Allen Frances shares his approach to chronic depression.

Publication Date: 12/30/2024 

Duration: 16 minutes, 45 seconds 

KELLIE NEWSOME: We used to call it dysthymic disorder. Now, with DSM-5, it’s Persistent Depressive Disorder, but the patients are the same, and today, Allen Frances shares his top tips on working with them. Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. 

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of the Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. When we started this interview with Allen Frances, he talked about how structured behavioral techniques are very effective for simple, limited problems like primary insomnia, panic disorder, and phobias, but for many patients, life is not so simple. They have multiple co-morbidities or long-standing psychiatric problems that strip away at their relationships, their physical health, and their identity.  

CHRIS AIKEN: All that reminded me of working with chronic depression. These are the patients who say they don'tknow what normal is. You ask them how long they've been depressed, and they'll say my whole life. For them, depression is not what they do; it's who they are, it's how they relate to people, and all this makes it difficult to parse it off as some kind of treatable, separate entity. Change is more difficult here because these patients don't have a healthy baseline to draw from; it's harder for them to engage in, like, the rational thinking that CBT depends on.  

KELLIE NEWSOME: The DSM used to call this dysthymic disorder, which is a long-standing, low-grade depressive temperament, but two things changed that. First, we learned that nearly everyone – 90% - with a dysthymic temperament went on to have full episodes of depression, so-called “double depression,” so it made little sense to parse it off as a separate disorder when it so often gets intermingled with full depression and with a lot of other problems, problems like alcohol use, poor physical health, poor sleep, personality disorders, anxiety disorders. Next came a study from 2010, which challenged the stereotype of dysthymia as mild, low-grade depression. In this survey of 43,000 adults, people with dysthymic disorder were 30% less likely to hold a job than those with acute depression and had worse social and even physical functioning. To counter the idea that dysthymia is “depression light”, they gave it the more somber name of Persistent Depressive Disorder 2013s DSM-5.  

CHRIS AIKEN: These patients have a harder time socializing, working, and just getting out of bed than do patients with major depression, and they also have a harder time in psychotherapy. Therapies that work well for acute depression, like CBT or problem-solving therapy, have fallen flat in studies of chronic depression, but therapy can work here. And the ones that do work, the therapist takes a more active role and pays a lot more attention to the therapeutic relationship, like one example is CBASP, Cognitive Behavioral Analysis System of Psychotherapy, which was developed as a behavioral model of psychodynamic therapy, which pays close attention to how the therapeutic alliance is playing out in the here and now, in the therapy room. So, all this work reminded me of what Dr. Frances said about complex problems needing a different approach, something we covered two podcasts ago. So, I asked Dr. Fances how he approaches chronic depression, and as often is the case with Dr. Frances, his answers hold some surprises. It's not only about the relationship. 

ALLEN FRANCES: Well, chronic depression is a whole heterogeneous bunch of different types of problems thrown together. Jim Kocsis, MD, and I, starting in the 80s, did a study of medication for chronic depression. The idea being that it wasn't all personality disorder, it may be that in some people, what had been presented as or presenting as personality disorder was really chronic depression, and some people need medication and do very well with medication. I think that in terms of the psychotherapy component, people with chronic depression, a very good example would be where you should be very familiar with psychodynamic techniques because some of this may be the carrying forward of pessimistic and troubled interpersonal relationships that started early that need to be understood longitudinally. Many people, probably most, will require a heavy dose of cognitive restructuring. Behavior change is crucially important. Exercise is one of the best things for chronic depression. They're getting people to do things that they normally wouldn't do, that they feel too tired to do or too afraid to do, reverses the pattern of demoralization. Demoralization is a very neglected area of psychotherapy practice. One of the things that was pointed out by Jerome Frank in the Persuasion and Healing book is that all therapies have in common the ability to reverse demoralization and that people tend to get into vicious cycles where things go wrong, they withdraw, and then they become even less connected with happy, good experiences, they withdraw more, and that one of the things that psychotherapy does is to reverse the vicious cycles, substituting virtuous cycles, where doing a little more helps you feel better, and then you do a little more, and then you feel even better, and you do a little more, and that all psychotherapies have in common that capacity to help to reverse demoralization and to create virtuous cycles. 

