Alternative Brief Interventions for Mild Depression

Depression has long been recognized as a primary concern for health care providers.^1-3 Many approaches to treating depression have been developed, ranging from medications, to long-term psychotherapy, to shorter, more structured cognitive-behavioral treatments--all of which help some of the patients, some of the time, to some extent. However, there are still many persons who never access treatment for reasons ranging from the stigma that still surrounds mental illness, to a lack of resources, both personal (eg, lack of money) and "professional" (eg, long wait for appointments). Furthermore, given the restrictions placed on practice by managed care, and the proliferation and success of brief, motivational enhancement treatments with other disorders, such as alcohol abuse,^4,5 it is important to develop similar treatments for those with depression and/or depressed mood to augment existing treatment options.

There is a growing realization that depression exists on a continuum,^6-9 and that treatments are needed at all levels of a "stepped-care" approach.^10-12 In particular, those with mild symptoms of depression are less apt to seek treatment, yet they are at risk for development of a major depressive episode and experiencing other consequences of depressed mood.^7,8,13,14

Two groups particularly underserved by the current treatment system are adolescents and college students. Research indicates that adolescents (aged up to 19 years) are the "least likely to be recognized, diagnosed, and treated in the health care system compared with [those with] depression in other age groups."¹⁵ College students are vulnerable because they often encounter increased stressors and incidents of depression and depressed mood while also facing barriers to treatment.^16-19 However, treatment options for those with subclinical depression or depressed mood are bleak.³ Most receive no treatment for their symptoms; the Surgeon General recently stated that promoting treatment is a more significant problem than developing better treatments.²⁰

Persons with less history of depression or those who are mildly depressed may best be helped with an educational, motivation-enhancement approach. Alternative, lower-cost, brief treatments are starting to emerge in an effort to reach persons with various levels of depressed mood. In addition to computer- and telephone-administered treatments,^21-23 some writing and bibliotherapy approaches have been shown to reduce symptoms of depression.

Writing approaches

Writing brief narratives is a low-cost way of reducing depressed mood in college students and others. James W. Pennebaker has conducted dozens of studies over 15 years examining the cognitive, emotional, and language processes involved in writing short narrative disclosures.²⁴ For example, writing about traumatic experiences for 10 minutes a day for several days or for even a single writing period has been shown to reduce health-center visits and improve grade point averages, immune function, hormonal activity, and subjective well being.^25,26 Effect sizes in these studies ranged from 0.45 to 0.70, similar to those with other psychological treatments. The effects are presumed to occur through changing cognitions during the writing process. This activity forces the person to think about events and process the emotional and objective elements of the event, while reducing rumination. Results are obtained not merely through "venting" or "catharsis"; writing about only emotions without a description of the event itself did not show the same benefits.²⁷

Writing about trauma also reduces the frequency and impact of intrusive thoughts about the event. Furthermore, writing changes how individuals interact with others, their patterns of speaking, use of self-reference, and use of positive emotion words, which brings about changes in objective social behaviors in the real world.²⁵ Writing has also been compared with talking into a tape-recorder or to a therapist with comparable results in healthy subjects.^27,28 This presents an inexpensive yet effective way to help patients feel better.

Reading approaches

A study looking at mildly to moderately depressed older adults found that bibliotherapy (reading books, such as Control Your Depression by Lewinsohn, Munoz, Youngren, and Zeiss, or Feeling Good by David Burns) was an effective form of treatment that reduced symptoms. The gains were maintained for up to 2 years with 77% of the patients not seeking other treatment.²⁹

In a primary care study of 156 adult outpatients with depression, investigators sought to enhance treatment with antidepressants by providing written and videotaped educational materials that explained biologic and behavioral elements of depression.³⁰ In addition to those materials, the patients attended 4 to 6 sessions of psychotherapy with behavioral activation and cognitive interventions geared to education, skills training, and homework. The study found that 70% of the patients who received education and psychotherapy intervention had a 50% or more reduction in symptoms compared with 40% in the treatment-as-usual cohort.

Recently, researchers have successfully used normative mailed feedback to reduce college students' problem drinking.^31-36 In a recent study, this approach was extended to the treatment of college students with depressed mood. The study showed that symptoms of depression were reduced by 20% in students who were given a personalized letter that reflected the symptoms they were experiencing and positive coping strategies they were using; in addition they received a brochure listing a variety of additional strategies shown to combat depression (eg, seeking social support, pleasant activities, exercise, suggestions for self-help literature) compared with a reduction of 8% in the control group. In addition, receiving the information reduced hopelessness by 31% in the intervention group compared with 7% in the control group.³⁷ This was a low-cost intervention that could be used alone for those with mild depression or in conjunction with other approaches for those on the higher end of the depression continuum.

There are beneficial clinical implications of alternative approaches that have been shown to reduce depressed mood. Low-cost approaches that provide education for those experiencing subthreshold depression could prevent full-blown major depressive episodes. Mailing materials removes some of the barriers to treatment often encountered in mental health. Finally, for those already depressed and seeking treatment, providing concrete, simple techniques that can be accessed at home may augment existing approaches. Future directions should aim at studying the effectiveness of such alternative approaches in psychiatric and primary care settings, as well as with those persons who have more severe depression.

Irene Geisner is a project coordinator in the department of psychiatry and behavioral sciences at the University of Washington in Seattle and a PhD candidate. She reports that she has no conflicts of interest concerning the subject matter of this article. This research was supported in part by the National Institute on Alcohol Abuse and Alcoholism Grant T32AA07455 and the Stanley Foundation.

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