the usual care for depression. Patients with case management and evidence-based medicine reported fewer depressive symptoms, better mental health-related quality of life, and more satisfaction with mental-health care.

Give me money, honey, if you want to get along with life
Delivering higher quality care for depression cost about $300 to $500 per patient, in part because the psychotherapists attended a one-day workshop, and were supervised during their initial treatments. John Keats quote: 'I am in that temper that if I were under water I would scarcely kick to come to the top.'The price tag, Wells says, is "not out of the realm" of what it costs to introduce a new medical technology, and "For most people, the benefit greatly exceeds the cost."

In other studies, Wells and colleagues have used the structured approach with minorities and low-income people, "who have a high burden of disease and low access to care." Simply offering better care "caused minorities to improve four or five times more than the whites," Wells says. "They had almost no prior experience with treatment, so there were a lot of treatment-responsive people who got their first chance at better care."

The benefit of the structured intervention was still evident five years later, Wells adds. At that point, 80 percent of whites were well or getting care, compared to only 50 percent of the minorities in the control group. However 70 percent to 80 percent of the minority people who had received the structured care were either well or in treatment. "Basically that means the outcome disparity was overcome just by having the opportunity for one episode for better care," Wells says. "People learned something about their disease; they did not have five years of micromanagement. They got it in one shot, and they figured out what they needed to stay well."

Lynn Rehm of the University of Houston agrees that while antidepressant medicines can heal, they don't teach. "If you are off medications, you are off treatment, and are susceptible to relapse. There is fairly good evidence that ... if you go through the newer cognitive-behavioral therapy, your probability of relapse is significantly reduced. Presumably you have learned some skills for dealing with stressors that will carry you forward in the future."

Check out the anti-depression bibliography.


Megan Anderson, project assistant; Terry Devitt, editor; S.V. Medaris, designer/illustrator; David Tenenbaum, feature writer; Amy Toburen, content development executive

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