MAJOR DEPRESSIVE DISORDER
“Carlos was born in 1975 in Philadelphia, Pennsylvania. His parents were both born in Puerto Rico but moved to the mainland before their 4 children were born. Trained in Puerto Rico as a plumber, Carlos’s father readily found profitable work in the continental United States. Eventually he moved into selling wholesale plumbing parts and supplies. He worked hard to make his business work and involved all 4 children in the fledgling company at early ages.
Most people with a mood disorder have unipolar depression; that is, they have no history of mania and return to normal or nearly normal mood when their depression lifts. Bipolar disorder, in which people alternate between depression and mania, is the subject of Case 6.
Carlos A Comfortable Climb
By the time Carlos graduated from high school and began working in the family business full time, it was a solid company that sold supplies to plumbers, builders, and contractors in several states. Carlos’s family assumed that he would make a career for himself in the plumbing supply business. Only an average student in school, he couldn’t imagine what would have become of him if he had had to make it on his own. He was proud to carry his load in the family business, and indeed, he felt he had a certain business expertise that his father and brothers respected.
On the other hand, as the baby in a family business, he had a lower status than his brothers during the early years of the business. His brothers did not dominate him deliberately; there were just occasional moments when they would pull rank, so to speak. At the same time, Carlos felt a certain safety and security in what was basically a loving family atmosphere.
At age 22, Carlos married Sonia, whose family was also from Puerto Rico. They dated in high school and got engaged 2 years after graduation. Two years later they were married in a large church wedding. They set up a relatively traditional household, with Carlos working in the family business and Sonia working part-time while taking college courses online. She gave birth to a daughter within a year of their marriage; another daughter followed 4 years later, then a son, and then another son.
Carlos A Sudden Decline
At age 39, Carlos, by now the successful part-owner of his family’s plumbing supplies business and the proud father of 4 children, became increasingly preoccupied with his health. His cousin, who was about 15 years older than Carlos, had recently died of a heart attack. Carlos was saddened by the loss but didn’t think much more of it at the time. However, within a few months he started to worry about himself and ultimately was convinced that he might also have a heart condition. He began taking his pulse constantly and putting his hand to his chest to decide whether his heartbeat was palpable, believing that a pounding heart could be the sign of a heart attack.
According to the DSM-5, it is now possible to diagnose an individual with major depressive disorder even in the context of bereavement. Ultimately, clinical judgment is used to determine whether the reaction is considered appropriate to the loss or a major depressive episode is present in conjunction with the expected symptoms of loss (APA, 2013).
Eventually, Carlos went to see his doctor, even though he had just had a checkup a few months before. The doctor performed an electrocardiogram (EKG) in his office; the results were completely normal. Carlos left the doctor’s office reassured in a factual sense, but somehow it didn’t help his mood. “A heart attack is still possible,” he thought.
Of persons with depression, 41 percent initially go to a physician with complaints of feeling generally ill, 37 percent complain of pain, and 12 percent report fatigue (Katon & Walker, 1998).
In the succeeding weeks, he could not get over the idea of disaster striking. He envisioned the effect his death would have on his wife, children, and brothers and found it devastating. On several nights he awoke with an overwhelming sense of despair and sobbed quietly to himself while Sonia lay asleep next to him.
At work, Carlos lost all interest in his usual activities and could barely focus his thoughts at times. What did anything matter, he thought, when such tragedy could strike? At home he just sat and moped. He looked at his children as if they were already orphans, and tears would come to his eyes.
Carlos decided to see his doctor again. This time, the physician told Carlos that his preoccupation with the idea of a heart attack was getting out of hand. “You’re fine, my friend, so stop your worrying.” As the doctor spoke, Carlos’s eyes welled up with tears, and the doctor realized that this patient was more troubled than he had at first suspected. The physician recommended that Carlos see a psychologist, Dr. Alex Willard, who was also a member of their church, and he told Carlos that a few months with the psychologist would probably be enough to set him on the right track.
Upon hearing Carlos’s recital of his symptoms—feelings of despair, poor concentration, difficulty sleeping, loss of interest in usual activities, and tearfulness—the psychologist told Carlos that he believed he had depression and would benefit from psychological treatment. Dr. Willard also recommended that Carlos consult a psychiatrist, who could advise him on the benefits of antidepressant medication.
Approximately 8 percent of adults in the United States have a severe unipolar pattern of depression in any given year, while another 5 percent have mild forms (Gonzalez et al., 2010; Kessler et al., 2010, 2005). About 19 percent of adults have an episode of severe unipolar depression at some point in their lives.
Carlos left the psychologist’s office shaken. He had not expected to hear an actual diagnosis, and the idea of medication gave him the feeling that the real threat to his well-being was not a heart attack but rather mental illness. In fact, Carlos’s older sister had been diagnosed with schizophrenia years ago and had spent the past 2 decades in and out of institutions. Despite the psychologist’s assurances that Carlos did not have any symptoms of schizophrenia, the troubled man now focused on the possibility that a similar fate could befall him.
