Depressed? You Don't Need Drugs, Psychiatrist Says Depression is said to affect more than 20 million people in the United States, but psychiatrist James Gordon argues that it's not disease. In his book, Unstuck, Gordon makes the case that most people don't need drugs to feel better.

Depressed? You Don't Need Drugs, Psychiatrist Says

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This is Talk of the Nation Science Friday. I am Ira Flatow. According to the National Institute of Mental Health nearly 21 million American adults, nearly 10 percent of us, suffer from some form of depression. Depression is the major cause of disability for adults in this country and each year Americans spend billions of dollars on antidepressant medications like Prozac and Paxil. And psychiatrists say critics no longer spend much time in talk therapy with their patients. They have become drug dispensers. You want to talk to somebody, here is the name of the psychologist. I've only got 15 minutes on your healthcare plan. So, what's the best way to treat depression?

One of my guests this hour says don't treat it as a disease with drugs because it is not a disease. Dr. James Gordon is the founder and director of the Center for Mind-Body Medicine. He's a clinical professor in Psychiatry and Family Medicine at Georgetown University School of Medicine in Washington. His new book is called "Unstuck: Your Guide to the Seven Stage Journey of Depression," and he joins us from WWNO in New Orleans. That should be "out of depression" I should say. Welcome back to Science Friday, Dr. Gordon.

Dr. JAMES GORDON (Founder and Director of the CMBM and Clinical Professor in Psychiatry and Family Medicine, Georgetown University School of Medicine, Washington; Author, "Unstuck: Your Guide to the Seven Stage Journey Out of Depression"): Hey, it's nice to be here again, Ira.

FLATOW: Thank you. Also with us is Dr. Peter Kramer. He's a clinical professor of Psychiatry at Brown University and the author of several books, including "Listening to Prozac" and "Against Depression." And he joins us from Providence. Welcome back to Science Friday, Dr. Kramer.

Dr. PETER KRAMER (Author and Clinical Professor of Psychiatry, Brown University): Hi. Thank you.

FLATOW: Our number 1-800-989-8255. I invite you to give us a call. But, remember, as always when we talk about medical or any kinds of issues that affect your body, we cannot talk about your condition specifically so don't ask us please. Don't ask our guests to diagnose or treat you over the phone. It's not ethical for us or for them to do that. And if you have questions about your own medical condition, we tell you to talk to your own doctor. And of course if you want more information, you can surf over to our Web site at the and talk to other folks in Second Life in Science Friday Island. James Gordon, the first line in the preface of your book is and you repeat it over and over again in many places is depression is not a disease. It's not? What is it?

Dr. GORDON: Well, depression is first and foremost a human experience, and it's a question of how we're going to look at that human experience. There is certainly some evidence that it's a disease, but it doesn't seem to me that we have gotten to the point where we've established it's a disease in a way that, for example, insulin-dependent diabetes is. I see depression, the signs and symptoms of depression as signs and symptoms that our life is out of balance. That change is necessary. It's not the end-stage of a disease process, but a wakeup call. It's the beginning of a process of potentially great and transformative change.

FLATOW: Would you say then that we're living our lives incorrectly if we're suffering from depression?

Dr. GORDON: You know, when you start saying, using words like incorrectly there's a kind of judgmental quality to it. But in a sense, you're right we're living our lives in a way that's not suiting us for the most part, or we simply suffered a tremendous loss and we need to recover and rebalance. So either something has happened to us that we have to deal that's overwhelming to us or in many cases, we gotten ourselves into a place where we feel we can't move ahead in a way that we have been accustomed to. We feel stuck. Hence, the title of the book "Unstuck." So it's - depression comes from many reasons. I work in war zones and post-war and post-disaster situations like New Orleans and there are lots of people who are clinically depressed after Hurricane Katrina. So the question really is, given the fact that you are depressed as an individual or as a whole population or significant percentage of the whole population, what do you do now? And that's really what I feel is most important.

FLATOW: Peter Kramer, your take on depression as a disease.

