RESEARCH FINDINGS USING GUIDED IMAGERY FOR
Dimensions and Costs of the Problem
MDD (Major Depressive Disorder) is defined as a depressed mood, accompanied by loss of interest in usual activities, changes in appetite, energy level, or sleep pattern, hampered mental and physical function, or suicidal thoughts or action (APA, 1994).
Depression is the leading cause of disability in the U.S. and established market economies worldwide; the various types of mood disorders affected approximately 20.9 million American adults in a given year (The Numbers Count, 2006). Women are about twice as likely as men to suffer from depression (Robins and Reiger, 1990).
The total cost to the U.S. economy in 1990 rose to $83.1 billion, which included $26.1 billion in direct medical costs; $51.5 billion in workplace costs, and $5.4 billion in suicide-related costs (Greenberg, Kessler, et al, 2003). Depression ranks among the top three workplace problems for employee assistance professionals, following only family crisis and stress (Greenberg, Stiglin, et al, 1993).
The milder form of depression, called dysthymic disorder, affects approximately 1.5% of the population age 18 and older during their lifetime (Kessler, Chiu, et al, 2005).
Depression can end lives as well as impoverish them. In 2003, 41,484 people died from suicide in the U.S. The vast majority of these people suffered from depression (Hoyert and Heron, 2006). Depression also contributes to increased deaths and severity of heart disease and other conditions (Ades, Savage, et al, 2002; Williams, Kasl, et al, 2002).
The causes of depression are thought to include genetic predisposition, stress, loss, physical symptoms such as pain or disability, low sense of self-efficiency, learned helplessness, repressed anger, distorted, negative thinking, and metabolic processes (Bresler, 2001). Decreased levels of the neurotransmitter serotonin are usually found in depressed patients.
Treatment of Depression
Selective Serotonin Reuptake Inhibitors (SSRIs) have largely replaced the somewhat more dangerous tricyclics and monamine oxidase inhibitors. Still, SSRIs are no more effective than those older drugs for most indications (Summary of Current Evidence, 2000). SSRIs can have many side effects, especially gastrointestinal symptoms, loss of sexual desire or ability, tremors and nervousness.
Fifteen to 30% percent of patients in various studies took themselves off an SSRI because of side effects, and 20-50% fail to show any benefit from these medications (Aberg-Wistedt, Agren, et al, 2000; Summary, 2000). Even when SSRIs work, they leave the patient unprepared for future episodes of depression, which may require re-treatment.
Non-drug Approaches Including Imagery
Psychotherapeutic approaches include cognitive therapy (changing patients’ distorted negative thinking), behavioral therapy (especially stress management programs), psychodynamic approaches, solution-oriented brief therapy, and others (Bresler, 2001). Many experts believe that combining psychotherapy or behavioral therapy with SSRIs is a more effective approach for depression than either treatment alone, at least in women (Altshuler, Cohen, et al, 2001). Exercise often has lasting positive effects (Babyak, Blumenthal, et al, 2000).
We know that therapy, including cognitive behavioral therapy (CBT), can change the brain (Linden, 2006). Use of CBT has been effective in reducing the number of relapses (Hollon, DeRubeis, et al, 2005; Lam, Watkins, et al, 2003). In another study, CBT had been so successful that in six-year follow up, CBT patients had significantly lower relapse rates, even when medication was discontinued (Fava, Ruini, et al, 2004). CBT enhances the effectiveness of Fluoxetine (March, Silva, et al, 2004). Absenteeism, depression, and anxiety in workers showed improvement after using CBT (Grime, 2004). Cognitive therapy has also reduced depression in cancer patients (Savard, Simard, et al., 2006).
Web-based, CBT programs have also shown promise (Christensen, Griffiths, & Korten, 2002).
