Always look on the rational side of life

Cognitive behavioural therapy helps depressed patients see the silver lining. A new study shows it works like SSRIs

Marcello Palmieri

Before cognitive behavioural therapy (CBT): "My situation is awful, it's a catastrophe that I lost my job and it only shows what a loser I am." After CBT: "I'm talented. My wife loves me. I'm financially secure." (From Psychotherapy: a cognitive approach)

In recent years, CBT has found a place alongside standard antidepressant drug regimens as an effective way of beating the blues. A psychological approach used to treat clinical depression and anxiety, CBT teaches patients how to identify negative thoughts and then replace them with more positive and reasonable thoughts. How effective is it? CBT actually creates changes at the brain level, much like antidepressants.

According to a new study published in the January 2004 issue of the Archives of General Psychiatry,

THE THEORY
In the study, neuroscientists from Toronto's Rotman Research Institute at Baycrest Centre for Geriatric Care, in collaboration with the Centre for Addiction and Mental Health and the U of T, revealed for the first time that depressed patients receiving CBT showed brain changes that were distinct from patients using drug therapy. This understanding of how the brain reacts differently to different treatments is helping researchers unravel the mystery of why one treatment works for some patients, but not others.

Dr Helen Mayberg, Chair of Neuropsychiatry at the University of Toronto, led a team studying 14 adults with clinical depression who received 15 to 20 individualized sessions of CBT but without drugs. Their progress was compared to 13 adults who only received the antidepressant paroxetine (Paxil).

The researchers scanned the patients' brains before and after therapy using positron emission tomography (PET). They discovered that CBT targets many of the same regions as the drug therapy, but in different ways. "The two treatments are complementary but not overlapping," says Dr Mayberg. In the 14 adults receiving CBT, brain scans showed a decrease in activity in upper brain regions, but an increase in activity in lower brain regions. For the group receiving the antidepressant, the complete opposite was seen, yet patients from both groups showed significant improvements.

THE PRACTICE
Dr Mark Berber, consultant psychiatrist at Markham Stouffville Hospital in Markham, ON has seen the same results on the ground. "Pharmacotherapy is enhanced when used together with CBT. In my experience, this combination has brought the most lasting beneficial effects for my patients," he says. That said, getting his patients to learn about CBT hasn't been easy. "One of the problems I've experienced as a clinician is explaining the basics of CBT in a short yet effective manner. Patients told me they found the books too long and overwhelming."

Dr Berber decided to take matters into his own hands, and rolled up his sleeves and went to work to present the CBT concepts in small bite-sized portions, one step at a time. He tackled all the major CBT books and extracted the essential ingredients. The result is a 12-page booklet entitled Psychotherapy: A Cognitive Approach, published with help from Wyeth-Ayerst in May 2002. "The booklet is meant as a springboard that aims to educate both patients and physicians about CBT and have them read it from cover to cover," explains Dr Berber.

In the booklet, Dr Berber describes the case of John, a 40-year-old married man who becomes depressed after he unexpectedly loses his job as a computer engineer. John's immediate reaction is hopelessness. The therapist intervenes and challenges his negative thoughts by asking two key questions: "What is the evidence for these thoughts?" and "What is the evidence against these thoughts?" Through therapy and reflection John is able to reason that the positive aspects of his talents, reputation, and personal life far outweighed his recent calamity.

The doctor suggests that there are six 'life zones' -- personal growth, health, relationships, work, money, and leisure -- that need to be considered. If there's a problem in one zone, a person will feel 'out of sorts.' But if the other five are in good shape, taking a hit in one won't seem like it's the end of the world. The booklet also contains a variety of tips, forms, and recommended reading for doctors and patients interested in CBT.

Copies are available by calling 1-800-263-1188 (ext.4333 or ext.3985).