Dr. KRAMER: I think depression clearly is a disease. There's a question about how societies defines diseases, and there are few conditions that are not diseases in some societies and are others, and we could talk about those. But generally, if something causes a great deal of pain and suffering, if it's syndromal that has a form involving a cluster of symptoms and has some of these others sort of cloud of conditions that define diseases that runs in families it's partly heritable, it correlates with other diseases, then it's a disease.

And I think one area that Dr. Gordon and I might disagree about is I think also in the past 10 or 15 years there is one other criteria that we think about which is, is there a bodily location of disease? Is there something that's gone wrong that causes the disease or something that the disease causes that goes wrong in the body? And I think there just has been so much brain science pointing to disruptions that either cause or caused by depression that it's met sort of that last criteria and it really is a disease. And of course, there's one other criteria, which is that it has a history of being thought of, at least some of the time, as a disease in this culture, and depression meets that standard as well.

FLATOW: Are you - I'll let you respond in a second, James. Are you both talking about the same thing when you're talking about depression?

Dr. KRAMER: Well, I think with diseases, we start with the severe, like why is acne a disease? Well, there are terrible forms of acne or psoriasis. If you saw only mild psoriasis, well you'd say that's not a disease, but people die of psoriasis. So, I think when we think about whether something is a disease, in the case of depression, we think about people that we say have a family, strong family history of depression that become very depressed, very stuck frankly at a very young age. They can't get out of it by ordinary psychological means. The fact that their circumstances are good, don't solve it. And then there are all these other correlations, which is they die younger at every stage of life. They have more heart disease, more stroke. They, of course, die more often of suicide. And I think we start with that core, and I think most people in this culture right now by the way say that would be a disease. Now, I would say some other things where there's a more obvious cause, but you respond in this extreme stuck way and others wouldn't, and then also the depression becomes recurrent and worse with future episodes and so on. I would say that those are part of the disease as well.

FLATOW: Dr. Gordon.

Dr. GORDON: You know, I certainly agree and I think Dr. Kramer has actually done a wonderful job of summarizing some of the recent brain science in his book "Against Depression" which I cite in my book. But the issue that I see as most important is indeed there are changes in the brain of some people - first of all, I want to make that point very clearly. It's not 100 percent or anywhere near a hundred percent consistent. There are changes in the brains of people who are depressed, there are changes in cortical function, changes in the hippocampus of the brain. And those changes, as I think both Dr. Kramer and I would agree, are generally the product of significant stress.

The issue for me really is that if you can reverse those changes by simple non-pharmacological methods, relaxation, meditation, physical exercise, learning to see and understand the world differently in a less pessimistic, less self-defeating way, why is it so important to focus on depression as a disease? Why not take the opportunity to focus instead on it as a human experience and then to give human beings the tools they need to reverse those biological changes where everything that happens to us is biological. There is a recent study published in one of the neuroscience journals showing brain changes in mothers who are smiling at their babies. So, you know, that's...

FLATOW: For that reason - well, that's where my question about are we talking about the same range of depression? I mean, people who are truly depressed, who don't smile, can't get out of the bed, can't, you know, just can't function, are they able to go through your seven-stage journey? If some people who really, really are clinically depressed?

Dr. GORDON: Yes. Many of them are. Many of the people whom I've seen many of the people I describe in the book have been diagnosed not by me, but initially by other psychiatrists including those with the National Institute of Mental Health and the major medical centers as clinically depressed. I would agree there is a range and those people whom I certainly remember seeing and I don't see as often now. It's not that they don't exist, of course they do. Who literally can't get out of bed, who can't eat anything. That's at one end of the continuum, that's not a very large number of the people that you quoted figure of 21 million people. I would say that's a small percentage of those 21 million people. The people whom I see do indeed have the signs and symptoms of depression, two weeks of lack of pleasure in their life, of not being able, feeling like they can't move of agitation, difficulty sleeping, difficulty eating, sometimes suicidal thoughts and feelings, that's clinical depression. Everybody I see has clinical - whom I write about in the book, has clinical depression.

FLATOW: Peter Kramer, you agree? I mean, a lot of times we hear people say, oh I'm blue, I'm feeling depressed, I didn't get my paycheck this week, you know, my vacation is canceled. Then they go to their doctors and they - of course there are commercials on TV say, hey ask your doctor if you're feeling like this, and then their doctor gives them something.

