MetaChat is an informal place for MeFites to touch base and post, discuss and
chatter about topics that may not belong on MetaFilter. Questions? Check the FAQ. Please note: This is important.
Kidding aside, I think it's very cool that he replied. I should have posted this on the blue so more people could read about his approach.
I wonder how he arranges his 14-week plan for the participants. Does he gradually add, or does he start out with all six measures (TLC essentials).
Regardless, I think it's a great approach that a lot of people could benefit from.
The six TLC essentials:
EXERCISE: Aerobic exercise is a potent antidepressant. Elevate your pulse between 120 to 160 beats per minute for 35 minutes three times weekly.
SLEEP: Chronic sleep deprivation puts one at risk for depression; get 7 or 8 hours nightly.
SUNLIGHT: The brain needs 2,500 lux for 30 to 60 minutes per day. Spend a half hour outdoors on a sunny day or in front of a 10,000 lux light when it is overcast.
EAT FISH: 1,000 milligrams daily of Omega-3 type EPA fatty acids has been shown to relieve depression. It is found in highly concentrated fish oil, also in tuna, mackerel, sardines, lake trout and salmon.
SOCIALIZE: Social support helps prevent depression during major losses. Separation from friends and family is a common trigger for depression.
THINK POSITIVE: Dont dwell on repetitive, negative thoughts. Learn to redirect attention to more engaging activities.
According to the article, the participants also attend group talk therapy.
It's a cool project, but it's also the same list my therapist gave me when I went for depression treatment a few years ago. The innovative part is not the supporting research, but assembling it into the program, which makes sense as a sort of intensive approach.
Miko, the nice thing about this program is that if it's consistently successful it'll end up mainstream, which means that doctors who are currently prescribing meds as a one-size-fits-all solution will start considering this program first. Or, even better, patients will start asking for it. Most of the people I know on Prozac (or equivalents) get it from their physician and they get it because they ask for it. That's the beginning and end of their therapy.
I responded in more depth in the original thread, but the approach, while good, is revolutionary in neither approach (all sensible recommendations that many therapists have been using for years) nor in success (we've known since the 80s that therapy is remarkably effective). So I disagree with you, small_ruminant, if the only thing necessary for people to consider therapy before meds were for therapy to be a documented success, we would already be where you imagine we might be in the future.
(Two years ago the British Medical Journal recommended in an editorial that therapy be used first with most depressive episodes before meds are considered.)
While I agree it's not revolutionary, there may be something to be said for publicizing the message. Doctors need to hear it more, laypeople need to hear it more, and I suspect a number of therapists need to hear it more.
Seriously though, I know those are all things I should be doing to overcome my own depression instead of simply depending on my prescription for Effexor (which seems to be losing is efficacy). I want to be better, but how do I make myself do them? In other words - wanting is one thing, doing is whole 'nother ball of wax.
Doctors need to hear it more, laypeople need to hear it more, and I suspect a number of therapists need to hear it more.
I agree, of course, which is why I always harp on what we know to be effective in psychotherapy.
But, as I said in the original thread, that's part of my objection to this. If we know (and we do) that these specific things, that this particular technique, is not magical, then we should be talking less about finding a new way to do things and more about what we already know works. Like the myth of the fad diet, talking too much about specific ingredients actually obscures the general constituents that can do the most good.
If we know (and we do) that these specific things, that this particular technique, is not magical, then we should be talking less about finding a new way to do things and more about what we already know works.
Well, part of the problem, at least in the States, is that most insurance won't pay for therapy, or it will only pay for a really limited amount of therapy. I think mine lets you see a therapist 10 times or something like that. And if you don't have insurance at all, then therapy can be prohibitively expensive. I've been very lucky in sort of circumventing that (shhhh) by finding a therapist who actually donates time to a center that has a sliding scale - so I can afford to go on seeing him so that he can, repeatedly, encourage me to go outside, exercise, get enough sleep, notice when I'm slipping into bean overanalysis, etc. I need that encouragement, too, because otherwise it's just too easy not to do those things. It's very difficult to get it together and manage those "TLC Essentials" by yourself when you're depressed.
In the immortal words of my mother, if you can remember to drink half a gallon of water and take two aspirin before bed, you weren't drunk enough to get a hangover anyway. Likewise, if you can manage to eat properly and sleep properly and exercise properly and socialize and so on, you're already doing pretty damn well.