CHRIS AIKEN: As we're talking about vicious cycles, it reminds me of the opposite of virtuous cycles, that is, what you called in your 2013 book, Saving Normal, homeostasis. It's my favorite passage from your book, so let me read it here: We can feel sadness, grief, worry, anger, disgust, and terror because these are all adaptive. At times, our emotions may temporarily get out of hand and cause considerable distress or impairment. But homeostasis and time are great natural healers, and most people resiliently right themselves and regain their normal balance. Psychiatric disorder consists of symptoms and behaviors that are not self-correcting—a breakdown in the normal homeostatic healing process. 

ALLEN FRANCES: Yeah, I think everything in life is homeostasis in the physical world and in the biological world. The systems tend to find a balance, and one of the things about people with psychiatric disorder is that they've lost that balance. Losing the balance often leads to a positive feedback loop of negative experiences. Once one thing goes wrong in your life, it's likely that that's going to lead to a cycle, a tumbling cycle, a slippery slope downward, a spiral into more and more things going wrong. You have your first panic attack, and you stop doing things because you're afraid of having a panic attack. You withdraw from the world, and you then get depressed, and you're less successful. You're not able to form new relationships. Your job is failing, and you get more depressed, and it becomes a self-fulfilling prophecy that one bad thing leads to another, but the nice thing about understanding it this way is that if you can reverse the downward vicious cycle with even small changes, it tends not to just result in a small incremental improvement, but the corrective emotional experience tends to feed on itself, and you can spiral up just as you spiral down. I get lots of calls from people who've been to every treatment, and nothing's worked. They've had years of psychotherapy, they've been on every medication, and nothing's worked, and my usual first instinct is to recommend exercise.  

CHRIS AIKEN: Yeah, exercise, particularly aerobic exercise, has about 80 clinical trials in major depression, and it even has some positive trials in treatment-resistant depression, so there is some hope that it can work there. 

ALLEN FRANCES: Well, there's lots of stuff, actually, a lot of it done at Duke, about the antidepressant effects of exercise. I'm not thinking of it just as having possible antidepressant effect in itself. But if you take a walk for 30 minutes a day; if you start including more good minutes in a day, put it that way with patients, we need to figure out what gives you a good minute and a very bad day, and we'll start out with just maybe a few good minutes a day, maybe we can build on that, and a 30-minute walk is usually the easiest way for someone who's been demoralized, who feels nothing will work to start changing their life in a positive direction.  

CHRIS AIKEN: What do we know from research about the benefits of therapy versus medication, say, in major depression? 

ALLEN FRANCES: One of the most powerful outcomes from the psychotherapy research has been the fact that for a number of different conditions when they're mild to moderate, psychotherapy does as well as meds and may have a more enduring effect. It may be slightly slower in the gains, but then they're more enduring. A very powerful finding. It means that when in our country, 12% of individuals are on antidepressants. Amongst women over 40, it's 25%. 4 % of our population is on a benzodiazepine. 8 % of the elderly are on benzodiazepines. 80 % of psychiatric meds are given by primary care doctors, not psychiatrists most of that's given after a very brief session, 10 or 15 minutes. A person comes in with an emotional problem, which may be transient and self-limited, once they're put on an antidepressant, they'llmisinterpret the improvement, which is probably due to time and placebo as being a med effect, and stay on the medicine for a long period of time. It's a powerful finding that most people with mild to moderate problems won't need medication. That either with watchful waiting or psychotherapy, they'll get better, and if the world realized this, if insurance companies realized this, they would tend to want to provide more psychotherapy, more time for primary care doctors to get to know their patients so they wouldn't jump to medication. 

CHRIS AIKEN: The NICE guidelines in England agree with you there. They don't recommend antidepressants for mild depression, only therapy and exercise for mild cases. 

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.  