Dr. KRAMER: You know I have more respect for internists and family doctors probably than the people who put up, you know, that sort of straw man. I think that they are part of the diagnosis of depression is that it really has to interfere with your functioning. And I think when it gets to that point it really is different and a number of the objections to depression don't - to depression being a disease, don't take into account the level of severity of that that really is required. I think the disease label is very important because depression is dangerous.

I agree that often depression response is psychotherapy and the response to other things that resemble psychotherapy, and things like bright lights in winter, and exercise and probably dietary changes and so on. But for me the real measure of success of a treatment is that it succeeds, and I think if you have tried the things that you find more appealing as first steps, and if they haven't worked you are at risk for all the things that go with depression like the strokes and heart attack, and recurrences, and problems with career and relationship and so on. And I think in that case it makes sense to think about some of the better studies. Interventions which as they say are psychotherapy and, yes, medication. I think the medications, you know, to put on the table really what I think a lot of discussion's about is should we run the medications?

The medications are reasonably effective relative to these other changes that people talk about. And the big difference, you know, in the percentage of people are said to get better in studies of medications and studies of things like yoga and so on, is that the standards of study for medication have gotten very high, appropriately so, but they include looking at all the people who entered the study looking mostly at the people who get fully better. Looking at large population, looking at giving - people giving medication or don't have an interest in the medication and don't or you know aren't - don't have a stake in the outcome. And I think those sorts of tests largely haven't been done for things like meditation and so on.

FLATOW: Absolutely. We're going to get back. James, give you - Dr. Gordon, give you a chance to reply. Talking with James Gordon author "Unstuck: Your Guide to the Seven-Stage Journey Out of Depression", also talking with Dr. Peter Kramer author of "Listening to Prozac" and "Against Depression." Our number 1-800-989-8255. Stay with us, we'll be right back.

FLATOW: I'm Ira Flatow this is Talk Of The Nation Science Friday from NPR News.

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FLATOW: You're listening to Talk of the Nation Science Friday, I'm Ira Flatow. We're talking this hour about depression with my guest Dr. Peter Kramer, author of "Listening to Prozac" and "Against Depression." Also talking with Dr. James Gordon, he's founder and director for the Center for Mind-Body Medicine and author of the new book "Unstuck: Your Guide to the Seven-Stage Journey Out of Depression". Our number 1-800-989-8255. Dr. Gordon, good point raised by Dr. Kramer. How well have these holistic medicines, they've been studied? Yoga, meditation, even I put acupuncture in there.

Dr. GORDON: Let me address a couple of points here if I could.

FLATOW: OK, sure.

Dr. GORDON: I would first of all disagree somewhat Dr. Kramer about the effectiveness of the antidepressant drugs. And I know - I don't want to get into a long debate about it, but there have been some looks again at whether or not the drugs are as effective as the published studies show. And when it turns out in a couple of studies that have been presented, looking at all the unpublished as well as the published studies, that the anti-depressants aren't nearly as effective - would appear not to be nearly as effective as they have looked over in recent years. Secondly, antidepressant drugs have, in large numbers of people, significant side effects.

So, what I would say is that an approach which has virtually only positive side benefits, an approach which doesn't use one particular intervention, say yoga or meditation, or exercise, or group support, or psychotherapy, but combines all of those, each of which has been shown to be better than placebo, in treating depression, is the approach with which I would begin together with, often enough, group support. If that approach doesn't work, and incidentally we have been doing both open trials of hundreds of people and now randomized controlled trials of a method that puts together these techniques and these approaches. But if that approach doesn't work, that seems to me to be the appropriate time for medication, which is a potentially useful, but also brings with it certain hazards. And I would agree with Dr. Kramer that it is important to treat depression right away. But if you can improve as both the people whom I describe in "Unstuck" have using these other methods as a number of studies have begun to show, there're not as many studies on these methods as on antidepressant drugs. They need to be studied more thoroughly.

