me and my incoherent brain

While reading Voelker's brief article on proposed links between sleep disruptions and depression in college students, I flashed back to vivid memories of college friends dealing with depression who felt unable to get up in the morning despite multiple alarm clocks--who stayed asleep in bed until 4 or 5 pm, missing all their classes. Their problems with depression seemed intimately tied to abnormal sleep patterns and an inability to establish a healthy sleep-wake rhythm. Sleep problems can be devastating to individuals' daily functioning (lost jobs, failed classes...), so I'd be interested to know the statistics on abnormal sleep patterns in persons with depression. [Armitage's observation of poor coherence during the sleep of some individuals with depression was certainly provocative, but I'd be interested to see the findings replicated.]

Thinking along these lines, it seems to me that incorporating sleep hygiene goals in a behavioral activation therapy program for depression could be highly useful. Bootzin & Epstein discuss establishing appropriate discriminative stimuli for falling asleep by reserving the bed and bedroom for sleep only; along with establishing appropriate cues for sleep, they recommend certain daytime activities as well: avoiding naps, engaging in light, regular exercise, and exposing oneself to bright light. It seems to me that the stimulus control instructions would mesh well with goals for behavioral activation; developing simple goals early in therapy such as "I will not stay in bed for more than 15 minutes after waking in the morning" and "I will not use my bed for purposes other than sleeping (or sexual activity)" and moving on to more challenging goals such as "I will avoid naps" and "I will spend 15 minutes a day doing [fill in form of light exercise here]" as therapy progresses could help the client both to "activate" and to resolve sleep disturbances--which, in turn, would likely assist the client in activating yet further.

Certainly, resolving sleep problems will not automatically resolve depression, but it seems to me that these issues may, for many individuals, have a reciprocal relationship; anxiety or catastrophizing may feed insomnia, but then insomnia may further feed anxiety. Certain depressed persons might be predisposed to certain kinds of sleep disturbances, and these sleep disturbances may lead to impaired performance at school or at work--which may worsen a depressed individual's perception of their own efficacy. It seems to me that it would only make sense to tackle these problems together. I'd be interested to see any research that tackled this question empirically.

good storytellers

Despite Jim's disclaimer in class last week, I really enjoyed this week's readings and they went by quickly. I was particularly interested by Jacobson, Martell, and Dimidjian's 2001 article on behavioral activation treatment for depression. Their focus on action, rather than cognition, intrigued me. "One of the primary goals of presenting the BA model," they state, "is to dispel the myth that changes in mood need to occur before changes in behavior" (p. 260). I put a little exclamation point next to this statement on my paper copy, because in making this claim, Jacobson et al. draw upon a large body of social psychology research that supports the notion that behaviors have the ability to change cognitions just as much as, if not more than, cognitions have the ability to change behaviors. If forced, for example, to choose between two equally appealing alternatives, we later devalue the one we did not choose and increase our evaluation of the one we did choose. A study I particularly like that illustrates our behaviors' ability to drive our judgment is one in which participants were asked to engage in an excruciatingly boring task for a long period of time. (For the life of me, I cannot remember who did this study!) Once the task had been completed, researchers either offered the participants $1 or $15 to tell the future participants that the task had been interesting. Participants who received $15 did so, but later rated the study as boring. Participants who received $1 also told others the study was interesting, but when privately rating the study, said they had actually found it interesting. Presumably, they could not justify lying about the study for just $1, and so explained their behavior by coming to believe that they had actually found the repetitive task interesting! This and other similar studies suggest that while we don't always know the reason for our behaviors, we're very good at coming up with plausible explanations after the fact.

Although we would like to believe that we are perfectly rational creatures, oftentimes our self-stories are used not to guide our behaviors but to make sense of what we do. By encouraging depressed individuals to engage in personally reinforcing activities, BA uses behaviors as a guide to change cognitions (i.e., "if I am choosing to get out of bed and engage in this activity, then I must be feeling more energetic"). I doubt that this would work if goals were not worked out collaboratively; if the therapist were more active-directive, I imagine that the client would then be able to attribute their actions to the "orders" of the therapist, and would consequently not derive as much benefit. I therefore see the program's emphasis on helping the client to select activities that they personally find reinforcing to be a plus. Getting the client to make choices about goals and carry them out independently as homework drives them to ascribe their positive behaviors to their own internal states rather than to the dictates of the therapist.

Overall, I found theirs to be an intriguing and potentially very useful perspective on the treatment of depression. Looking forward to hearing from everyone else on this!