Archives: Consumer Topics

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

References

1 Blehar MD, Oren DA. Gender differences in depression. Medscape Women's Health, 1997; 2(2):3. Revised from: Women's increased vulnerability to mood disorders: integrating psychobiology and epidemiology. Depression, 1995; 3:3 12.

2 Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubin Stiper M, Wells JE, Wickramaratne PJ, Wittchen H, Yeh EK. Cross national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association, 1996; 276: 293 9.

3 Narrow WE. One year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. Unpublished table.

4 Sackeim HA. Commentary: Functional brain circuits in major depression and remission. Archives of General Psychiatry, 2001; 58(7): 649 50.

5 Regier DA, Rae DS, Narrow WE, Kaelber CT, Schatzberg AF. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, 1998; 173(Suppl. 34): 24 8.

6 Depression Guideline Panel. Clinical practice guideline, number 5. Depression in primary care: volume 1. Detection and diagnosis. AHCPR Pub. No. 93 0551. Rockville: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, 1993.

7 Shalev AY, Freedman S, Perry T, Brandes D, Sahar T, Orr SP, Pitman RK. Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 1998; 155(5): 630 7.

8 Strakowski SM, DelBello MP. The co occurrence of bipolar and substance use disorders. Clinical Psychology Review, 2000; 20(2): 191 206.

9 NIMH Fact Sheets on Depression and Other Illnesses. June 2002.

10 Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.

11 Lewinsohn PM, Hoberman HH, Rosenbaum M. A prospective study of risk factors for unipolar depression. Journal of Abnormal Psychology, 1988; 97(3): 251 64.

12 Pollack W. Mourning, melancholia, and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147 66.

13 Cochran SV, Rabinowitz FE. Men and depression: clinical and empirical perspectives. San Diego: Academic Press, 2000.

14 Robins L, Regier D. Psychiatric disorders in America. New York: Free Press, 1991.

15 Kochanek KD, Murphy SL, Anderson, RN, Scott, C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.

16 Moscicki EK. Epidemiology of suicide. In: Jacobs D, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey Bass, 1999; 40 71.

17 Moscicki EK. Epidemiology of completed and attempted suicide: toward a framework for prevention. Clinical Neuroscience Research, 2001; 1: 310 23.

18 Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278(14): 1186 90.

19 Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. American Family Physician, 1999; 60(3): 820 6.

20 Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide and Life Threatening Behavior, 2001; 31(Suppl): 32 47.

21 Bruce ML, Pearson JL. Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Dialogues in Clinical Neuroscience, 1999; 1(2): 100 12.

22 Little JT, Reynolds CF III, Dew MA, Frank E, Begley AE, Miller MD, Cornes C, Mazumdar S, Perel JM, Kupfer DJ. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 1998; 155(8): 1035 8.

23 Reynolds CF III, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA, Stack JA, Pollock BG, Kupfer DJ. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 1999; 281(1): 39 45.

24 Klerman GL, Weissman M. Increasing rates of depression. Journal of the American Medical Association, 1989; 261: 2229 35.

25 Weissman MM, Wolk S, Goldstein RB, Moreau D, Adams P, Greenwald S, Klier CM, Ryan ND, Dahl RE, Wickramaratne P. Depressed adolescents grown up. Journal of the American Medical Association, 1999; 281(18): 1701 13.

26 Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab Stone ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, Regier DA. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC 2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865 77.

27 Angold A, Worthman CW. Puberty onset of gender differences in rates of depression: a developmental, epidemiologic and neuroendocrine perspective. Journal of Affective Disorders, 1993; 29: 145 58.

28 Angold A, Costello EJ. Depressive comorbidity in children and adolescents: empirical, theoretical, and methodological issues. American Journal of Psychiatry, 1993; 150(12): 1779 91.

29 Kovacs M. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care, 1997; 20(1): 36 44.

30 Birmaher B, Brent DA, Benson RS. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(11): 1234 8.

31 Ryan ND, Puig Antich J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, Iyengar S, Twomey J. The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 1987; 44(10): 854 61.

32 March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807 20.

33 McClellan J, Werry J. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(Suppl 10): 157S 76S.

34 Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339 48.

35 Shaffer D, Craft L. Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 1999; 60(Suppl 2): 70 4; discussion 75 6, 113 6.

36 Kochanek KD, Murphy SL, Anderson, RN, Scott, C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.

37 Ferguson JM. SSRI antidepression medications: adverse effects and tolerability. Primary April 12, 2005Care Companion Journal of Clinical Psychiatry. 2001; 3: 22 27.

38 Clayton AH, Warnock JK, Kornstein SG, Pinkerton R, Sheldon Keller, McGaravey EL.A placebo-controlled trial of bupropion SR as an antidote for selective serotonin reuptake inhibitor-induced sexual dysfunction. Journal of Clinical Psychiatry, 2004; 65(1): 62 67.

39 Nurnberg HG, Hensley PL, Gelenberg AJ, Fava M, Lauriello J, Paine S. Treatment of antidepressant associated sexual dysfunction with sildenafil: a randomized controlled trial. Journal of the American Medical Association, 2003; 289(1): 56 64.

40 U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/home.html

41 Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. Journal of the American Medical Association, 2001; 285(10): 1299 307.

42 Rami, L; Bernardo, M; Boget, T; Ferrer, J;Portella, M; Gil Verona, J; Salamero, M. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one year longitudinal study. The Journal of Neuropsychiatry Clinical Neurosciences, 2004; 16: 465 71.

43 Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized, controlled trial. Journal of the American Medical Association, 2002; 287(14): 1807 14.

The following staff of the NIMH Public Information and Communications Branch were contributing writers and editors of this booklet: Rayford Kytle, Margaret Strock, Melissa Spearing, Clarissa Wittenberg, Daisy Whittemore, Ruth Dubois, Lisa D. Alberts, Jennifer K. Loukissas, and James Petersen. Scientific review was provided by Matthew V. Rudorfer, M.D., and Jane L. Pearson, Ph.D., of NIMH.

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

NIH Publication No. 4972
Page last reviewed by NIH September 23, 2010

Reviewed by athealth on February 5, 2014.

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

How to Help Yourself if You Are Depressed

"It affects the way you think. It affects the way you feel. It just simply invades every pore of your skin. It's a blanket that covers everything. The act of pretending to be well was so exhausting. All I could do was shut down. At times you just say 'It's enough already.'" --Steve Lappen, Writer

Depressive disorders can make one feel exhausted, worthless, helpless, and hopeless. It is important to realize that these negative views are part of the depression and do not accurately reflect the actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Engage in mild exercise. Go to a movie, a ballgame, or participate in religious, social, or other activities.
• Set realistic goals and assume a reasonable amount of responsibility.
• Break large tasks into small ones, set some priorities, and do what you can as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Expect your mood to improve gradually, not immediately. Feeling better takes time. Often during treatment of depression, sleep and appetite will begin to improve before depressed mood lifts.
• Postpone important decisions. Before deciding to make a significant transition–change jobs, get married or divorced–discuss it with others who know you well and have a more objective view of your situation.
• Do not expect to 'snap out of' a depression. But do expect to feel a little better day by day.
• Remember, positive thinking will replace the negative thinking as your depression responds to treatment.
• Let your family and friends help you.