One of the reasons incidentally that they're not studied as thoroughly is because there's no massive profit. You can't patent yoga, you can't patent meditation, you can't patent group support, whereas you can patent and profit from drugs so a lot more money goes into the studies. So what I'm saying is we need to look at this approach and I would say very strongly that we should use this approach preferentially. This approach that mobilizes people to help themselves rather than an approach that relies primarily on drugs. And if that approach doesn't work then it's time to look at the drugs.

FLATOW: What's wrong with that logic, Dr. Kramer? Sounds like it should work.

Dr. KRAMER: I don't - myself advocate an approach that mostly relies on drugs. I like to see my depressed patients exercise, use bright lights up here in New England in the winter. I like to see them improve their social relationships their thoughts about social relationships. And I always have them in psychotherapy. So I think it's true we want - you know, I think that goes with my thought about this as a dangerous, risky condition because I don't want to throw as much at it that's ever been shown to work as I can. And I think most of those things are useful in people's lives as well. I just want to say that I wouldn't leave medication out of the mix. You know, fairly soon I would think about it, if other things aren't making the condition budge. And of course we do have some notion of how bad things are. I think some people, you know, are doing pretty well despite not sleeping and eating, and brooding and so on. And we can go for awhile with them. Other people I think we worry. There's been a history of suicide in the family, they're really not mobilized at all, and then I think there we want to move in a little more quickly.

FLATOW: Well, you're speaking as a psychiatrist. But don't statistics show, and I'm quoting from a scientific American article from February 27th of this year, "43 percent of those who have prescribed antidepressants had no psychiatric diagnosis or any mental health care beyond the prescription of the drug, and chances are they got that drug from their family physician who will show very little follow-up following that."

Dr. KRAMER: No. That is shameful and that approach has been shown not to work. I think I would say that this is like if we had a culture in which we would say the patients you have cancer and for this cancer the best treatment is radiation and chemotherapy but we can't afford the radiations. You know, you're only going to get the chemotherapy. The insurance company buildings would be torn down brick by brick. And I think that does hold for a psychotherapy.

FLATOW: But this is the reality of the situation is it not?

Dr. KRAMER: It is...

Dr. GIORDON: Yeah. I'm sorry go ahead, Peter.

Dr. KRAMER: Yeah, I mean it is often a reality of the situation. Not to say that family doctors, GPs, internist can't do a good job with mood disorders. There are plenty of studies showing with the right support and so on, they can. But you can't just give them medicine and cross your fingers and say come back in six months.

FLATOW: Go ahead. Dr. Gordon, you wanted to say something?

Dr. GORDON: Yeah. What I want to say is I'm really advocating very strongly for a shift in the approach. And this, I wrote "Unstuck" because of the thousands of people who have said to me can you put in book form this program that you do. And I do it because my strongest belief is that our capacity to understand and help ourselves is far greater than we know, far greater than most of us as physicians either have experienced or believed, and that the whole way of working with depression has to shift from a reliance on the physician to the physician being a guide who helps people develop their own capacity to help themselves to balance and change their own biology, their own psychology.

FLATOW: Can you give us a thumbnail version of your seven-stage journey?

Dr. GORDON: The seven stages - the first is the call, the recognition that you are depressed. I think it's very important. That's important to recognize for many of the reasons Dr. Kramer says and just because it's blighting people's lives. Depression is not - but some people just don't know they have it. So waking up to the fact that you're depressed, beginning to see that there are things already in your life that you're doing to make yourself feel better. One of the examples I give right at the beginning of my book is a woman who felt better when she did yoga, when she called her friend Barbara, and when she went to church. So what she's realizing is she's not as helpless and hopeless as she and most depressed people think. There are things she can do.

The second part is looking for guides. I do feel that most people when they're depressed do need guides to help them make their way through and out of and beyond depression. Some of those guides may be people, they may be physicians, particularly physicians who are accustomed to working with nutrition, and to giving people the nourishment and the supplementation, and exploring some of the physical, potential physical causes of depression. And they also need guides who, in our society, are psychotherapists. People who they feel welcome by, not people as you mentioned at the top of the show who sort of listen for a few minutes and write out a prescription. I think that's counter-therapeutic. In any case, people need someone - could be a primary care physician, more often it could be a psychiatrist, could be a psychotherapist who is there for them and who has confidence and trust in them and hope for them, and who understands this difficult territory of depression.