Eventually, he went to see the psychiatrist, Dr. Charles Hsu, who had been recommended by Dr. Willard. After interviewing Carlos, Dr. Hsu concurred with the diagnosis of depression. He also reiterated that Carlos’s symptoms had nothing to do with schizophrenia. Dr. Hsu then recommended that Carlos begin taking antidepressant medications.
The psychiatrist explained that antidepressant drugs are ordinarily very effective. Carlos would simply have to follow the medication regimen, taking one or 2 capsules of fluoxetine (Prozac) per day, and this might well be enough to relieve his depression and tide him over this difficult period. When Carlos asked whether he would have to undergo psychotherapy as well, Dr. Hsu replied that many people found taking the medication and undergoing psychotherapy at the same time very helpful, while others improved with medication alone. Carlos decided to try sticking with the medication alone for the time being.
About 60 percent of people with severe unipolar depression respond well to antidepressant medications (Hirschfeld, 1999). However, a recent meta-analysis suggests that the combination of pharmacotherapy and psychotherapy is more effective than either treatment on its own (Cuijpers et al., 2013).
He began taking Prozac but after a few days concluded that he didn’t like the side effects. He called Dr. Hsu and told him that he felt like he was about to “jump out of his skin.” The psychiatrist explained that the jitters were sometimes an initial side effect of Prozac but that they often dissipated with time. He urged Carlos to continue with the medication a bit longer. However, Carlos simply couldn’t stand this feeling and pushed for a change.
Dr. Hsu switched Carlos to a similar antidepressant, sertraline (Zoloft). Although the patient had fewer jittery side effects, he didn’t seem to derive much benefit from the new medication. Furthermore, the sexual side effects were more than he could handle. His feeling of despair persisted, apparently fueled by his sense of defeat at not getting better with Prozac in the first place. The longer Carlos remained depressed, the more he became convinced that he was indeed headed toward a nervous breakdown, like his sister before him. Eventually, he was refusing outright to go to work, and Dr. Hsu felt it would be best to hospitalize him so a concentrated effort could be launched to find an effective medication regimen. Unfortunately, this also meant that Carlos’s worst fears were now (in his eyes) about to be realized.
Carlos spent 3 weeks in the hospital, where various combinations of antidepressant and antianxiety drugs were tried. Ultimately, one combination provided some relief. Carlos was discharged from the hospital, with the plan of continuing to see Dr. Hsu once a week.
Although no longer hospitalized, Carlos was nevertheless struggling mightily. He hoped that if he just continued to take the medication and kept the demands on himself to a minimum, he would gradually recover. Accordingly, he cut his work hours by half, stopped seeing customers, and restricted his activities at the office to paperwork and occasional meetings with his brothers. In his spare time, he thought it best to lead a minimalist existence. At home, he told his wife he could no longer help take care of the children or do any other household chores. Accordingly, he spent his spare time napping, jogging in the park, and trying to watch an occasional television show.
Studies have demonstrated that exercise compares favorably to antidepressant medications for mild to moderate cases of depression (Carek, Laibstain, & Carek, 2011).
The summer went fairly well by Carlos’s current standards. As in the past, the family made their weekend trips to the beach, and Carlos resumed playing softball in his summer league. He was starting to feel a little bit better. Maybe, he thought, this whole horrible business would soon be behind him. As the summer drew to a close, however, Carlos started to get an uneasy feeling, which gradually built into a sense of impending doom. Somehow, he had gotten it into his mind that the end of summer would signal a turning point for him. He became convinced that with the approaching fall, he would either recover or descend into an abyss.
Approximately 40 percent of people with unipolar depression begin to recover within 3 months, with 80 percent recovering somewhat within a year (APA, 2013).
Unfortunately, it was the latter. When fall arrived and Carlos still did not feel completely better, he lost hope of ever recovering, and his condition started to deteriorate again. He became preoccupied with the possibility of becoming sick again, and in due time this preoccupation grew into the previous symptom picture: depressed mood, poor concentration, and loss of interest in usual activities.
Sonia’s View Sinking Along with Carlos
Carlos was not the only person affected by his depression. His wife, Sonia, and their children—the people who lived with him and cared about him—were hurt by it as well. And like Carlos, they were confused by the dramatic changes that they had seen in him. As Sonia explained to her sister:
For years I lived with this strong man who was a good father and caring husband and who worked hard every day to provide a good life for all of us. Then over the course of weeks, I watched him change into a sad, frightened, weak person who could think of nothing but himself—his pain, his health, his unhappiness.
It seemed innocent enough when it first started. When Frank [the cousin] died, we were all upset, and it was natural to think about how young he was and how something like that could happen to any of us. But while the rest of us—his brothers, his cousins, and I myself—got over it and got back to our lives, it seemed to trigger something in Carlos that wouldn’t let go of him.
About half of people with severe unipolar depression also have an anxiety disorder (Fava et al., 2000). In most such cases, the anxiety symptoms precede the depressive symptoms, often by years (Regier et al., 1998).