I thought it might be good to take a few minutes to address some of the comments and questions about Therapeutic Lifestyle Change that you've posted here.
1) LoriFLA - As you suspected, we introduce the six primary elements of TLC quite gradually, as it's important to enhance each patient's sense of self-efficacy/confidence by building on success. Thus, in the first group session, aside from making introductions, covering the treatment model in depth, explaining symptoms and causes of depression, etc. - the only major intervention we introduce is the omega-3 supplement. In week 2 we add material about identifying the process of rumination and various strategies for interrupting it, etc.
2) Miko - You're absolutely right . . . even though there has existed solid research support for each element of TLC for at least 5 years, they've never been empirically tested in combination before, and there has never existed an integrative protocol for helping patients put them all into practice. Several years ago I had a horrific sinus infection (my first), and my gp put me on a standard antibiotic at a standard dose. I returned 10 days later even more miserable, so he upped the dose. After 3 weeks of agony, I finally self-referred to an ENT specialist who told me, "with an infection this bad, we need to hit it with everything we have: 2 different antibiotics, a nasal steroid, a decongestant, an expectorant, and time spent with a humidifier." Within a few days I was a a new man! The same principle seems to be involved in our TLC approach to depression. Depressive illness is often a horribly difficult-to-treat disorder, and it just makes sense that we'd want to hit it with a number of different efficacious interventions.
3) Omiewise - I couldn't agree more that a key issue in fighting the depression epidemic right now is getting the word out to the public that there are effective treatments available other than meds, which often have intolerable side effects. In fact, according to an analysis by Valuck et al. published in American Journal of Psychiatry (August 2007), antidepressant use has plummeted in the past couple years since the FDA advisory regarding increased risk of suicide, but many diagnosed depressed patients are simply getting no treatment at all.
Regarding your other points, though, Omiewise, I'm afraid I'm going to have to disagree somewhat. You suggest that the TLC interventions have been widely used by therapists for years, but that does not at all match either the self-report of patients in our clinical trials, or the report of the hundreds of depressed college students I've talked with in recent years. Most of them tell me that, at best, their therapists might have done a little hand-waving about the potential benefit of exercise or fish oil or bright light exposure, with no concrete information provided about: (a) specific dosage (e.g., of the few that had actually started taking an omega-3 supplement, fewer than 10% were taking the recommended dose of 1000mg/day of the psychoactive EPA molecule - most were simply taking one pill per day when it would have required SIX to get an adequate dose); and (b) specific guidance about HOW to make these lifestyle changes, i.e., how to go from theory to practice.
Finally, I'll note that our preliminary results in TLC in a sample of over 60 depressed patients (mostly severe, chronically depressed, and treatment-resistant) have been very encouraging, with a 76% rate of favorable response compared with 27% response rate among those receiving treatment-as-usual in the community (meds and/or traditional therapy).
I probably won't have time to make it back on this site for a while, but I want to invite anyone with further questions or comments to drop by my blog at http://psychpundit.blogspot.com.
Steve--I'm really glad you're seeing such great results. If your results truly do contest the null hypothesis that it's the general and not the specific factors of psychotherapy that are helpful, it will be fascinating to read them. Since the evidence for that hypothesis is so strong (several hundred studies analyzed in several substantial meta-analyses), however, until I read the evidence I'm going to continue to take the null hypothesis as proved. Not incidentally, those same analyses put the effect size for psychotherapy in general @ 0.80 (or, 79% of patients helped), numbers which mirror yours. This suggests that your treatment is as (or slightly less) efficacious than all other therapy.
'Effect size' in meta-analyses refers to the difference (in standard deviations) between the therapy and control conditions on the dependent variable of interest. The effect size estimate tells you nothing, in and of itself, about the proportion of patients helped, which will tend by vary dramatically by diagnosis. Its interpretation also hinges critically on the intervention represented by the control condition.
In our preliminary outcome data with TLC, we've seen an effect size of about 1.50 thus far (much larger than those in the aforementioned meta-analyses), and considerably larger than typically reported in the depression treatment outcome literature. Accordingly, I'm cautiously optimistic . . .
photo by splunge
photo by TheophileEscargot
photo by Kronos_to_Earth
photo by ethylene