The third stage is, I call, surrendering to change. Moving back into the current of your life. When you're depressed you're sidelined. Symptoms of immobility and stasis and stuckness. And I think physical exercise can be very, very important even if it's just a little, even for those people who feel just almost immobilized, getting them to move a little. Incidentally, a physical exercise has been shown in animals to regenerate cells in the hippocampus, an area of the brain that's probably involved in depression.

The fourth stage is dealing with the demons. Dealing we might call them aspects of our character, issues in our lives, loneliness, lethargy, perfectionism, procrastination, guilt, all the things that characterize many of us. Some of us who aren't depressed as well as some of us who are and learning. And I give some exercises whereby you could have - relax with and learn from, have dialogs with and learn from these different aspects that are troubling to you.

The sixth stage that's comes to some of us is understanding and recognizing the dark night of the soul. That despair that may predispose us or push us to suicidal feelings and even to suicidal acts. And I think particularly here in the dark night it's crucial to reach out to guides, but I think it's important to see suicide - suicidal feelings as not necessarily sort of the certification that you've got this terrible disease, but as a certification of a sense of desperation and of no alternatives. And what's crucial here, I think, is to have someone who can help you look at possible alternatives. This is incidentally sometimes where medication...

FLATOW: Right. If you have suicidal feelings, you should get professional help, would you...

Dr. GORDON: I agree completely.


Dr. GORDON: That's exactly what I'm saying. And the professional need not panic. There's some studies that have come out in recent years showing 10 percent of - I'm sorry, one in five American adolescents has suicide - significant suicidal feelings.

Dr. KRAMER: Can I jump in here?

FLATOW: Sure, sure.

Dr. KRAMER: This - you know, hearing this list, you know, put together in this way makes me very uncomfortable. It has a moral and spiritual feel to it that I think in a way, takes away from the notion of depression as disease. My last book, my most recent one was a Freud biography, and I think it even moves away from that sort of neutrality in a psychoanalysis that Freud didn't practice, but that was the ideal of psychoanalysis, the notion of a guide or a coach. I mean, I have to say I don't think of myself as a great advocate for medication, but if I had something that was really a danger to my health and well-being altogether. And if it were the case, say that medication worked without enormous side effects, I might very well prefer that intervention as a first recourse than having to put myself in the hands of someone who has all these beliefs about how the world works and what my direction should be.

Dr. GORDON: That - and of course that's your choice. I'm offering a way many of the people. there are millions people in this country who have taken anti-depressants and do not - have not found much benefit from them and do not like taking them. If people have the choice, what I'm presenting is a way that I have - a way that I've worked with people now for 40 years, a way that we've trained thousands of people to work, I don't see it as moralistic at all. Spiritual, yes, that's the next stage. This is - our work is spiritual work. And as you know, the word psyche has to do, you know, is really the word for soul, it's not just a word for (unintelligible) pointed out. That we are in a profession of helping to heal souls and we - as well as being scientists. And, you know in some it's only - it's moral in the sense of my respect, my utter respect for people's capacity to help themselves and my willingness to be there with them as they go through this experience.

Dr. KRAMER: I think where I pulled back was...

Dr. GORDON: That doesn't say that people shouldn't take medication.

FLATOW: Dr. Kramer.

Dr. KRAMER: Probably though, I think where I pulled back was probably the word God. I think it's true that we have spiritual sides and that psychotherapy taps into those and, you know, allows us to make change through that part of our self. But I think that it is ideally, you know, a bit more of a hands-off process than what I'm imagining in this...

Dr. GORDON: I'm not sure.

FLATOW: Hang on. I have to give an ID. We're running out of time, we're talking with Dr. James Gordon and with Dr. Peter Kramer on Talk of the Nation Science Friday from NPR News. Dr. Gordon is author of "Unstuck: Your Guide to the Seven-Stage Journey Out of Depression." And of course Peter Kramer is author of "Listening to Prozac" and "Against Depression." See if we can get a phone call or two in here. John in Wichita. Hi, John.