First it was his fear of having a heart attack. Then his concern about dying. Then worrying about every little thing, overprotecting himself, seeing doom everywhere. I would walk into the family room and find him sobbing. Over what? He was healthy, he was successful, he had a beautiful family, yet he was sobbing.
Time and again, I tried to point out the brighter side of things, to snap him back to his old self, but nothing helped. I talked my guts out, but it was always, “Yes, but this” or “Yes, but that.” He felt doomed and hopeless about everything; nothing made a difference.
It was horrible to see him so upset, but worse was the way he stopped doing anything. At home he stopped being a father and husband. The kids would need help with their homework or have to be driven somewhere. The sink or car would need fixing. Or I would need to talk about finances with him. He could do none of it. He would just sit there, usually staring into space, sighing, or crying. He became like a fifth child. Actually, it was worse than that. At least I could reason with the children, get them to do things, have fun with them.
At work it was the same. His brother Enrique called one day, worried to death about Carlos. He was no longer doing anything there; he hardly was coming into work at all. The brothers had to pick up his work and they were worried. They were angry, too. They couldn’t really understand what was going on, and sometimes they resented the way they had to cover for him, the way he pitied himself, the way he turned them away. What could I tell Ricky? I too was confused and worried and angry. I too was watching him sink.
I was relieved when he went to the hospital. The medicine was not helping and he was only getting worse, and his behavior was really upsetting the children. In addition, I felt that I was in over my head. He was sinking and nothing I did made a difference. What if he decided to do something to himself? He certainly was dropping enough hints in that direction. Finally, I thought, we’ll get this fixed. Actually, it was much easier at home while he was hospitalized. We didn’t have to tiptoe around Carlos or worry about upsetting him or disturbing him. We missed him and were worried about him, but at the same time, the cloud of darkness was temporarily lifted from the house; our spirits improved as well.
Between 6 percent and 15 percent of people with severe unipolar depression commit suicide (Mulholland, 2010; Taube-Schiff & Lau, 2008).
Overall, the hospitalization seemed to help him, and his new medications brought some relief. After his return home, he was very shaky at first. In fact, he did even less than before. But then he seemed to gradually be getting better. By the middle of the summer, I was sure that he had turned the corner. He was more active again, seeing friends and even playing ball again. And he started to do more with the children. I really felt hopeful that I was getting my husband back.
That was a big mistake. For some reason, Carlos crashed down once again in the autumn, just like the leaves falling from the trees. It was like the summer had been a vacation from his depression, and now the vacation was over. I love him, but I don’t think I can take another bout of this. Neither can the children. I doubt that Carlos can take it anymore, either. You know, I used to dismiss it when he said that he wasn’t going to recover, wasn’t ever going to feel happy again. Now I wonder whether he might be right. One thing is for sure. Something has to be done. I told Carlos and his psychiatrist that more must be done. The hospitalization did not work. The medications are not working. More must be done. Last night, I found a video that we made at the beach a year ago. It shocked me. Carlos was a totally different person. I had almost forgotten how confident and happy he used to be. I almost couldn’t recognize him. For his sake, and for ours, we must find that man again. In the meantime, I’ve lost my husband and my children have lost their father.
Carlos in Treatment Focusing on Cognitions
Given Carlos’s latest decline, Dr. Hsu suggested that now was the time to consider psychotherapy, which Carlos had initially hoped to avoid by taking the medication. The psychiatrist explained that he would continue trying to find a medication combination that provided some benefit, but that they should now cover the bases that had been missed up to this point. In particular, Dr. Hsu explained, there was a cognitive form of psychotherapy, suited specifically for depression, that might provide the missing ingredient in the treatment Carlos had received up to this point. He wanted very much for Carlos to see a specialist in this kind of psychotherapy.
Carlos, now more willing to pursue psychotherapy, began treatment with Dr. Robert Walden. Dr. Walden was a psychologist who had trained with Judith Beck, daughter of Aaron Beck, a pioneer in the development of cognitive therapy, at Beck’s Center for Cognitive Therapy in Philadelphia. Dr. Walden agreed with Dr. Hsu and Carlos’s previous practitioners that their client met the DSM-5 criteria for a diagnosis of major depressive disorder. He exhibited a depressed mood most of the time, had markedly reduced pleasure or interest in his usual activities, had difficulty sleeping, and had lost both his energy and his ability to concentrate.
About 60 percent of people with severe unipolar depression respond successfully to cognitive therapy (DeRubeis et al., 2000).
Like other cognitive therapists and researchers, Dr. Walden explained and treated depression largely by focusing on a person’s style of thinking. Although a disturbance in mood is the most obvious symptom of this disorder, research suggests that disturbances in cognition have an important—perhaps primary—role in the disorder. Cognitive therapists believe that depressed individuals have a severe negative bias in their perceptions and interpretations of events, a bias that leads them to experience themselves, events in their lives, and their futures in very negative—depressing—terms. The goal of cognitive therapy is to change this negative bias and negative style of interpretation, and in so doing, remove the source of depression.