Relaxation, guided imagery, meditation, and other mind-body approaches improve mood and decrease depressive symptoms (Jarvinen and Gold, 1983), often significantly (p=0.001) (Finucane and Mercer, 2006). Breath work and yoga are useful adjunctive approach to reducing depression (Brown and Gerbarg, 2005a, 2005b). Mindfulness meditation shows promise in reducing suicidal ideation (Williams, Duggan, et al, 2006).
Mind-body techniques also improve depression in subjects with medical conditions: cancer patients (Burns, 2001); post-operative and other procedure patients (Kim S and Kim H, 2005; Leja, 1989); postpartum first-time mothers (Rees, 1995); multiple sclerosis patients (Maguire, 1996), diabetics (McGinnis, McGrady, et al, 2005), cardiac patients (van Dixhoorn and White, 2005), and those in chronic pain (Turner, Ersek, and Kemp, 2005).
Autogenic relaxation training is also helpful for children with depression and other psychological symptoms (Goldbeck, Schmid, 2003). These techniques are also helpful for otherwise healthy adults (McKinney, Antoni, et al, 1997), and college students (Gold, Jarvinen, and Teague, 1982).
The anti-depressant effects of guided imagery and relaxation may result from reduced anxiety and an increased sense of control over life stresses (Bresler, 2001; Kabat-Zinn, Massion, et al, 1992).
Guided imagery can improve people’s ability to cope with depression, and will lift mood in many cases. This leads to decreased use of medical resources, better quality of life, and possibly, improved physical health status in some users.
Aberg-Wistedt A, Agren H, Ekselius L, Bengtsson F, Akerblad AC Sertraline versus paroxetine in major depression: clinical outcome after six months of continuous therapy. J Clin Psychopharmacol. 2000 Dec;20(6):645-52.
Ades PA, Savage PD, Tischler MD, Poehlman ET, Dee J, Niggel J. Determinants of disability in older coronary patients. Am Heart J. 2002 Jan;143(1):151-6.
Altshuler LL, Cohen LS, Moline ML, Kahn DA, Carpenter D, Docherty JP. The Expert Consensus Guideline Series. Treatment of depression in women. Postgrad Med. 2001 Mar;(Spec No):1-107.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV.) Washington DC, APA 1994 p.327.
Babyak M, Blumenthal JA, Herman S, Khatri P, Doraiswamy M, Moore K, Craighead WE, Baldewicz TT, Krishnan KR. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med. 62(2000):633-8.
Bresler, DE. Depression as Emotional Pain: A Mind Body Approach. In Strohecker J and N Strohecker, Awaken Your Energy for Life. New York: Perigree Press, 2001.
Brown RP, Gerbarg, PL. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part I – neurophysiologic model. J Altern Complement Med. 2005a Aug;11(2):383-4.
Brown RP, Gerbarg, PL. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part II – clinical applications and guidelines. J Altern Complement Med. 2005b Aug;11(4):711-7.
Burns DS. The effect of the bonny method of guided imagery and music on the mood and life quality of cancer patients. J Music Ther. 2001 Spring;38(1):51-65.
Christensen H, Griffiths KM, Korten A. Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. J Med Internet Res. 2002 Jan-Mar;4(1):e3.
Fava GA, Ruini C, Rafanelli C, Finos L, Conti S, Grandi S. Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. American Journal of Psychiatry. 2004 Oct; 161 (10):1872-6.
Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of Mindfulness-Based Cognitive Therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006 Apr 7;6:14.
Grime PR. Computerized cognitive behavioural therapy at work: a randomized controlled trial in employees with recent stress-related absenteeism. Occupational Medicine (Lond). 2004 Aug; 54 (5):353-9.
Gold SR, Jarvinen, PJ, Teague, RG. Imagery elaboration and clarity in modifying college students’ depression. Journal of Clinical Psychology. 1982; 38(2): 312-314.
Goldbeck L, Schmid K. Effectiveness of autogenic relaxation training on children and adolescents with behavioral and emotional problems. J Am Acad Child Adolesc Psychiatry. 2003 Sep;42(9):1046-54.
Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, Corey-Lisle PL. The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry. 1993 v.64, n.12, Dec03.