How Family and Friends Can Help

The most important thing anyone can do for a man who may have depression is to help him get to a doctor for a diagnostic evaluation and treatment. First, try to talk to him about depression­help him understand that depression is a common illness among men and is nothing to be ashamed about. Perhaps share this booklet with him. Then encourage him to see a doctor to determine the cause of his symptoms and obtain appropriate treatment.

Occasionally, you may need to make an appointment for the depressed person and accompany him to the doctor. Once he is in treatment, you may continue to help by encouraging him to stay with treatment until symptoms begin to lift (several weeks) or to seek different treatment if no improvement occurs. This may also mean monitoring whether he is taking prescribed medication and/or attending therapy sessions. Encourage him to be honest with the doctor about his use of alcohol and prescription or recreational drugs, and to follow the doctor's orders about the use of these substances while on antidepressant medication.

The second most important thing is to offer emotional support to the depressed person. This involves understanding, patience, affection, and encouragement. Engage him in conversation and listen carefully. Do not disparage the feelings he may express, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's doctor. In an emergency, call 911. Invite him for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push him to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure.

Do not accuse the depressed person of laziness or of faking illness, or expect him 'to snap out of it.' Eventually, with treatment, most people do get better. Keep that in mind, and keep reassuring him that, with time and help, he will feel better.

Where to Get Help

If unsure where to go for help, talk to people you trust who have experience in mental health, for example, a doctor, nurse, social worker, or religious counselor. Ask their advice on where to seek treatment. If there is a university nearby, its departments of psychiatry or psychology may offer private and/or sliding scale fee clinic treatment options. Otherwise, check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians," for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for a mental health problem, and will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.

• Family doctors
• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Religious leaders/counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University or medical school affiliated programs
• State hospital outpatient clinics
• Social service agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

Within the Federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers a "Services Locator" for mental health and substance abuse treatment programs and resources nationwide. Visit their Web site athttp://www.mentalhealth.samhsa.gov/databases/ or call toll-free, 1-800-789-2647.

Conclusion

A man can experience depression in many different ways. He may be grumpy or irritable, or have lost his sense of humor. He might drink too much or abuse drugs. It may be that he physically or verbally abuses his wife and his kids. He might work all the time, or compulsively seek thrills in high risk behavior. Or, he may seem isolated, withdrawn, and no longer interested in the people or activities he used to enjoy.

Perhaps this man sounds like you. If so, it is important to understand that there is a brain disorder called depression that may be underlying these feelings and behaviors. It's real: scientists have developed sensitive imaging devices that enable us to see depression in the brain. And it's treatable: more than 80 percent of those suffering from depression respond to existing treatments, and new ones are continually becoming available and helping more people. Talk to a healthcare provider about how you are feeling, and ask for help.

Or perhaps this man sound like someone you care about. Try to talk to him, or to someone who has a chance of getting through to him. Help him to understand that depression is a common illness among men and is nothing to be ashamed about. Encourage him to see a doctor and get an evaluation for depression.

For most men with depression, life doesn't have to be so dark and hopeless. Life is hard enough as it is; and treating depression can free up vital resources to cope with life's challenges effectively. When a man is depressed, he's not the only one who suffers. His depression also darkens the lives of his family, his friends, virtually everyone close to him. Getting him into treatment can send ripples of healing and hope into all of those lives.

Depression is a real illness; it is treatable; and men can have it. It takes courage to ask for help, but help can make all the difference.

"And pretty soon you start having good thoughts about yourself and that you're not worthless and you kind of turn your head over your shoulder and look back at that, that rutted, muddy, dirt road that you just traveled and now you're on some smooth asphalt and go, 'Wow, what a trip. Still got a ways to go, but I wouldn't want to go down that road again.'" --Patrick McCathern, First Sergeant, U.S. Air Force, Retired

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Diagnostic Evaluation and Treatment

Your tendency is just to wait it out, you know, let it get better. You don't want to go to the doctor. You don't want to admit to how bad you're really feeling. -Paul Gottlieb, Publisher

The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional.

A good diagnostic evaluation will include a complete history of symptoms: i.e., when they started, how long they have lasted, their severity, and whether the patient had them before and, if so, if the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and if they were effective. Last, a diagnostic evaluation should include a mental status examination to determine if speech, thought patterns, or memory has been affected, as sometimes happens with depressive disorders.

Treatment choice will depend on the patient's diagnosis, severity of symptoms, and preference. There are a variety of treatments, including medications and short term psychotherapies (i.e., "talk" therapies), that have proven effective for depressive disorders. In general, severe depressive illnesses, particularly those that are recurrent, will require a combination of treatments for the best outcome.

Medications

There are several types of medications used to treat depression. These include newer antidepressant medications–chiefly the selective serotonin reuptake inhibitors (SSRIs)–and older ones, the tricyclics and the monoamine oxidase inhibitors (MAOIs). The SSRIs (and other newer medications that affect neurotransmitters such as dopamine or norepinephrine) generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects, pages 19 20) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, you should never discontinue your medication without first talking to your doctor. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.

For more information, visit the NIMH website at http://www.nimh.nih.gov/healthinformation/antidepressant_child.cfm.

Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, doctors must carefully monitor these treatments to determine if the patient is getting the most effective dosage. The doctor should check regularly the dosage of each medicine and its effectiveness.

For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis (a sharp increase in blood pressure) that can lead to a stroke. The doctor should furnish a complete list of prohibited foods, and the patient should carry it at all times. Other forms of antidepressants require no food restrictions. Efforts are underway to develop a "skin patch" system for one of the newer MAOIs, selegiline. If successful, this may be a more convenient and safer medication option than the older MAOI tablets.

Medications of any kind ­ prescribed, over the counter, or borrowed ­ should never be mixed without consulting a doctor. Health professionals who may prescribe a medication, such as a dentist or other medical specialist, should be told of all the medications the patient is taking. Some medications, although safe when taken alone, can cause severe and dangerous side effects if taken in combination with others.

Alcohol, including wine, beer, and hard liquor, or street drugs may reduce the effectiveness of antidepressants and should be avoided. However, doctors may permit people who have not had a problem with alcohol abuse or dependence to use a modest amount of alcohol while taking one of the newer antidepressants.

Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally, under close supervision, in medically ill depressed patients.

Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this illness. Doctors must carefully monitor its use as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood stabilizing anticonvulsants, valproate (Depakote®) and carbamazepine (Tegretol®). Both of these medications have gained wide acceptance in clinical practice, and the Food and Drug Administration has approved valproate for first line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal®), and topiramate (Topamax®); however, their role in the treatment of bipolar disorder is not yet proven and remains under study.

Most people who have bipolar disorder take more than one medication. In addition to lithium and/or an anticonvulsant, doctors often prescribe a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.

Side Effects

Before starting a new medication, ask the doctor to tell you about any side effects you may experience. Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically, these are annoying, but not serious. However, any unusual reactions or side effects, or those that interfere with functioning, should be reported to the doctor immediately.

The most common side effects of the newer antidepressants (SSRIs and others) are:

• Headache ­ will usually go away.
• Nausea ­ also temporary, but even when it occurs, it is short lived after each dose.
• Insomnia and nervousness (trouble falling asleep or waking often during the night) ­ may occur during the first few weeks but are usually resolved over time or with a reduction in dosage.
• Agitation (feeling jittery) ­ notify your doctor if this happens for the first time after the drug is taken and is persistent.
• Sexual problems ­ consult your doctor if the problem is persistent or worrisome. Although depression itself can lower libido and impair sexual performance, SSRIs and some other antidepressants can provoke sexual dysfunction. These side effects can affect more than half of adults taking SSRIs. In men, common problems include reduced sexual drive, erectile dysfunction, and delayed ejaculation. For some men, dosage reductions or acquired tolerance to the medication reduce sexual dysfunction symptoms. Although changing from one SSRI to another has generally not been shown to be beneficial, one study showed that citalopram (Celexa®) did not seem to cause sexual impairment in patients who had experienced such events with another SSRI.³⁷

Some clinicians treating men with antidepressant associated sexual dysfunction report improvement with the addition of bupropion (Wellbutrin®)38 or sildenafil (Viagra®)³⁹ to ongoing treatment. Be sure to discuss the various options with your doctor and inquire about other interventions that can help.

Tricyclic antidepressants have different types of side effects:

• Dry mouth ­ drinking sips of water, chewing sugarless gum, and cleaning teeth daily is helpful.
• Constipation ­ adding bran cereals, prunes, fruit, and vegetables to your diet should help.
• Bladder problems ­ emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; notify your doctor if there is marked difficulty or pain. This side effect may be particularly problematic in older men with enlarged prostate conditions.
• Sexual problems ­ sexual functioning may change; men may experience some loss of interest in sex, difficulty in maintaining an erection or achieving orgasm. If they are worrisome, discuss these side effects you're your doctor.
• Blurred vision – will pass soon and will not usually necessitate a new glasses prescription.
• Dizziness ­ rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem – usually passes soon. If you feel drowsy or sedated you should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

Psychotherapies

Several forms of psychotherapy, including some short term (10 20 weeks) therapies, can help people with depressive disorders. Two of the short term psychotherapies that research has shown to be effective for depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive behavioral therapists help patients change the negative thinking and behavior patterns that contribute to, or result from, depression. Through verbal exchange with the therapist, as well as "homework" assignments between therapy sessions, CBT helps patients understand their depression and resolve problems related to it. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression. Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and mental health counselors.

For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment. Some psychiatrists offer both types of intervention. Alternatively, two mental health professionals may collaborate in the treatment of a person with depression; for example, a psychiatrist or other physician, such as a family doctor, may prescribe medication while a nonmedical therapist provides ongoing psychotherapy.

"You start to have these little thoughts, 'Wait, maybe I can get through this. Maybe these things that are happening to me aren't so bad.' And you start thinking to yourself, 'Maybe I can deal with things for now.' And it's just little tiny thoughts until you realize that it's gone and then you go, 'Oh my God, thank you, I don't feel sad anymore.' And then when it was finally gone, when I felt happy, I was back to the usual things that I was doing in my life. You get so happy because you think to yourself, 'I never thought it would leave.'" --Shawn Colten, National Diving Champion

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is another treatment option that may be particularly useful for individuals whose depression is severe or life threatening, or who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. The exact mechanisms by which ECT exerts its therapeutic effect are not yet known.⁴⁰

In recent years, ECT has much improved. Before treatment, which is done under brief anesthesia, patients are given a muscle relaxant. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) generalized seizure within the brain, which is necessary for therapeutic efficacy. The person receiving ECT does not consciously experience the electrical stimulus.

A typical course of ECT entails six to 12 treatments, administered at a rate of three times per week, on either an inpatient or outpatient basis. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, must be instituted. Some individuals may require maintenance ECT (M ECT), which is delivered on an outpatient basis at a rate usually of one treatment weekly, tapered off to bi weekly to monthly for up to one year.

The most common side effects of ECT are confusion and memory loss for events surrounding the period of ECT treatment. The confusion and disorientation experienced upon awakening after ECT typically clear within an hour. More persistent memory problems are variable and can be minimized with the use of modern treatment techniques, such as application of both stimulus electrodes to the right side of the head (unilateral ECT).^40,41 A recent study showed no adverse cognitive effects of M ECT after one year.⁴²

Herbal Therapy

In the past several years, there has been an increase in public interest in the use of herbs for the treatment of both depression and anxiety. The extract from St. John's wort (Hypericum perforatum), a wild growing plant with yellow flowers, has been used extensively in Europe as a treatment for mild to moderate depression, and it now ranks among the top selling botanical products in the United States. Because of the increase in Americans' use of St. John's wort and the need to answer important remaining questions about the herb's efficacy for long term treatment of depression, the National Institutes of Health (NIH) conducted a clinical trial to determine whether a well standardized extract of St. John's wort is effective in the treatment of adults suffering from major depression of moderate severity. The trial found that St. John's wort was no more effective for treating major depression of moderate severity than an inert pill (placebo).⁴³ Another study is underway looking at St. John's wort for the treatment of minor depression.

Research from NIH has shown that St. John's wort interacts with some drugs including certain drugs used to control HIV infection. The Food and Drug Administration issued a Public Health Advisory on February 10, 2000, which stated that the herb appears to affect an important metabolic pathway that many prescription drugs use to treat conditions such as heart disease, depression, seizures, certain cancers, and rejection of organ transplants. The same pathway is also responsible for the effectiveness of oral contraceptives to prevent pregnancy. Using the herb may limit the effectiveness of these medications. People taking HIV medications should be especially careful since St. John's wort may reduce the HIV medication levels in the bloodstream and could allow the AIDS virus to rebound, perhaps in a drug resistant form. Health care providers should alert their patients about these potential drug interactions, and patients should always consult their health care provider before taking any herbal supplement.

