Rapid Responses to:

ANALYSIS: Paul Biegler Autonomy, stress, and treatment of depression BMJ 2008; 336: 1046-1048 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Autonomy or integration: How does psychotherapy deal with depression?

Atul Agarwal   (11 May 2008)

Increase of autonomy cannot be an argument in favour of cognitive behavioural therapy

Dieneke Hubbeling   (14 May 2008)

Autonomy or integration: How does psychotherapy deal with depression? 11 May 2008
Atul Agarwal, Retired professor of medicine Laxminagar, Nagpur (India) 440022 Send response to journal: Re: Autonomy or integration: How does psychotherapy deal with depression?	In his well intentioned article Biegler(1) talks about autonomy while he should be talking about integration as a means of dealing with depression. Psychotherapies further integration of the individual with ambient biological, social, and cultural environments. Biological environment is our body and the disease(s) that one may be having. Social environment is family, workplace, and society. Cultural environment is language, values, practices, and other behaviors rooted in individual’s culture not necessarily the dominant culture. It is well known that lack of satisfying relationships & family support can lead to stress, depression, and illness.(2-4) A reciprocal relationship between depression and physical illness is being increasingly recognized.(5-8) I have come across diabetics who want to party merely to keep their social contacts intact or growing. They have two integrative needs that are in conflict. To have adequate control over diabetes they need to adopt a healthy eating pattern and that is in conflict with their social integrative needs. Uncontrolled diabetes may lead to complications and depression later in life. However, loosing social contacts may mean loss of business, social isolation, and depression in the near future. Dealing with this tricky situation may in itself be quite stressful. They may ask: how to integrate with diabetes while keeping social integration intact? They need more integration and ‘not’ more autonomy. Psychotherapy can be of help by providing insight that other - probably better - (autonomous) choices can be availed for better integration and by making the individual comfortable and at home with these ‘other’ choices. Drugs do not deal with the context in which depression occurs. They merely reduce the symptoms. A depressed individual may continue with his cigarettes while his wife or child suffers from asthma in silence. Or an alcoholic may continue with drinking while his family and job suffers. Such individuals obviously require more integration and not more autonomy. Psychotherapy adds value to autonomy or it helps the individual in making a better (autonomous) choice for the purpose of better integration. The purpose (of psychotherapy) is integration and not autonomy. The reason for recommending psychotherapy to depressed individuals is because it shall be of help to them in becoming more integrated and not because it shall enhance their “personal autonomy” as described by Biegler.(1) References: 1. Beigler P. Autonomy, stress, and treatment of depression. BMJ 2008; 336: 1046-1048. 2. House JS, Landis KR, and Umberson D. Social Relationships and Health. Science 1988; 241: 540-545. 3. Sun R. Worry about Medical Care, Family Support, and Depression of the Elders in Urban China. Res Aging 2004; 26: 559-585. 4. Dalgard OS, Bjork S, & Tambs K. Social support, negative life events and mental health. Br J Psychiatry 1995; 166: 29-34. 5. Simon GE, Von Korff M, Saunders K, Miglioretti DL, Crane PK, van Belle G, Kessler RC. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry 2006;63:824–30. 6. Bjerkeset O, Romundstad P, Evans J, and Gunnell D. Association of Adult Body Mass Index and Height with Anxiety, Depression, and Suicide in the General Population: The HUNT Study. Am J Epidemiol 2008;167:193-202. 7. Lustman PJ and Clouse RE. Depression in Diabetes: The Chicken or the Egg? Psychosom Med 2007; 69: 297 - 299. 8. Chida Y, Hamer M, and Steptoe A. A Bidirectional Relationship Between Psychosocial Factors and Atopic Disorders: A Systematic Review and Meta-Analysis. Psychosom Med 2008 70: 102-116. Competing interests: None declared
Increase of autonomy cannot be an argument in favour of cognitive behavioural therapy 14 May 2008
Dieneke Hubbeling, Consultant Psychiatrist Springfield Hospital SW17 7DJ Send response to journal: Re: Increase of autonomy cannot be an argument in favour of cognitive behavioural therapy	Biegler[1] discussed the relative merits of cognitive behavioural therapy and drug treatment for depression. One of his key arguments was that cognitive behavioural therapy can help people to make more accurate appraisals during future events. Therefore, according to Biegler, cognitive behavioural therapy has an autonomy advantage over drug treatment of depression. Biegler stated that autonomy i.e. acting from informed and rational preferences has intrinsic value. However, in decision making, human beings are often influenced by non -conscious psychological processes and they do not always act from informed and rational preferences. Accurate conscious appraisals for future events are only aspect of decision making. Other non-conscious processes might be disturbed in depression, for example research has shown that depressed people have problems with theory of mind functions [2], with executive functions [3] and with problem solving [4]. There is no evidence that cognitive therapy improves these processes more than medication. It has not been tested. In my view, with the current stage of research one cannot use increase of autonomy as an argument in favour of cognitive behavioural therapy. Only clinical effectiveness of cognitive behavioural therapy is a valid argument, such as the findings from Hollon et al. [5], already cited by Biegler. References 1. Biegler, P., Autonomy, stress, and treatment of depression. BMJ, 2008. 336(7652): p. 1046-1048. 2. Channon, S. and P.S.S. Green, Executive function in depression: the role of performance strategies in aiding depressed and non-depressed participants. J Neurol Neurosurg Psychiatry, 1999. 66(2): p. 162-171. 3. Lee, L., et al., Mental state decoding abilities in clinical depression. Journal of Affective Disorders, 2005. 86(2-3): p. 247-258. 4. Channon, S. and J.E. Baker, Depression and problem-solving performance on a fault-diagnosis task. Applied Cognitive Psychology, 1996. 10(4): p. 327-336. 5. Hollon, S.D., et al., Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives of General Psychiatry, 2005. 62(4): p. 417-422. Competing interests: None declared