Although straightforward in principle, the application of cognitive therapy is no small matter. Concentrated methods have to be brought to bear to rid depressed persons of their cognitive bias. The process includes psychoeducation, self-monitoring by clients, self-examination, sustained questioning by therapists, personal research by clients, and retraining in how to think about things. In addition, behavioral methods are typically used to enhance the cognitive techniques.
Session 1 Most of the first session of psychotherapy was devoted to a discussion of Carlos’s current condition and the events leading up to it. In spite of his obvious distress, Carlos related the events of the past year in a coherent and organized fashion. At the same time, the desperation on his face was almost painful to observe, and his voice trembled with distress. He said he just wanted to know one thing: whether Dr. Walden believed that he could ever be cured. He stated that he had been through a lot and felt that he was down to his last hope. He said he just wanted the straight truth: Was he ever going to get back to normal or not?
As many as 20 percent of the relatives of severely depressed people are themselves depressed (Kamali & McInnis, 2011; Berrettini, 2006).
Like most mental health professionals who encounter a seriously disturbed patient, Dr. Walden found himself wondering for a moment whether Carlos could indeed be restored to his former self. At the same time, the psychologist knew that his own fleeting misgivings were the last thing that Carlos needed to hear right now. The psychologist told him that nothing was guaranteed but that he had agreed to treat Carlos because he had every expectation of bringing about a full recovery. Carlos pressed the matter further, wanting to know specifically when he could expect to be restored to normal. “How many months?” he asked. “Why can’t you tell me?”
Dr. Walden felt no antagonism in Carlos’s close questioning about the timetable. Rather, he knew the questioning reflected Carlos’s sense of desperation, his utter fear that he might be a hopeless case. He was obviously hanging on the psychologist’s every word, looking for some glint of reassurance.
The psychologist felt he had to walk a fine line. On the one hand, he wanted Carlos to have confidence in getting better. On the other hand, given Carlos’s history of becoming unduly focused on his rate of progress and then alarmed at not improving according to a self-determined timetable, Dr. Walden wanted to avoid setting up expectations for improvement by specific dates, foreseeing that if expectations were not met, it would fuel Carlos’s negative view of the future.
Dr. Walden:
I know you’re anxious to get better, and I don’t blame you. It’s natural to wonder when this is all going to end. As I said before, I’m seeing you because, as I told Dr. Hsu, I expect you will recover from this depression and I can hasten the process. At the same time, I am reluctant to place an exact timetable on it, simply because it has been my experience that the rate of improvement varies from person to person. I could, of course, hazard a guess as to when you’ll be better, but I’m concerned that if you don’t have a complete recovery by that date, you might think it means more than it really does.
Carlos:
I know. I would be upset.
Dr. Walden:
So I think it best that we leave the timetable open for now. If the time ever comes when I truly think we’re not getting anywhere, I’ll let you know honestly and we’ll consider our options.
Carlos:
OK. I guess I can live with that.
Dr. Walden spent the remaining 15 minutes of the session giving Carlos a brief overview of the cognitive theory of depression and the implied treatment. He used Carlos’s sensitivity to the timetable of recovery as an example of how certain negative perceptions or interpretations can have powerful effects on the way one feels. In particular, the psychologist noted that a different point of view, one that placed less importance on the exact timetable of recovery, would result in a less catastrophic response to the absence of a full recovery by a certain date.
The psychologist went on to explain that a major part of therapy would be discovering those aspects of Carlos’s thinking and behavior that were undermining his capacity to feel well and then helping him develop alternative ways of thinking and behaving that would ultimately reduce his depression. To begin, the psychologist explained that Carlos would be asked to monitor his emotional reactions throughout the next week, recording all thoughts or events that produced distress (sadness, anger, anxiety, or whatever) and rating their intensity. In the next session, Dr. Walden explained, they would discuss these matters so as to bring out Carlos’s thinking about them. In addition, the psychologist asked him to keep a record of his activities.
Later that evening, the psychologist called Dr. Hsu, as the 2 had agreed (with Carlos’s permission) to keep in close contact to coordinate their treatments. Dr. Hsu indicated that unless the psychologist had any particular objections, he would like to add a low starting dose of aripiprazole (Abilify) to his medication regimen. The psychologist agreed, so the plan was for Carlos to start the new medication the next day.
Atypical antipsychotic medications (traditionally used to treat schizophrenia and other psychotic disorders) are often added to an antidepressant to augment its effectiveness in people with treatment resistant depression (Schlaepfer et al., 2012).
Session 2 Dr. Walden reviewed Carlos’s records of both his moods and his activities, and these provided the focus of discussion. A distressing thought that Carlos had written down several times each day pertained to the seriousness of his current condition, expressed in several forms: “I’m a basket case.” “How did I get so sick?” “l can barely function.” These thoughts seemed to arise spontaneously, particularly when Carlos was inactive.