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Suicide

You are pushed to the point of considering suicide, because living becomes very painful. You are looking for a way out. You're looking for a way to eliminate this terrible psychic pain. And I remember, I never really tried to commit suicide, but I came awful close, because I used to play matador with buses. You know, I would walk out into the traffic of New York City, with no reference to traffic lights, red or green, almost hoping that I would get knocked down. --Paul Gottlieb, Publisher

Sometimes depression can cause people to feel like putting themselves in harm's way, or killing themselves. Although the majority of people with depression do not die by suicide, having depression does increase suicide risk compared to people without depression.

If you are thinking about suicide, get help immediately:

• Call your doctor's office.
• Call 911 for emergency services.
• Go to the emergency room of the nearest hospital.
• Ask a family member or friend to take you to the hospital or call your doctor.
• Call the toll free, 24 hour hotline of the National Suicide Prevention Lifeline at 1 800 273 TALK (1 800 273 8255) to be connected to a trained counselor at the suicide crisis center nearest you.

Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Research

Researchers estimate that at least six million men in the United States suffer from a depressive disorder every year.3 Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt.12,13 Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.13

"I'd drink and I'd just get numb. I'd get numb to try to numb my head. I mean, we're talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and it's still there. Because you have to deal with it, it doesn't just go away. It isn't a two hour movie and then at the end it goes 'The End' and you press off. I mean it's a twenty four hour a day movie and you're thinking there is no end. It's horrible." -Patrick McCathern, First Sergeant, U.S. Air Force, Retired

Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime;14 however, there is debate among researchers as to whether substance use is a "symptom" of underlying depression in men or a co occurring condition that more commonly develops in men. Nevertheless, substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.

Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm's way.

"When I was feeling depressed I was very reckless with my life. I didn't care about how I drove. I didn't care about walking across the street carefully. I didn't care about dangerous parts of the city. I wouldn't be affected by any kinds of warnings on travel or places to go. I didn't care. I didn't care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. And when you take those kinds of chances, you have a greater likelihood of dying." -Bill Maruyama, Lawyer

More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives.15,16 In addition to the fact that men attempt suicide using methods that are generally more lethal than those used by women, there may be other factors that protect women against suicide death. In light of research indicating that suicide is often associated with depression,17 the alarming suicide rate among men may reflect the fact that men are less likely to seek treatment for depression. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving.

More research is needed to understand all aspects of depression in men, including how men respond to stress and feelings associated with depression, how to make men more comfortable acknowledging these feelings and getting the help they need, and how to train physicians to better recognize and treat depression in men. Family members, friends, and employee assistance professionals in the workplace also can play important roles in recognizing depressive symptoms in men and helping them get treatment.

Depression in Elderly Men

Men must cope with several kinds of stress as they age. If they have been the primary wage earners for their families and have identified heavily with their jobs, they may feel stress upon retirement­loss of an important role, loss of self esteem­that can lead to depression. Similarly, the loss of friends and family and the onset of other health problems can trigger depression.

Depression is not a normal part of aging.18 Depression is an illness that can be effectively treated, thereby decreasing unnecessary suffering, improving the chances for recovery from other illnesses, and prolonging productive life. However, health care professionals may miss depressive symptoms in older patients. Older adults may be reluctant to discuss feelings of sadness or grief, or loss of interest in pleasurable activities.19 They may complain primarily of physical symptoms. It may be difficult to discern a co occurring depressive disorder in patients who present with other illnesses, such as heart disease, stroke, or cancer, which may cause depressive symptoms or may be treated with medications that have side effects that cause depression. If a depressive illness is diagnosed, treatment with appropriate medication and/or brief psychotherapy can help older adults manage both diseases, thus enhancing survival and quality of life.

"As you get sick, as you become drawn in more and more by depression, you lose that perspective. Events become more irritating, you get more frustrated about getting things done. You feel angrier, you feel sadder. Everything's magnified in an abnormal way." -Paul Gottlieb, Publisher

Identifying and treating depression in older adults is critical. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death; many have a depressive illness that goes undetected during these visits.20 This fact has led to research efforts to determine how to best improve physicians' abilities to detect and treat depression in older adults.21

Approximately 80 percent of older adults with depression improve when they receive treatment with antidepressant medication, psychotherapy, or a combination of both.22 In addition, research has shown that a combination of psychotherapy and antidepressant medication is highly effective for reducing recurrences of depression among older adults.23 Psychotherapy alone has been shown to prolong periods of good health free from depression, and is particularly useful for older patients who cannot or will not take medication.18 Improved recognition and treatment of depression in later life will make those years more enjoyable and fulfilling for the depressed elderly person, and his family and caregivers.

Depression in Boys and Adolescent Males

Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades.24 In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life.25 An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression.26 Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia.27 The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.

The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely "label" a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development. Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.28,29

Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior.25,30,31 Unfortunately, these disorders often go unrecognized by families and physicians alike.

Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment.32 Additional research is needed on how best to incorporate these treatments into primary care practice.

Bipolar disorder, although rare in young children, can appear in both children and adolescents.33 The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.

Depression in children and adolescents is associated with an increased risk of suicidal behaviors.25,34 This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.35 In 2002, suicide was the third leading cause of death among young males, age 15 to 24.36 NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years.25 Therefore, it is important for doctors and parents to take seriously any remarks about suicide.

NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young people's access to lethal agents­including firearms and medications­may hold the greatest suicide prevention value.

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Contents:

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

What causes depression?

Substantial evidence from neuroscience, genetics, and clinical investigation shows that depressive illnesses are disorders of the brain. However, the precise causes of these illnesses continue to be a matter of intense research.

Modern brain imaging technologies reveal that, in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and critical neurotransmitters­chemicals that brain cells use to communicate­ are out of balance. Studies of brain chemistry, including the effects of antidepressant medications, continue to inform our understanding of the biochemical processes involved in depression.

In some families, depressive disorders seem to occur generation after generation; however, they can also occur in people with no family history of these illnesses.¹⁰ Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other nongenetic factors.

Very often, a combination of genetic, cognitive, and environmental factors is involved in the onset of a depressive disorder.¹¹ Trauma, loss of a loved one, a difficult relationship, a financial problem, or any stressful change in life patterns, whether the change is unwelcome or desired, can trigger a depressive episode in vulnerable individuals. Later episodes of depression may occur without an obvious cause.

Part 1. What is depression?
Part 2. What causes depression?
Part 3. Men and depression research
Part 4. Suicide
Part 5. Treatment
Part 6. Find Help
Part 7. References

Acknowledgments

The development of earlier versions of this manual was supported by several research grants from the National Institute on Drug Abuse. The current manual was written by Dr. Kathleen Carroll of Yale University under Contract Number N-OIDA-4-2205 with the National Institute on Drug Abuse. Dr. Lisa Onken, the NIDA Project Officer, offered valuable guidance and comments throughout the preparation of this manual.