Hollon SD, DeRubeis RJ, Shelton RC, Amsterdam JD, Salomon RM, O'Reardon JP, Lovett ML, Young PR, Haman KL, Freeman BB, Gallop R. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives of General Psychiatry. 2005 Apr; 62 (4):417-22.
Hoyert DL, Heron M, Murphy SL, Kung HC. Deaths: Final data for 2003. Health E-Stats. Released January 19, 2006.
Accessed August, 2006.
Jarvinen PJ, Gold SR. Imagery as an aid in reducing depression. Journal of Clinical Psychology. 1983; 37(3):523-529.
Kabat-Zinn J, Massion AO, Kristeller J, Peterson LG, Fletcher KE, Pbert L, Lenderking WR, Santorelli SF. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry. 1992 Jul;149(7):936-43.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27 Erratum in: Arch Gen Psychiatry. 2005 Jul;62(7):709. Merikangas, Kathleen R [added].
Kim SD, Kim HS. Effects of a relaxation breathing exercise on anxiety, depression, and leukocyte in hemopoietic stem cell transplantation patients. Cancer Nurs. 2005 Jan-Feb;28(1):79-83.
Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, Parr-Davis G, Sham P. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry. 2003 Feb;60(2):145-52.
Leja AM. Using guided imagery to combat postsurgical depression. J Gerontol Nurs. 1989 Apr;15(4):7-11.
Linden DE. How psychotherapy changes the brain—the contribution of functional neuroimaging. Mol Psychiatry. 2006 Jun;11(6):528-38.
Maguire BI. The effects of imagery on attitudes and moods in multiple sclerosis patients. Alternative Therapies in Health and Medicine. 1996; 2(5):75 –79.
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. JAMA. 2004 Aug 18;292 (7): 807-20.
McGinnis RA, McGrady A, Cox SA, Grower-Dowling KA.Biofeedback-assisted relaxation in type 2 diabetes. Diabetes Care. 2005 Sep; vol. 28 (9): 2145-9.
McKinney CH, Antoni MH, Kumar M, Tims FC, McCabe PM. Effects of guided imagery and music (GIM) therapy on mood and cortisol in healthy adults. Health Psychol. 1997 Jul;16(4):390-400.
The Numbers Count: Mental Disorders in America. National Institutes of Mental Health. NIH Publication No. 06-4584. 2006. http://www.nimh.nih.gov/publicat/numbers.cfm
Accessed August, 2006.
Rees BL. Effect of relaxation with guided imagery on anxiety, depression, and self-esteem in primiparas. J Holist Nurs. 1995 Sep;13(3):255-67.
Robins LN, Regier DA (Eds). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study, 1990; New York: The Free Press.
Savard J, Simard S, Giguere I, Ivers H, Morin CM, Maunsell E, Gagnon P, Robert J, Marceau D. Randomized clinical trial on cognitive therapy for depression in women with metastatic breast cancer: psychological and immunological effects. Palliat Support Care. 2006 Sep;4(3):219-37.
Summary of the Current Evidence of Relative Effectiveness of SSRIs and TCAs in the First Line Treatment of Depression in Primary Care. Trent Institute for Health Services Research, Universities of Leicester, Nottingham and Sheffield. January, 2000.
Accessed August, 2006.
Turner JA, Ersek M, Kemp C. Self-efficacy for managing pain is associated with disability, depression, and pain coping among retirement community residents with chronic pain. J Pain. 2005 Jul;6(7):471-9.
Van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc rev Rehabil. 2005 June;12(3):193-202.
Williams JM, Duggan DS, Crane C. Fennell MJ. Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. J Clin Psychol. 2006 Feb;62(2):201-10.
Williams SA, Kasl SV, Heiat A, Abramson JL, Krumholz HM, Vaccarino V. Depression and Risk of Heart Failure Among the Elderly: A Prospective Community-Based Study. Psychosom Med. 2002 Jan-Feb;64(1):6-12.