Dr. Walden engaged Carlos in the type of Socratic dialogue that is typical of cognitive therapy.
Dr. Walden:
You say you are a “basket case” and can barely function. What leads you to those conclusions?
Carlos:
Well, I’ve been hospitalized. That’s how bad it’s been. I just can’t believe it.
Dr. Walden:
I know we discussed it last time, but tell me again what led to that hospitalization.
Carlos:
I sort of got panicked when the medicine didn’t help, and I stopped going to work or doing anything else. Dr. Hsu figured that as long as I wasn’t working, I might as well go into the hospital, where I could try different drugs without having to manage all the side effects on my own. I also was pretty miserable at the time. I told Dr. Hsu my family might be better off without me.
Dr. Walden:
Do you think they would be better off?
Carlos:
I don’t know. I’m not doing them much good.
Dr. Walden:
What would life be like for them without you?
Carlos:
It would be terrible for them. I suppose saying they’d be better off without me is going too far. As bad off as I am, I’m still able to do a few things.
Dr. Walden:
What are you able to do?
Carlos:
Well, I’m not in the hospital anymore. And I don’t think I will be back either. When I went into the hospital, I didn’t really feel any worse than I do now. I mainly went in because I thought I could get better treatment or whatever. But it didn’t pan out, so what would be the point of going back in?
Dr. Walden:
So the fact that you were in the hospital isn’t really a sign that you are now or ever were a “basket case,” which I take to mean someone who is completely helpless and can’t function.
Carlos:
No. If I knew then what I know now, I probably wouldn’t have been hospitalized at all. In looking back on it now, it was all basically voluntary. But that doesn’t erase the fact that I’m still a mess.
Dr. Walden:
How much of a mess are you?
Carlos:
I can’t work, I can’t help out at home, I can’t even watch a television show. What else do you want to know?
Dr. Walden:
A couple of minutes ago you said you were still able to do a few things. What are those?
Carlos:
I can drive to work and . . . I guess it’s an exaggeration to say that I can’t work at all. There are a few things that I do at the office.
Dr. Walden:
Like what?
With continued discussion, the psychologist helped Carlos to recognize the various capabilities that he did have, and how, in practical terms, he wasn’t as compromised as the terms “basket case” and “barely able to function” implied. Dr. Walden also pointed out that Carlos really didn’t know the limits of his capabilities because he had deliberately reduced the demands on himself under the questionable assumption that “stress” would worsen his condition. The psychologist suggested that they start testing this assumption by having Carlos make a few simple additions to his activities. After some discussion, it was decided that each day Carlos would make a concerted effort to get up and leave for work at 8:00 A.M., the same time he used to leave before his depression set in. Second, it was decided that Carlos would read a bedtime story to his 2 younger children each night; moreover, it was specified that he try hard to attend to the content of the story, rather than allow his thoughts to drift off into his own concerns. He was to note on his activity record his daily success in carrying out these 2 assignments.
Studies have found that depressed subjects have a variety of biases in attention, interpretation, and memory for negative events. They recall unpleasant experiences more readily than positive ones, denigrate their performance on various tasks, and expect to fail in various situations (Gotlib & Joormann, 2010; Wenze, Gunthert, & German, 2012).
Finally, Dr. Walden asked that Carlos continue to keep a record of his unpleasant emotions and the thoughts associated with them. This time, however, the client was also to try to produce alternative, more realistic thoughts by considering whether his initial thoughts truly reflected all the evidence. Furthermore, the more realistic thoughts were to be written down.
When nondepressed subjects are manipulated into reading negative statements about themselves, they become increasingly depressed (Bates et al., 1999).
Session 3 Carlos appeared upset when he came in for the third session. He said that he had begun taking the Abilify 5 days ago—he had put off starting it, even though Dr. Hsu had written the prescription almost 2 weeks ago—and he had pronounced light-headedness. He stated that the medication only made him feel worse, and he was inclined to stop.
The psychologist’s private feeling was that Carlos, although having actual side effects, was becoming unduly alarmed over the sensations and as a result was experiencing the effects more intensely than he might otherwise. He needed some help in tolerating the sensations psychologically until his body adjusted. Dr. Walden was particularly concerned that Carlos not repeat the scenario of 6 months ago with Prozac, when he became panicked over the initial side effects, insisted on going off the medicine, and lapsed into despair over his prospects of recovery.
Sales of antidepressant drugs total $11 billion annually. Antidepressants are also the third most prescribed class of drugs, just behind analgesics and antihyperlipidemics (CDC, 2010).
Dr. Walden:
Tell me exactly what you’ve been feeling since you started the medicine.
Carlos:
I feel light-headed, dizzy, especially when I get up suddenly.
Dr. Walden:
Have you spoken to Dr. Hsu about it?
Carlos:
Yeah. He says that this sometimes happens when people start this medicine, but it will probably get better.
Dr. Walden:
Why does it bother you so much?