The material presented in this manual is the result of a program of research by Dr. Kathleen Carroll and Dr. Bruce Rounsaville and their colleagues at Yale University. The development of this therapy model for treatment of drug abuse drew extensively from the work of Alan Marlatt and others (Marlatt and Gordon 1985; Chancy et al. 1978; Jaffe et al. 1988; Ito et al. 1984). The structure and sequence of sessions presented in this therapy model was partially developed by work on Project MATCH published by the National Institute on Alcohol Abuse and Alcoholism (Kadden et al. 1992) and the manual developed by Peter Monti and his colleagues (1989). These sources are particularly reflected here in the a skills-training material, and we have acknowledged the original sources in each of those sections.

Yale University Research Team

Coinvestigators:

• Bruce Rounsaville, MD
• Charla Nich, MS
• Sam Ball, PhD
• Lisa Fenton, PsyD
• Frank Gawin, MD
• Tom Kosten, MD
• Elinor McCance-Katz, MD, PhD
• Douglas Ziedonis, MD

Project Staff:

• Meghan Brio, MS
• Roseann Bisighini, MS
• Monica Canning-Ball
• Joanne Corvino, MPH
• Kea Cox
• Lynn Gordon, RN
• Tami Frankforter
• Jenniffer Owler

Therapists:

• Michael Barrios, PhD
• Dan Keller, PhD
• Andrew Grunebaum, PhD

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Appendix B: Clinical Research Supporting CBT

Cognitive-behavioral treatments are among the most frequently evaluated psychosocial approaches for the treatment of substance use disorders and have a comparatively strong level of empirical support (American Psychiatric Association 1995; General Accounting Office 1996; Holder et al. 1991). To date, more than 24 randomized controlled trials have been conducted among adult users of tobacco, alcohol, cocaine, marijuana, opiates, and other types of substances (Carroll 1996).

A review of this group of studies (Carroll 1996) suggests that, across substances of abuse but most strongly for tobacco, there is good evidence for the effectiveness of CBT compared with no-treatment controls. The most rigorous level of testing compared CBT with other active treatments (in effect asking the question, Is CBT more effective than other widely used treatments? rather than, Is CBT better than no treatment or minimal treatment?). These comparisons have led to less consistent results; some studies indicate the superiority of CBT, while others have shown CBT as comparable to but not more effective than other approaches. CBT may hold particular promise in reduction in the severity of relapses when they occur, enhanced durability of effects, and patient-treatment matching, particularly for patients at higher levels of impairment along such dimensions as psychopathology or dependence severity.

As this manual focuses specifically on CBT for cocaine abuse, what follows is a brief review of the series of studies conducted at the Substance Abuse Treatment Unit at Yale University, which has evaluated the CBT approach described in this manual with individuals meeting criteria for cocaine abuse or dependence. Moreover, because this manual is intended to provide practical strategies for therapists working with this population, this review focuses on what these studies may imply about means of more effectively applying these CBT strategies to cocaine-abusing populations.

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CBT and Interpersonal Therapy

In our first study (Carroll et al. 1991), we directly compared CBT to another active psychotherapy, Interpersonal Psychotherapy or IPT (Klerman et al. 1984), a treatment that was then in regular use in our clinics. The strategy of comparing two active treatments addressed several methodological and ethical questions associated with no treatment or nonspecific control groups, such as differences in demand characteristics and credibility of the offered treatments; lack of control of common factors in the therapies; and the problem of subjecting severely impaired treatment-seeking individuals to minimal or no-treatment control conditions (Basham 1986; Kazdin 1986; O'Leary and Borkovec 1978).

In this, as in all of our studies on CBT, we used a variety of methodological features that were intended to protect the integrity of the treatments evaluated and control other sources of variability. Subjects were randomly assigned to treatments. All treatments were manual guided and implemented by doctoral-level therapists who received extensive training and ongoing supervision. Patient outcomes were assessed by independent evaluators who were blind to the treatment assignment.

In this 12-week outpatient study, 42 subjects who met DSM-III criteria for cocaine dependence were randomly assigned to either CBT or IPT. Those assigned to CBT were more likely than subjects in IPT to complete treatment (67 versus 38 percent), attain 3 or more continuous weeks of abstinence (57 versus 33 percent), and be continuously abstinent 4 or more weeks when they left treatment (43 versus 19 percent).

Although the sample size was small and these differences did not reach statistical significance, significant differences by treatment group did emerge when subjects were stratified by severity of cocaine abuse. For example, among the subgroup of more severe cocaine users, subjects who received CBT were significantly more likely to achieve abstinence than those assigned to IPT (54 versus 9 percent). Among the subgroups of subjects with lower severity of cocaine abuse, outcomes were comparable for both treatments (Carroll et al. 1991). These findings suggest that more severely dependent cocaine abusers may require the greater structure and direction offered by CBT, which emphasizes learning and rehearsal of specific strategies to interrupt and control cocaine use, whereas the specific type of treatment offered may be less important for less severely dependent cocaine abusers.

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CBT and Clinical Management

Our next study was more complex because it involved both psychotherapy and pharmacotherapy (Carroll et al. 1994b). This time we compared CBT to Clinical Management (CM) (Fawcett et al. 1987), a nonspecific psychotherapy that satisfied many of the requirements of a control condition.

• CM provided common elements of a psychotherapeutic relationship, including a supportive doctor-patient relationship, education, empathy, and the instillation of hope, without providing active ingredients specific to relapse prevention.

• CM provided medication management as well as an opportunity to monitor patients' clinical status and treatment response.

• CM provided a convincing therapeutic rationale to foster greater retention in the protocol and compliance with medication.

It is important to note that these features, although desirable in a psychotherapy control condition because they address many ethical and methodological concerns, may be powerfully therapeutic on their own and thus also serve as a more stringent test of active psychotherapies than would alternatives such as no-treatment or waiting-list control conditions. All subjects received a medication, either desipramine (which was the most promising medication for cocaine dependence at the time) or a placebo. In this study, 121 individuals meeting DSM-III-R criteria for cocaine dependence were randomly assigned to one of four treatment conditions:

• CBT in combination with desipramine
• CBT plus placebo
• CM plus desipramine
• CM plus placebo

We hypothesized that both CBT and desipramine would be more effective than CM and placebo, respectively. Moreover, this design permitted detection of combined effects of psychotherapy and pharmacotherapy if these proved to be sufficiently strong.

After 12 weeks of treatment, subjects in all four groups showed significant reductions in cocaine use as well as improvement in several other problem areas. Significant main effects for medication or psychotherapy type were not found; that is, cocaine outcomes were comparable whether the patient received CBT or CM, or desipramine or placebo.