JOHN (Caller): Hello, Ira.

FLATOW: Hi, there.

JOHN: Thank you for your show. And Dr. Gordon and Dr. Kramer, thank you for your work in this area which I think is one of the most damnable diseases on the planet.

FLATOW: Have you got a question for us?

JOHN: I have a question. To Dr. Kramer, I want to know if the chemical imbalances that are often cited as the cause of depression, if these can be objectively measured in the clinic, a priority for prescribing the medicines?

FLATOW: All right.

Dr. KRAMER: Yes. No, the answer is no. I think there is some progress in predicting who will do well with what. There's some new genetic studies showing that, they actually involve what is informally called the chemical imbalance, they involve transporter in the brain that has to do with serotonin, one of the neuro-transmitters that thje chemical imbalance idea refers to. And it looks as if people with some genes do better on medication and people with other forms of the same gene do less well on medication. So I think that general theory that the transmitters have something to do with this has been getting - I think the public has the impression it has gotten less and less support over the last years.

It's gotten more and more. There was a review in the New England Journal of Medicine that cited evidence for some enzymes in the brain that break down these transmitters that people with long term depression seem to have less of. So I think the theory is getting more support but it's never been at the level of saying we can measure the transmitters in your brain and say whether you should get medication or not and which one. And by the way, I want to agree with Dr. Gordon, these medicines are not terrific, you know, they're just only so good.


Dr. GORDON: One thing I just want to add here is that one of the things that we do know is that stress is significantly implicated in depression, and many of the techniques that I'm talking about that anybody can learn from "Unstuck" or from a therapist who is working with them are these techniques to reduce stress. And if you reduce stress, you - significantly, you are likely to have a much better outcome. So I think this is - to me, this is the primary care for depression, reducing stress, looking at things in a more thoughtful, less fearful, less reactive way, feeling a connection. And we'll have to talk some time more about the difference between a guide and a therapist because I'm not sure that we're really all that different. But having somebody there who gives you what Carl Rogers - who I know you're, you know...

FLATOW: Let me just - let me just draw...

Dr. GORDON: Very connected to...

FLATOW: We have to take a break. And ask you, do you think that you can see that your therapies using yoga and different kinds of holistic medicine can work as good as the drugs or they're purported to work?

Dr. GORDON: Yes.

FLATOW: You do?

Dr. GORDON: That's a short answer...

FLATOW: And that's basically...

Dr. GORDON: Yes, and I...

FLATOW: And as the crux of the argument we're having here.

Dr. GORDON: And what I say, if you look at the scientific literature and I have hundreds and hundreds of references in "Unstuck," is that many of these approaches have been shown to work as much better than placebo, as antidepressant drugs. And sometimes when they've been compared to antidepressant drugs, they've done just as well and sometimes better. And that's used individually...

FLATOW: Dr. Kramer?

Dr. GORDON: I'm sorry?

FLATOW: Dr. Kramer, any commenting, about a minute before the break?

Dr. KRAMER: You know, I've just looked at the psychotherapy literature and the effects of psychotherapy have gone down steadily over the past 10 or 15 years. And the reason is the same reason that are for the changes in our view of medication that I've given which is the standards for what constitutes a good study and what constitutes a good outcome have gone up. And I think if you compare some - I mean, I don't know why when a particular one has these seven elements rather than some other six or seven elements - but if you compare studies of ethics, see from 20 years, 30 years ago, they just were much more liberal. And the reason psychotherapy looks less good in recent studies is that when you raise the standards, you know, this turns out to be a very hard condition to change.

FLATOW: OK. Let me interrupt. Can you gentlemen stay for a few more moments?

Dr. KRAMER: Glad to.

FLATOW: Good. We're going to take a short break and come and talk more with Dr. James Gordon, author of "Unstuck: Your Guide to the Seven-Stage Journey of Depression." Dr. Peter Kramer, author of "Against Depression." He'll stay with us also. So please, you're invited back, too. We'll be right back after the short break.