Carlos:
I don’t know. It makes me feel like I might topple over or something.
Dr. Walden:
Have you toppled over?
Carlos:
No. It just feels like I might.
Dr. Walden:
Has the light-headedness prevented you from doing anything? Were you able to drive here, for example?
Carlos:
I drove. In fact, while I’m driving I don’t seem to notice it that much.
Dr. Walden:
Is there anything that you feel you can’t do because of the symptoms?
Carlos:
Well, I didn’t leave for work at 8:00, like we had agreed. I figured, given the way I’m feeling, why push myself?
Dr. Walden:
What about reading to the kids?
Carlos:
I did that! It worked out fine. I made a point of focusing just on the story for the 15 minutes or so that it lasted, and I was amazed I could actually do it. I’ve read them a story every night this week.
Dr. Walden:
Great! I’m glad that you made that effort, and it sounds like you got some satisfaction from it.
Carlos:
Yeah. But this light-headedness, it really bothers me.
Dr. Walden:
Remember last week when I pointed out the principle of considering all the evidence both for and against a particularly upsetting thought that you have and then trying to produce a more balanced thought? How about trying your skill at this situation with the light-headedness? What is your immediate thought about the light-headedness? Why does it bother you so much?
Carlos:
Well, I guess my immediate thought is, “This light-headedness is terrible, I’m not going to be able to function at all.”
Dr. Walden:
What is the evidence?
Carlos:
I guess the evidence shows that I’m still doing at least as much this week as I did last week, in spite of the light-headedness. Also, considering what Dr. Hsu said, it probably won’t last, or it should get better.
Dr. Walden:
So what is the more balanced thought?
Carlos:
I guess it is that this is a damn nuisance, but it’s a known side effect of the medicine and does not mean that something is going wrong or that I’m going downhill.
Based on his more balanced conclusion for his behavior, Carlos decided it was worth putting up with the light-headedness temporarily to see if the medicine would benefit him. Second, he decided he should not eliminate any of his activities on account of the light-headedness unless there was clear evidence that carrying out the activity presented a physical hazard. This meant that if he noticed a surge of light-headedness, he would persevere with his ongoing activity. In addition, it was decided he would once again attempt last week’s assignment of leaving for work every morning by 8:00 A.M. and continue reading to the kids for 15 minutes every night.
Session 4 Dr. Walden asked Carlos first about the behavioral assignments. The client reported that he had continued to read to the children each evening throughout the week and was doing so with a “clear head.” On the other hand, he complained that for the rest of the evening, he would just sit around and mope, sometimes sitting in the living room chair for an hour or more worrying about his condition and his inability—or lack of desire—to do anything else while the rest of the family went about their normal activities. Dr. Walden asked him about his negative thoughts during this period, and the client replied that it was the same old thing, meaning thoughts about being a basket case and unable to function. The psychologist asked Carlos if he was able to refute such thoughts when they arose. The client replied that he was carrying out the exercise of weighing the evidence and forming alternative thoughts, but that within a few minutes the negative thoughts would return. Then he would carry out the thought exercise all over again. It was getting to be repetitive.
On hearing this, Dr. Walden reviewed with Carlos their earlier discussions about the objective extent of Carlos’s disability. The client acknowledged that his characterization of his condition as being a basket case was exaggerated, but he seemed to have trouble holding on to this more accurate assessment and had to remind himself constantly that he was in fact functioning reasonably well, all things considered.
Dr. Walden felt that the next step was for Carlos to bring the force of behavior behind his reformulated thoughts. That is, it was time for Carlos to participate more fully in the family’s evening routine. Such participation would help to refute his exaggerated perceptions of being dysfunctional and promote greater belief in the alternative: that he was temporarily depressed but still capable of doing more than he allowed. Second, more activity would provide a wider range of stimulation, thus diverting Carlos’s thinking from its strictly depressive content. Finally, from the standpoint of family dynamics, becoming more active would help to bring Carlos’s existence more in tune with the family’s, leading to a more normal family environment and at the same time reducing some of the tension with Sonia, who was becoming increasingly angry at being the only responsible adult in the household.
A large portion of this session was therefore devoted to working out in detail the appropriate routine for Carlos to follow in the evening at home. It was decided that he would follow a set routine upon returning home from work: (a) talk to his wife about her day, (b) eat dinner with the family, setting aside his own concerns and attending as closely as possible to the conversation, including asking the children some questions about their day, (c) assist the children with their homework, (d) read the newspaper or watch television, (e) read to the children before bed, (f) do household or work-related paperwork, (g) go to bed.
At the end of the session, the psychologist asked Carlos about his success in leaving for work by 8:00 A.M. Carlos reported that he had found he could do it but had learned that it was important not to get caught up in what he termed a “stall mode” in the morning—by which he meant becoming so wrapped up in his thoughts that he paused and brooded for several minutes at a time before proceeding to the next task. The best strategy, he observed, was to maintain his momentum by going directly from one task to another. As for the light-headedness, Carlos noted that it was greatly reduced this week, as Dr. Hsu had predicted, so he was less concerned about it.