We did find an interaction effect similar to that in our first study. That is, baseline severity of cocaine abuse was found to interact differently with the two forms of psychotherapy. Patients who were more severely dependent on cocaine stayed in treatment longer, attained longer periods of abstinence, and had fewer urine screens positive for cocaine when treated with CBT compared with CM. Again, this suggests that abusers with more intense involvement with cocaine may benefit from the additional structure, intensity, or didactic content of CBT, which focuses specifically on reducing access to cocaine and avoidance of high-risk situations for relapse. These results again suggest that low- intensity approaches may be effective for individuals less severely dependent on cocaine.

Additional effects were found in subsequent analyses of data from the study comparing CBT to CM. However, because these findings were based on exploratory, post hoc analyses, they should be interpreted with caution.

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CBT and Depressive Symptoms

Because of the clinical importance of affective disorders among cocaine abusers, we evaluated the role of depressive symptoms in response to study treatments (Carroll et al. 1995). We found that CBT was more effective than CM in retaining depressed subjects in treatment. There was also some evidence that it was more effective in reducing cocaine use. This may have occurred because the depressed subjects experienced more distress, which may have enhanced their motivation for treatment, availability for psychotherapy, and ability to implement and benefit from coping skills.

On the other hand, there was no evidence that CBT was more effective than CM in reducing depressive symptoms. While cognitive-behavioral approaches to treating depression have generally been effective and comparable to antidepressant medication in reducing depressive symptoms (Elkin et al. 1989; Simons et al. 1986), our CBT approach did not specifically address depressive symptoms as a treatment target or convey specific strategies for managing coexistent depression. Rather, we focused almost exclusively on helping patients develop strategies to reduce their cocaine use during the early stages of treatment, although we did address the relationship between negative affect and cocaine use. A possible implication of these findings is the need for CBT therapists to more explicitly address depressive symptoms with patients who experience them (Carroll et al. 1995).

Reductions in cocaine use and depression were closely associated throughout treatment, although the direction of these changes was not clear. One possible explanation for this finding is that reduction in depressive symptoms leads to reduction in cocaine use by reducing distress, thus enabling patients to make better use of their coping resources, become more available for psychotherapy, or reduce their possible self-medication of depressive symptoms with cocaine. Conversely, reduction of cocaine use might lead to improvements in depressive symptoms by decreasing depression associated with cocaine withdrawal, reestablishing normal sleep and eating patterns, and reducing exposure to other negative consequences of cocaine abuse.

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CBT and Alexithymia 

Alexithymia refers to a cognitive-affective style that results in specific disturbances in the expression and processing of emotions. Literally meaning "no words for feelings," the term was coined by Nemiah and Sifneos (1970) to refer to psychosomatic patients who exhibited four specific affective/cognitive impairments:

• Difficulty in verbalizing affect states

• A tendency to focus primarily on the somatic/physiological components of affective arousal

• An impoverished fantasy life

• A highly concrete cognitive style

We evaluated the rates and significance of alexithymia among cocaine abusers in our CBT and CM comparative study. We found that 39 percent of the cocaine abusers scored in the alexithymic range, based on responses to the Toronto Alexithymia Scale (Taylor et al. 1985). While alexithymic subjects did not differ from nonalexithymic patients with respect to overall treatment retention or outcome, alexithymic subjects did respond differently to psychotherapy. They had better retention and cocaine outcomes when treated with CM, whereas nonalexithymic subjects had better outcomes when treated with CBT.

The finding that cocaine abusers with higher alexithymia scores responded more poorly to CBT has several implications. Patients are asked to identify and articulate internal affect and cognitive states associated with cocaine use - a task particularly difficult for alexithymic patients. CBT encourages patients to identify, monitor, and analyze their cravings, negative affects, and many subtle fleeting cognitions. In essence, it requires patients to have good access to their internal world. These demands may be overwhelming for the alexithymic subjects. For example, one patient, as part of a self-monitoring assignment, was asked to note his feelings and their intensity in response to a variety of situations. Rather than describing feelings such as cheerful, irritable, or bored, he consistently wrote either yes or no, suggesting he had some awareness of strong affects, but little ability to articulate them or relate them to his drug use. Therapists may find it helpful to provide a preparatory phase before starting the monitoring of high-risk situations and skills training to prevent such patients from being overwhelmed and to help them identify their feelings and affect states.

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One-Year Followup

Some of the most intriguing findings from the CBT/CM comparative study emerged from the 1-year followup (Carroll et al. 1994a). As a group, subjects' cocaine abuse decreased overall or remained stable with respect to posttreatment levels, rather than rebounding to pretreatment levels. More importantly, there was consistent evidence of delayed effects for CBT compared with CM for cocaine outcomes, even when we controlled for the proportion of subjects who received some nonstudy treatment during the follow-up period. After leaving the study treatments, subjects who had received CBT continued to reduce their cocaine abuse, whereas cocaine abuse remained relatively stable in the CM group. These results may be related to delayed emergence of specific effects of CBT. During the acute phase of CBT and CM treatment, subjects in all groups received a variety of nonspecific interventions, including weekly urine monitoring, frequent assessment of cocaine use and other symptoms, support and encouragement from therapists and research staff, and positive expectations for treatment effects. These common factors may have been powerfully therapeutic and overwhelmed treatment-specific effects.

The cessation of these nonspecific interventions may have created the conditions under which the more durable and specific effects of CBT had an opportunity to emerge. CBT is intended to impart generalizable coping skills that can be implemented long after patients leave treatment, while supportive treatments may provide patients with fewer enduring resources (Carroll et al. 1994b).

In other clinical populations, follow-up studies of cognitive-behavioral treatments have indicated the durability of their effects with some consistency. For example, cognitive-behavioral treatments have been found to be superior or comparable to acute or continued tricyclic pharmacotherapy in preventing relapse of depressive and panic episodes (Miller et al. 1989; Simons et al. 1986). Moreover, some studies (Beutler et al. 1987), including a recent one with alcoholic subjects (O'Malley et al. 1994), have shown continuing improvement or delayed emergence of effects during follow-up after cognitive-behavioral therapy.

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CBT and Alcoholic Cocaine Abusers

Our experience pointed to the significance of alcohol abuse and dependence, which occurs quite frequently among clinical populations of cocaine abusers. In a survey of psychiatric disorders among 298 cocaine abusers, we found that alcohol dependence was the most frequently diagnosed comorbid disorder, with 62 percent of the sample meeting RDC criteria for lifetime alcohol dependence and almost 30 percent meeting criteria for current use (Carroll et al. 1993a). This is consistent with reports from large-scale community samples, such as the Epidemiological Catchment Area study, which found that 85 percent of individuals who met criteria for cocaine dependence also met criteria for alcohol abuse or dependence, a rate far higher than that of alcoholism among those meeting criteria for heroin-opioid (65 percent), cannabis (45 percent), or sedative-hypnotic-anxiolytic (71 percent) dependence (Regier et al. 1990). More importantly, comorbid alcohol-cocaine dependence has been associated with more severe drug dependence, poorer retention in treatment, and poorer outcome with respect to either disorder alone (Brady et al. 1995; Carroll et al. 1993b; Walsh et al. 1991).

