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Economic Depression and the Economic Burden

Dr Justin Thomas (LIVING) 20 May 2009



It seems almost ironic that as the world teeters on the precipice of Depression 2.0, depression the psychological illness is also poised to become one of the worlds leading burdens of disease. A study commissioned by the World Bank several years ago foretold that by the year 2020 the economic burden of depression would be second only to that of heart disease, and amongst women, it would become the number one burden globally, today it already stands at number 4. These rising rates of depression worldwide, and the massive financial implications of treating depression have directed significant research activity towards identifying the most effective treatments. In the search for clinical and cost effective treatments for depression talk-based psychotherapies are the emergent star performer. They have been found to perform at least as well as drugs sometimes even better in terms of immediate symptom relief. Furthermore one of the key reasons depression is so costly in economic terms is its near chronic relapse rates, some studies suggest as many as 80 per cent of patients will have multiple episodes, on average of 4 major episodes within a lifetime, with an average duration of 20 weeks each. For this reason it is massively important that a treatment is also able to prevent relapse. One particular, psychotherapy known as cognitive behavioral therapy (CBT), often outperforms antidepressant drugs in clinical trials, but more importantly, it has also consistently been found to reduce the rate of relapse in depression. These findings have lead several nations, the UK being a particularly notable case, to recommend CBT as a treatment of choice for depression. The first thing to note about CBT is that is not entirely new, and its techniques have arguably been used for millennia. History in general is full of examples of individuals employing what we might today consider CBT interventions. For example, the Greek Philosopher Socrates argued that it was through reason and logic he was able to transcend his predisposition to laziness and womanising. Islamic history too has many examples, Ibn Hazm an 11th century scholar from Islamic Spain proposes a specific imaginal exercise to be employed in the case of chronic jealousy. This particular intervention involved imagining that the person one envied came from a distant land. Ibn Hazm based this technique on the interesting social psychological insight that people tend to envy those they view as more similar to themselves. Moving further East a 9th century case study from Syria describes how the eminent physician Bukhtishu Ibn Jibrail successfully employs a form of cognitive behavioural psychotherapy to help the young Prince, Al Mutazzbillah, overcome what is arguably the first recorded case of Anorexia Nervosa. The established psychotheraputic tradition we know today as Cognitive Behavioral Therapy grew from dissatisfaction with the prevailing psychotherapeutic trends of the 1950s. At that time there were two dominant schools, the Freudian psychoanalytic school with its emphasis on the unconscious mind and childhood experiences; and its antithesis, the behaviourist school, which totally ignored thought, insisting the mind was not a legitimate object of enquiry, and therefore focused exclusively on observable behaviour. At one end of the spectrum there was a complex, speculative, and abstract psychoanalysis, and on the other a very objective but rather restrictive behaviour therapy. CBT rejected, but also drew on both traditions, as with psychoanalysis there is a focus on mental activity, but rather than speculate about unconscious mental processes and early childhood experiences, CBT primarily focuses on conscious thought in the here and now. In common with behaviour therapy, cognitive therapy can be highly structured, it too emphasises the scientific method, and it also makes use of many behavioural techniques. Despite sharing techniques with behaviour therapy, cognitive therapy radically diverges in its view of the mechanisms of change. For the behaviour therapist emotional change is assumed to occur through the process of habituation, whereas for the cognitive therapist the change is brought about through the conscious construction of new operating principals and beliefs, in short, changes in thinking. The basic assumption of CBT is that distorted thinking patterns and dysfunctional beliefs contribute to the onset and maintenance of depression. The main aim of the therapist is to work collaboratively with clients to identify and replace these distorted patterns of thinking, with more functional ones. By the end of therapy a client has typically gained some valuable techniques they can employ by themselves to help stave off future episodes. This is the main benefit of CBT, it helps the client, the true expert on their situation, become his or her own therapist. If Depression 2.0 persists and deepens as some predict it will, the need for therapists trained in CBT may be even greater than that predicted by the World Bank study. Dr Justin Thomas is a psychologist and an Assistant Professor with the department of Natural Sciences & Public Health at Zayed University Abu Dhabi
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