Treatment of Major Depression at the Austen Riggs Center: An Integrated and Personalized Treatment Approach
by David Mintz, MD
Is Depression Just a Chemical Imbalance?
Over the last several decades, the mainstream psychiatric understanding and treatment of major depression has increasingly been seen through the lens of neurobiology: a problem of chemical imbalance, for which the first line treatment is often the correction of the chemical imbalance with antidepressant medications. While it is undoubtedly true that major depression involves alterations in brain chemistry, this approach has proven to have severe limitations. First, there is little evidence for the “chemical imbalance” theory of depression (Leventhal & Antonuccio, 2009; Pies 2014). More importantly, despite the widespread use of antidepressants in the U.S. population, rates of depression appear to be rising, not falling (Compton et al., 2006, Twenge, 2014). Within mainstream psychiatry, “treatment resistance” is increasingly recognized as a crisis for the field, with an exponential increase in references in the psychiatric literature to the problem of treatment resistance (Mintz & Flynn, 2012). The chemical imbalance theory itself may even contribute directly to the epidemic of treatment resistance by increasing social and self-stigmatization (Kemp et al, 1014).
This is not to say that antidepressants do not offer benefits, but that these benefits are often incomplete. Evidence suggests that the average patient who has benefited from antidepressant medications will be left with residual symptoms severe enough that a reasonable person with such symptoms would seek treatment to alleviate those symptoms (Westen & Morrison, 2001).
A Biopsychosocial Approach to Treating Depression
At the Austen Riggs Center, we recognize that depression represents a complex and unique interplay of biological vulnerabilities, social stressors, adaptive efforts (which are also often maladaptive), and other psychological factors. Given that, the treatment program at Riggs is integrated and personalized to addresses all aspects of the biopsychosocial continuum. This integration assumes that the vulnerability to depression is most effectively treated when patients are supported in their efforts to become more efficacious, more resilient, and better able to form and make healthy use of relationships. The combination of individual and community treatment (which you will read about in Part 2 of this series), supported by thoughtful pharmacotherapy, aims not simply to reduce symptoms (which is the primary aim of many treatments), but to support personal growth and enhance the capacity to function.
Individual Psychodynamic Psychotherapy for Major Depression
All treatments are anchored in and guided by an in-depth psychological understanding of the patient that is developed with the patient’s psychotherapist in four-times-weekly psychotherapy. This understanding relies not only on what is learned in the psychotherapy, but gathers a range of experiences of the patient in group settings and in interaction with other members of the treatment team. The deep understanding of the patient allows for individualization of treatments. The depressed patient, for example, who becomes hopeless in the context of unbearable losses or traumas is likely to have different needs from the depressed patient whose perfectionism leaves him or her vulnerable to relentless and crushing self-criticism.
The Role of Family Work in Treating Depression
In a comprehensive and integrated treatment of depression, family work is often an important element of treatment. It is not unusual, for example, to discover some aspect of the family culture, often passed down from distant generations, that has generally been experienced as adaptive, and that represents an important mismatch with the depressed patient’s psychology. In this way, families may find that efforts to help the patient paradoxically seem to complicate things. An understanding of how family dynamics affect the identified patient helps families to become more flexible and better able to support the growth of the patient and other members of the family.
Psychodynamic Psychopharmacology – the Meaning Behind Medication
The majority of patients with depression at the Austen Riggs Center are also treated pharmacologically, though our research suggests that they do leave here generally on fewer medications than when they arrived. What differentiates psychopharmacology at the Austen Riggs Center is that prescribers are attentive to those aspects of the evidence base (Mintz & Flynn, 2012) that suggest psychological and interpersonal factors have a profound influence on medication outcome. Medication outcomes are enhanced by a focus on what medications mean to the patient (and perhaps even the family). Ambivalence about treatment is taken seriously and incorporated into a collaborative effort to find a medication that will help the patient achieve their developmental aims. The recognition that a good doctor-patient alliance has a robust impact on medication outcome means that the patient-pharmacotherapist pair will also attend to the status of their relationship as a routine aspect of the work.
Compton W.M., Conway K.P., Stinson F.S., and Grant B.F. “Changes in the Prevalence of Major Depression and Comorbid Substance Use Disorders in the United States Between 1991-1992 and 2001-2002.” American Journal of Psychiatry, 164 (December 2006): 2141-2147. doi: 10.1176/ajp.2006.163.12.2141.
Kemp, J. J., Lickel, J. J., and Deacon, B. J. “Effects of a Chemical Imbalance Causal Explanation on Individuals' Perceptions of their Depressive Symptoms.” Behaviour Research and Therapy, 56 (May 2014): 47-52. doi: 10.1016/j.brat.2014.02.009.
Leventhal, A. M., and Antonuccio, D. O. “On Chemical Imbalances, Antidepressants, and the Diagnosis of Depression. Ethical Human Psychology and Psychiatry 11, no. 3 (December 2009): 199-214. doi: 10.1891/1559-4318.104.22.168.