We then evaluated CBT and other psychosocial and pharmacologic treatments for this large and challenging population (Carroll et al. in press). We compared CBT to two other treatments, CM and Twelve-Step Facilitation (TSF) (Nowinski et al. 1992), an individual approach consistent with the 12 steps of Alcoholics Anonymous (AA) which has the primary goal of fostering the patient's lasting involvement with the traditional fellowship activities of AA or Cocaine Anonymous. We also evaluated disulfiram (Antabuse) in this study because of pilot data that suggested that reduction in alcohol use through disulfiram may be associated with reductions in cocaine use as well (Carroll et al. 1993c). Preliminary data from this study suggest that the two active psychotherapies - CBT and TSF - were more effective than CM in fostering consecutive periods of abstinence from cocaine and abstinence from both cocaine and alcohol concurrently. The two active psychotherapies also yielded a higher percentage of cocaine-free urine specimens. In addition, CBT and TSF, compared with CM, were associated with significant reductions in cocaine use across time, particularly for subjects who received at least minimal exposure to treatment.

Finding that CBT and TSF were more effective than the psychotherapy control condition underlines the important role that well-defined, competently delivered psychosocial interventions play in the treatment of cocaine dependence. Because CM provided a control for general, nonspecific aspects of psychotherapy (including a supportive doctor-patient relationship), this study provided a rigorous test of the specific, active ingredients of CBT and TSF above and beyond simple support and attention.

The finding that CBT was more effective than CM in reducing cocaine use contrasts with the finding from our previous clinical trial, which did not show overall differences between CBT and CM (Carroll et al. 1994b). However, in that study, CBT was found to be more effective than CM for the subgroup of subjects who were more severely dependent on cocaine. Again, because concurrent cocaine-alcohol dependence has been associated with higher severity of cocaine use and poorer prognosis with respect to cocaine dependence alone, subjects in this study may be similar to the more severely dependent subsample from our earlier study. Thus, findings from these two studies taken together may suggest that more severe groups of cocaine-dependent individuals differentially benefit more from the comparatively intensive active ingredients of CBT or TSF than from the supportive but less structured and less directive CM, which also makes fewer demands on patients to carry out assignments outside of sessions.

It is also important to note that study findings did not show significant differences between the two active psychotherapies, TSF and CBT, in either cocaine or alcohol outcomes. This suggests that these two forms of treatment were equally effective with this population in this study. The comparable outcomes occurred despite clear differences in the theoretical basis of these treatments, the specific interventions used by the therapists (as detected by independent raters blind to subjects' treatment assignments), and the evidence that subjects demonstrated specific behavioral changes consistent with the theoretical mechanisms of action of their study treatments (changes in coping skills in CBT, more AA involvement in TSF). This is consistent with other recent research with cocaine-dependent samples (Wells et al. 1994; Carroll et al. in press).

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Appendix A: Therapist Selection, Training, and Supervision

With appropriate training and supervision, a diverse range of therapists can implement CBT effectively. However, because this manual focuses on specific cognitive-behavioral techniques and does not cover basic clinical skills, certain minimal requirements are recommended.

• A master's degree or equivalent in psychology, counseling, social work, or a closely related field
• At least 3 years experience working with a substance-abusing population
• Some familiarity with and commitment to a cognitive-behavioral approach

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Therapist Training

Just as reading a textbook on surgery does not produce a qualified surgeon, mere review of this manual would be inadequate for the therapist to apply CBT strategies and techniques in clinical practice or research. Appropriate therapist training for CBT for cocaine dependence requires completion of a didactic seminar and at least two closely supervised training cases.

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Didactic Seminar

The didactic seminar usually lasts from 2 days to 1 week, depending on the experience level of the therapists. The seminar includes review of basic cognitive-behavioral theory and technique, topic-by-topic review of the manual, watching videotaped examples of therapists implementing the treatment, several role-play and practice exercises, discussion of case examples, and rehearsing strategies for difficult or challenging cases.

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Supervised Training Cases

Supervised training cases offer an opportunity for therapists to try this approach and learn to adapt their usual approach to conform more closely to manual guidelines. The number of training cases varies according to the experience and skill level of the therapist. Generally, more experienced therapists require only one or two training cases to achieve high levels of competence. Less experienced therapists generally require two to four supervised cases.

Each session can be videotaped and forwarded to the supervisor. The supervisor should:

• Review each session.

• Complete a rating form to evaluate the therapist's adherence to CBT guidelines and competence in implementing the treatment that session.

• Provide 1 hour of individual supervision to the therapist. Supervision sessions are structured around ratings of adherence to CBT and competence in delivering the treatment, with the supervisor noting when the therapist delivered the treatment effectively as well as areas in need of improvement.

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Rating of Therapists

To have a concrete basis on which to evaluate therapist implementation of CBT, therapists and supervisors should complete parallel adherence-rating forms (Exhibit 13: CBT Therapist Checklist and Exhibit 14: CBT Rating Scale) after each session conducted or viewed . (A copy of the rating manual and rater's guidelines that accompany these forms are available from Dr. Carroll.) They consist of Likert-type items that cover a range of key CBT interventions (e.g., review of homework, skills training).

Therapist Checklist

The CBT Therapist Checklist asks therapists to rate the CBT strategies and interventions that were implemented in a given session and how much the intervention was used. The checklist has a variety of purposes -

• To remind the therapist, at each session, of the key active ingredients of CBT.

• To foster greater therapist adherence to the CBT sessions and topics through self-monitoring.

• To organize and provide the basis for supervision, since therapists can readily note and explore with the supervisor the strategies and interventions they have trouble implementing with a given patient.

• To generate a useful record of which interventions were or were not delivered to each patient in a given session. For example, one can construct a session-by-session map of the order and intensity of CBT interventions introduced to a range of different patient types.

Rating Scale

The supervisor's version of the form, called the CBT Rating Scale, differs from the therapist's version by adding a skillfulness rating for each item. Thus, for each intervention, both quantity and quality are rated. The scale is an essential part of training.

• It provides structured feedback to the therapist and forms the basis of supervision.

• It provides a method of determining whether a therapist in training is ready to be certified to deliver the treatment.

• When used with ongoing supervision, it enables the supervisor to monitor and correct therapist "drift" in implementing the treatment.

• For therapists who have trouble adhering adequately to manual guidelines, but who maintain that they do follow it, pointing out discrepancies between the scale and the checklist is a useful strategy for enhancing adherence. Not all items on the rating forms are expected to be covered, or covered at a high level, during all sessions. However, items 3-11 reflect the essential CBT approach that should be present, at least to a moderate level, in the majority of sessions.

