August, 2006

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.


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