FLATOW: You're listening to Talk of the Nation Science Friday, I'm Ira Flatow. We're talking this hour about depression with Dr. James Gordon, author of "Unstuck: Your Guide to the Seven-Stage Journey of Depression," Dr. Peter Kramer, author of "Listening to Prozac" and "Against Depression." Our number 1-800-989-8255. Let's get a quick phone call or two if we can. Trevor in Portland, Oregon. Hi, Trevor. Trevor, are you there? OK. Oh, let's go now to Mary in Maryland. Hi, Mary.

MARY (Caller): Hi. Thank you for taking my call. I'm a psychiatrist in private practice. I do both therapy and medication. And I just had an observation that seems to be somewhat at odds with what Dr. Gordon is saying. And I just wanted to get some - your guest's comments on that. And that is that in my practice, I would say the majority of people who come to see me really have tried very hard to manage their depression on their own. And, you know, in my area it's a pretty medically sophisticated community and so they've tried acupuncture and yoga and exercise and even bright lights to some extent and I certainly encourage them to do that. And talk to them about nutrition, too but I, you know often medication is called for.

And I guess, I feel like Dr. Gordon's perspective seems to be somewhat in line with the idea in the popular culture that people are just looking for quote, unquote, "happy toe" and, you know, going in to the psychiatrist at the drop of a hat and getting on medication for normal everyday stresses. And that's just really not been the case with my - I realize Dr. Gordon is not saying that. But I guess - I'm concerned that people could - it could be detrimental to people's understanding of depression that it really is something I should just pull myself by my bootstraps.

FLATOW: All right, Dr. Mary. Let me get a comment from Dr. Gordon. Yes.

Dr. GORDON: First of all, I hope you'll read "Unstuck" and then call me and tell me what you think. Because I don't say something like that at all. I say that this is indeed a very serious time, it's a time when things are really out of balance and not going right, it's a time for significant change including in most cases, finding a professional with whom you can work. I think the difference is that what I'm saying is that if you can put together a program which includes a number of approaches which have a fair amount of scientific evidence supporting them which have no negative side effects, and that if you can help people to see what they can do for themselves in an organized coherent way, not a little bit of this here and a little bit of that there.

Some of which may make sense and some of which may not, is that the people I see, virtually everyone of whom, and I live in Washington D.C., virtually everyone of whom either had been on antidepressants or had been told to take antidepressants. I think everybody I write about in the book had a diagnosis of clinical depression that if you can put this program together for people, if you can help them put it together for themselves, they can get better, that there is hope, there is possibility. I'm not saying that some of them may not need medication. I think that remains to be seen. I'm just saying it should be a last resort and not a first choice.

FLATOW: Thanks for calling, Mary.

Dr. KRAMER: Can I say...

FLATOW: Yes, please, Dr. Kramer.

Dr. KRAMER: You know, it is obviously to the problem with a clinical perspective, we see each others failures. Dr. Gordon doesn't see people who have done very well on medicine, and never come to him and Mary doesn't see people have done terrifically with yoga and meditation and don't come to her. This thing is something I should have said earlier is that I have really struggled with the data, the statistics, you know, what do we really know on this and put a lot of little essays about this sort of tutorials on Web site, which is associated with Psychology Today, my part of it called impractice. And have - tried to make sense about why things look better and worse, that is why is it that psychotherapy isn't doing as well in studies lately than it has done in the past. And I'm a great fan and a practitioner and teacher of psychotherapy.

FLATOW: All right. We've run out of time, gentlemen. I'd like to thank you both for taking time to be with us and it's been an enlightening discussion about depression, and I think we've all learned something from it. Dr. James Gordon, clinical professor in Psychiatry, Family Medicine at Georgetown University School of Medicine and author of "Unstuck: Your Guide to the Seven-Stage Journey of Depression." And Dr. Peter Kramer is clinical professor of Psychiatry at Brown University, author of "Against Depression" and he also does write that blog for Psychology Today and you could find a link to it at Thank you both for taking time to be with us today.

Dr. GORDON: Thank you, Ira. Thank you, Peter too.

Dr. KRAMER: Thank you, Jim.

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