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Certification of Therapists

Therapists are certified, or approved, to implement the treatment at lower levels of supervision when the supervisor determines that they have completed an adequate number of training cases successfully. More objective criteria would be an adherence score of a 3 or more on the key CBT items (items 3-11) for the most recent case and no skill rating below a 4 (adequate) on any item representing an aspect of CBT.

After certification, levels of therapist adherence to CBT guidelines are monitored closely using the CBT Rating Scale. When therapists stray from adequate adherence to the manual, supervisors increase the frequency of supervision until performance returns to an acceptable level.

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Ongoing Supervision

The level and intensity of ongoing supervision reflects the experience and skill of the therapist as well as the time available for supervision. The minimum acceptable level of ongoing supervision for an experienced therapist is once a month; once-a-week supervision is recommended for less experienced therapists. Supervisors should also review and evaluate, using the CBT Rating Scale, one or two randomly selected sessions per patient.

Supervision sessions themselves should include a general review of the therapist's current cases, discussion of any problems in implementing CBT, and review of recent ratings from the supervisor. At least one of every two supervision sessions should include review of a session videotape with both the therapist and patient being present.

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Guidelines

Supervision is most effective under the following circumstances.

• It is conducted at a consistent place, date, and time.

• The goals of the supervision are clear and both participants' roles are defined.

• The procedures that will be used for evaluation of the therapist are clear.

• Feedback to the therapist is focused and concrete.

"When you debriefed X's last slip, I thought you didn't get enough information for either of you to really understand what was going on. For example, it wasn't clear to me what was going on beforehand, how much she used, where she got the cocaine, and how the episode ended and she got back in control. I think you should be more thorough in doing functional analysis any time there is an episode of use."

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Common Problems Encountered in Supervision

Balance

The structure of CBT sessions (and the 20/20/20 rule) is intended to integrate skills training with effective, supportive therapy that meets the needs of each patient as an individual. Novice therapists, particularly those with little experience in treating substance abusers or unaccustomed to a high level of structure in treatment, often let sessions become unfocused, without clear goals, and do not make the transitions needed to deliver skills training effectively. Such therapists often wait to introduce skills training until the last few minutes of the session. This results in rushing through important points, failing to use patient examples or get patient feedback, and neglecting review of the practice exercise - all of which gives the impression that skills training is not very important.

Other therapists allow themselves to become overwhelmed by the constant substance abuse-related crises presented by a patient and fail to focus on skills training or use it as an effective strategy to help the patient learn to avoid or manage crises. Falling into a crisis-driven approach tends to increase, rather than decrease, patient anxiety and to undermine self-efficacy. On the other hand, maintaining a relatively consistent session routine and balancing the patient-driven discussion of current concerns with a focus on skills and strategies is also a means by which the therapist can model effective coping and problem solving.

Conversely, some therapists become overly fixed and inflexible in their application of skills training and adherence to the manual. Anxious to get it right, they present the material in the manual more or less verbatim and fail to adapt it to the specific needs, coping style, and readiness of the particular patient.

For example, even though skills training requires considerable activity and commitment from the patient, some therapists launch into it with patients who are still highly ambivalent or even resistant to treatment. It is important to remind such therapists that the manual is not a script but rather is a blueprint or set of guidelines that provides a clear set of goals and overall structure for the treatment. This often requires considerable familiarity with the didactic material so that therapists can alter the material for each patient and present it in a way that sounds fresh and dynamic. Patients should never be aware that the therapist is following a manual.

Speeding Through Material

Many of the skills-training concepts, while seemingly straightforward and based on common sense, are quite complex, particularly for patients who have cognitive impairment, dual diagnoses, or low baseline levels of coping skills. A common error made by many therapists is to fail to check back with patients to make sure they understand the material and how it might be applied to their current concerns. When this occurs, it often takes the form of a lecture rather than a dialog between the patient and therapist. Ideally, for each concept presented, therapists should stop and ask patients to provide an example or to describe the idea in their own words.

Overwhelming The Patient

Some therapists try to present to each patient all of the coping strategies in the order given in the manual. For many patients, this is overwhelming. Learning and feeling comfortable with one or two coping strategies is preferable to having only a surface understanding of several strategies. Similarly, if too much material is presented, the time available for practice is limited.

A good general tactic is to start by presenting one of the coping strategies the patient already uses and is familiar with, and then to introduce one or two more that are consistent with the patient's coping style. Also, new coping strategies can be introduced over two sessions.

Unclear Strategies

Therapists should attempt to teach general coping strategies using specific examples. However, some therapists use the coping strategies during the session but do not effectively communicate the basic underlying strategy. For example, they may effectively apply problem solving strategies to patients' problems but fail to make the problem solving steps explicit or assure that patients understand the concepts. It is essential that therapists use examples to teach the general, underlying strategy, but it is equally important that the general strategy be made clear.

No Specific Examples

Just as some therapists do not effectively communicate underlying principles, others fail to make the coping skills material alive by using specific examples, based on material provided by the patient, to illustrate their points. Skillful therapists make the transition from the patient's report of current concerns to the skill-focused section of the session by using specific examples.

"Earlier, you talked about how hard it was to deal with Joe and his continuing to use, and today, I thought we would talk about some ways you might be able to effectively say no to him. How does that sound?"

Again, skills training should be presented as a dialog between the patient and therapist, with the therapist attempting to convey the message, "Here is something I think can help you with what you're struggling with right now."

Downplaying Practice Exercises

Although most patients do their practice exercises, and those who practice outside sessions have better cocaine outcomes, a number of therapists do not sufficiently attend to practice exercises. This takes the form of cursory review of completion of tasks in the beginning of sessions. It also leads to rushing through task assignments at the end of sessions, not being creative in task assignments, and letting practices slide if the patient does not do them. Often, this reflects a therapist's low expectations about the patient's attempting the exercise (and, often, low expectations about the patient's prognosis).

A review of the assignment provides some structure to the first part of the session and sends the message that outside practice is important. Generally, therapists who expect their patients to practice outside of sessions have patients who do so. Also, therapists and patients are by no means limited to the practice exercises suggested in the manual. In fact, it is preferable for patients to come up with their own extra-session tasks.

Abandoning The Manual With Difficult Patients

Many patients present with a range of complex and severe comorbid problems. Therapists may become overwhelmed by concurrent problems and drift from use of the manual in an attempt to address all the patient's problems. In such cases, therapists often take a less structured approach rather than the greater structure needed by the patient.

Generally, if the patient is sufficiently stable for outpatient therapy, the treatment described in the manual is adequate, even for fairly disturbed patients. CBT provides short-term therapy that includes the major attributes of an effective initial approach to cocaine abuse.

• A highly structured approach to treatment
• Prioritizing of concurrent problems
• Limited case management
• A primary focus on achieving abstinence

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