1. What is Dr. Frances’ top behavioral intervention for chronic depression?  

A. Exercise 

B. Sleep hygiene 

C. An empathic, supportive relationship 

D. Gratitude journal 

ALLEN FRANCES: Very severe depressions, depressions that require hospitalization, melancholia, delusions. Psychotherapy is irrelevant because that person is too withdrawn and doesn't have the energy to participate, and trying to push yourself on them may feel like just an added stressor. But for most severe depressions that are short of that, psychotherapy in a medically supportive way can be quite useful. 

I hated the idea of calling anything a medication clinic, or this is a medication visit, that every visit with a person, even if it's 20 minutes once a month, sure, it's going to be to judge the dosage, and the side effects and adherence, but it's also going to be a psychotherapy visit. I think you saw the blog on Zen and the Art of Psychotherapy. 

CHRIS AIKEN: You can find the article that Dr. Frances has recommended here, Zen and the Art of Psychotherapy, Brief Session Cognitive Therapy in Japan. It's free online, and just Google those words. It's by Yutaka Ono, Y U T A K A O N O. It's on the website Japanpsychiatrist.com. 

ALLEN FRANCES: The guy who wrote that, Yutaka Ono, came to America. He and I became involved and friends; he stayed in the US for three years before he left, he did six months with the Becks, and he went to Japan, and now he has 3000 cognitive therapists in Japan. Incredible, brought cognitive therapy to Japan. In Japan, psychiatrists don't spend more than 10 to 15 minutes, but at least the good ones are always thinking about that as an important moment in the person's life not to be taken trivially. That it may be routine for us to see 20 patients or 30 patients for 20 minutes or half an hour a day, but for the patient that once a month visit to a psychiatrist can be very important, and we shouldn't see it as just I'm gonna be renewing the prescription. It should be that I can try to find something to say in these 20 minutes, and it will be meaningful for that person for the rest of their life.  

CHRIS AIKEN: We used to hear a lot that psychotherapy wasn't helpful for severe depression. In fact, in the 2010 APA guidelines, they kind of imply that. But in the last decade, there have been some positive trials of therapies like behavioral activation in severe depression. Are you saying that therapy can be helpful here as long as the patient can engage and communicate?  

ALLEN FRANCES: I'm putting it in a slightly different way, that the visit is inherently psychotherapeutic, and the more you're aware to the relationship aspects of it, and the fact that you never know... one of the things that's been very striking in my career working in emergency rooms is the number of times I've been approached by people years later in the hallway who say, Doc, you probably don't remember me, but I saw you in the emergency room and you only saw me for a few minutes, but you said something and stuck with me and helped change my life. On the other hand, I've treated someone for 14 years twice a week with no impact. It's not the amount of time you spend with someone; it's the impact that you have, and so I would see that every visit, even if it's once a month or once every three months. Even if it'sjust 20 minutes or 30 minutes that, that visit should be seen as not just a prescription renewal visit; it's a psychotherapy visit. It may be supportive psychotherapy. It may be that you're not going to be using any fancy techniques that you'velearned along the way; you're just going to be there with the person, commiserate with their problems, maybe suggest a way of seeing things slightly differently. But you never know when ow important that might be to the patient; even though it seems like just a small part of your day, it may be a very big part of the person's life, and something you say may make an enormous difference, and I think that we should never see the next patient. Oh, this is the 10th patient I've seen. It'salways an exciting moment, and I may be able to do something to help this person.  

CHRIS AIKEN: Thank you for talking with us. Dr Frances. 

KELLIE NEWSOME: Allen Frances is a psychiatrist, psychoanalyst, and Chair Emeritus for the Department of Psychiatry at Duke. He helped build DSM-IV and then went on to challenge DSM in his 2013 book Saving Normal. He has a popular feed on X/Twitter, hosts the Talking Therapy podcast, and his latest book is Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump. Do you like the Carlat Medication Fact Book? Well, there’s a new version outfor inpatient psych, the Hospital Psychiatry Fact Book by Victoria Hendrick and Danny Carlat. It includes chapters on medication, therapeutic, and legal aspects for disorders commonly seen in the inpatient setting, as well as psychiatric emergencies, hospital safety protocols, and everyone’s favorite: navigating healthcare administration. Find it on Amazon or on the Carlat Website.