The main assignments for the coming week were outlined on paper: (a) Continue to leave for work at 8:00 A.M. consistently, avoiding the “stall mode,” (b) follow the new evening routine, and (c) continue to record negative thoughts and to produce more balanced alternatives.
Session 5 Carlos reported that he had been able to follow the prescribed routine at home. He found that keeping his attention focused on the concrete tasks before him—reading the kids a story, asking them questions about school, doing some paperwork—had a way of reducing his pattern of depressive thinking. He told Dr. Walden he was pleased with his ability to do these things, and he was even starting to enjoy some activities. In fact, he spontaneously decided to go to the playground a couple of times to play catch with his older son and had a pleasant time. His wife, on the other hand, was not so pleased with the changes, Carlos remarked.
Carlos:
Well, she obviously prefers me this way as compared to the old way, but now she’s asking me why I couldn’t do these things before. Her idea, basically, is that it is too little too late. She said she’s had a year of misery.
Dr. Walden:
What are your thoughts on why you couldn’t do those things before?
Carlos:
I don’t know. It’s still sometimes a struggle to do them now, but I feel better doing them. I never realized the connection between how I was thinking and acting and how I felt. Also, I wonder if the new medicine has anything to do with it. I’m feeling better, but I tried at least a dozen different medicines in the past and none really seemed to do that much. Do you think this one is helping? I don’t want to be taking something that isn’t necessary.
Dr. Walden:
There is no way of knowing for sure how much the medicine is helping. The 2 treatments—the psychotherapy and the drug therapy—were started more or less at the same time, so your improvement could be due to the medicine, the psychotherapy, or the combination. Regardless, the good news is that you are improving, so I don’t think we should even consider your going off the medicine for the time being.
Further discussion returned to the question of Sonia and her resentment of the past. Carlos’s initial thinking was, “She’s self-centered; she has no appreciation for what I’ve been through; she’s just going to make my condition worse and undo my progress. Pretty soon I’ll just be back in the same boat.” Dr. Walden had him weigh the evidence both for and against such notions. The client recognized that most of Sonia’s actions in the past year had indeed been supportive, even if she did have occasional lapses into frustration. He also recognized that he would get worse only if he himself strayed from his current regimen, and he had no intention of doing so. His more rational conclusion was, “She’s been a good wife throughout all of this, especially considering the hard time she’s been through. If I just show some understanding, it will probably help her frustration. In the meantime, she’s not doing anything that would prevent me from getting better.”
As many as half of depressed clients may have marital problems. In such cases, couple therapy may be as helpful as cognitive therapy (Teichman et al., 1995).
The next discussion turned to Carlos’s routine at work. He reported that he was spending about 6 hours a day at work (9:00 A.M. to 3:00 P.M.), but he found himself frequently feeling depressed there. Apparently he had severely cut down his activities at work under the assumption that stress could exacerbate his condition. As a result, he had a lot of dead time on his hands, which he would spend sitting at his desk, staring at his computer and brooding over the extent of his disability and his rate of progress. Carlos was doing his best to refute his negative thinking—reminding himself of his improvements—but it seemed like a never-ending process.
Dr. Walden pointed out the inconsistency between Carlos’s attempts to refute his negative thoughts and his actual behavior in the situation:
Dr. Walden:
It’s good that you’re challenging the incorrect idea that you’re a basket case and can’t function. But if you really know that such thinking is wrong, why are you still limiting your activities at work?
Carlos:
I guess I’m afraid that any increased stress might ruin my progress.
Dr. Walden:
What happened when you started taking on more responsibilities at home?
Carlos:
I got less wrapped up in my worries.
People who consistently ruminate—that is, repeatedly dwell on their moods without acting to change them—are more likely to become clinically depressed than people who do not generally ruminate (McLaughlin & Nolen-Hoeksema, 2011; Zetsche et al., 2012).
Dr. Walden:
What lesson does that seem to teach for the work situation?
Carlos:
That I should start doing more things. I’m not even doing the minimum. And I can’t say that I ever had that much stress from work. I mean, I’m one of the owners. I set my own pace. I always put in a good day’s work—at least I used to—but I never saw any point in going overboard.
Dr. Walden:
So getting back to my original question about how to conduct yourself at work . . .
Carlos:
I know, I know. It makes no sense at this point to be slacking off like I am.
Carlos agreed to gradually start building up his activities at work. Specifically, he would (a) leave the office at 5:00 P.M. rather than 3:00 P.M., (b) resume handling telephone sales calls, and (c) resume attending the daily sales meetings with his brothers and the sales associates. For now, he would omit seeing customers face-to-face, going on sales visits, or taking overnight business trips.
All other aspects of the treatment program (record keeping, thought exercises, the home routine) remained in place.
Later, the psychologist once again contacted Dr. Hsu to exchange observations. Dr. Hsu said he had met with Carlos the previous day and was impressed with the gains he was making. He said he normally would be inclined to increase the Abilify dose at this point but decided to hold off, since Carlos was doing so well at the low dose. In Dr. Hsu’s experience, every increase in medication caused a level of disturbance in Carlos that it was probably better to avoid. Dr. Hsu indicated that he planned to maintain Carlos’s current medications indefinitely.
If people who respond to antidepressant medications stop taking the drugs immediately after obtaining relief, they run as much as a 50 percent risk of relapsing within a year. The risk of relapse decreases considerably if they continue taking the drugs for 5 months or so after being free of depressive symptoms (Kim et al., 2011; Ballas, Benton, & Evans, 2010).
Session 6 This session focused on Carlos’s adjustment to the fuller day at work. The client’s overall impression was that it was going well. He noted particularly that when he was actively engaged in practical activities—talking on the phone to customers, attending meetings, speaking to co-workers about business concerns—he tended not to brood. In contrast, when he retreated to his office and sat idly at his desk, he became caught up in depressive thoughts and images.
Dr. Walden suggested that Carlos use this observation to his advantage and do what he could to minimize the brooding. The psychologist recommended that he follow a 4-step mental procedure to cope with periods of brooding. Step one was simply to recognize that he was getting caught up in depressive thinking. Step 2 was to identify the specific negative thoughts he was having. Step 3 was to consider the evidence and then produce more rational or balanced thoughts. Step 4 was to put the issue aside and turn his attention to practical matters.
Carlos liked the idea of having a concrete procedure to follow and remarked that he had already applied a similar strategy on his own in a few situations. But why couldn’t he just sit and do nothing without getting depressed? Dr. Walden explained that there was no such thing as doing nothing. The mind is always active; if it is not engaged in one thing, it is engaged in something else. The point was for Carlos to keep his mind engaged in rational and constructive activities rather than irrational and destructive ones.
Sessions 7 to 9 Over the course of the next 3 weeks, Carlos applied the 4-step procedure as consistently as possible and was reaping the benefits. He was becoming more and more engaged in the practical aspects of daily life and less consumed with negative thinking. As a result he was feeling normal most of the time. He was participating fully in the family routine, and at work he was meeting the responsibilities he had set for himself. As he functioned better, it strengthened his conviction that he was not headed for a permanent mental collapse.
During this period Carlos had an episode of anger after his eldest brother questioned a decision that he had made at work. An extended therapy discussion revealed Carlos’s negative thinking: “Ricky thinks I’m incompetent; he has no respect for the good work I do around here; he thinks he’s smarter than anybody.” With Dr. Walden asking Carlos to weigh the evidence, he came to realize that this characterization was not accurate. Far from thinking he was smarter than anybody, Ricky was a nervous person who fretted constantly about the smallest business details, worrying about mistakes he might have made, and generally making a pest of himself with everybody. Carlos now recognized that when Ricky questioned one of Carlos’s decisions, it reflected his brother’s own insecurity more than anything else. With this understanding, Carlos felt he could take his brother’s comments more in stride.
Studies reveal that depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendships (Moos & Cronkite, 1999).
Sessions 10 to 14 In the 4 weeks comprising Sessions 10 to 14, Carlos had returned to full functioning and was in good spirits most of the time. He had even resumed going on overnight business trips. Accordingly, the therapy sessions themselves were now devoted to relapse prevention. The goal was to help Carlos understand the basic beliefs underlying much of his depressive thinking.
It was, for example, apparent that the client’s most fundamental depressive belief was a so-called vulnerability to harm and illness schema—a belief that disaster is about to strike at any time and that the client is helpless to protect himself. This particular belief seemed to be the basis of Carlos’s original preoccupation with heart disease and his preoccupation later on with the prospect of a total mental breakdown.
Session time was spent reviewing the various negative thoughts that had arisen from this belief. The goal was to improve Carlos’s ability to recognize when the belief was active and to take it as a cue to confront the resulting negative thoughts. As one exercise, the therapist had Carlos practice verbally refuting those negative thoughts.
In a related vein, Carlos’s current behavior patterns were scrutinized for any remaining practices that might inappropriately be producing a sense of vulnerability in him. In this regard, he noted that he was still cutting short his exercise regimen, a remnant from the time when he was preoccupied with heart attacks. He decided he would now reinstate an exercise level more in tune with his athletic interests and his true physical capacity.
Epilogue
Because Carlos had had such a severe depression prior to cognitive therapy, both Dr. Walden and Dr. Hsu decided to follow up with him monthly and have him continue to take a low dose of his medicines for at least 18 months. Carlos continued to feel well during this period, and his symptoms did not return after the medicines were withdrawn. With each day, he became more convinced that a dark cloud had been lifted from his life—more accurately, that he had lifted the cloud. It was not that he felt happy every minute of every day, but rather that he felt armed to cope with and even conquer life. Problems were now perceived as challenges—challenges that could be overcome, challenges from which he could grow. The dark cloud had indeed been lifted.”
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