ten years towards big impact: david burns’ feeling good

One of the awesome aspects of grad school (besides the occasional “free” pizza as you listen to the latest in research) is the sharing of resources among colleagues who are undergoing the same experiences.  One grad school friend gave out copies of David Burns‘ seminal Feeling Good, an exercise book that explains how to practice cognitive behavioral therapy (CBT).

Back in the fall, the Stanford alumni magazine had an article about how Burns became convinced of CBT’s efficacy over prescription drugs as a tool for treating depression, anxiety, perfectionism, and other paralyzing feelings:

What Burns did in Feeling Good, the first mass-market, evidence-based, self-help book for the relief of depression, was explain the tenets of cognitive behavioral therapy (CBT) for the lay person: that depression is caused by self-defeating beliefs and negative thoughts—thoughts like “I’m not good enough,” “I’ll never amount to anything,” or “I have no friends.” Feeling Good included exercises readers could use to change how they reacted to such thoughts and to stop depression before it spiraled down into an endless abyss of despair and pain. Study after study has since demonstrated CBT’s effectiveness.

Burns did not invent CBT; its philosophical underpinnings can be traced back to the Buddha or to Epictetus, the Stoic. Credit for laying the foundation of modern CBT generally goes to Philadelphia psychiatrist T. Aaron Beck and the late New York psychologist Albert Ellis. Burns remembers when he, like most psychiatrists, didn’t believe that something as simple as how we think could cause depression.

Working at the University of Pennsylvania’s Depression Research Unit in the 1970s, Burns researched the theory that low serotonin levels cause depression, an idea widely accepted as the “chemical imbalance theory” and conventional wisdom among popular media, many physicians and much of the public. Although Burns won the A. E. Bennett award from the Society of Biological Psychiatry in 1975 for his research on brain serotonin metabolism, he was not convinced that the chemical imbalance theory was valid. In one study, he and his colleagues gave massive daily doses of the amino acid l-Trytophan to depressed veterans in a double-blind study. L-Trytophan goes directly from the stomach to the blood to the brain, where it is transformed into serotonin. If depression results from a deficiency of brain serotonin, the massive increase should have triggered clinical improvement, but it didn’t.

The study was published in a top research journal but did little to dim the growing excitement about the chemical imbalance theory. In 1988, Lilly launched the world’s first blockbuster SSRI antidepressant, a drug with powerful effects on brain serotonin receptors. During its first 13 years, Prozac generated $21 billion in sales, or 30 percent of Lilly’s revenues. Burns still wasn’t convinced.

“I always wanted to see people’s lives transformed from depression and anxiety to joy and peace,” he says. In his clinical work, he didn’t see that happening very often, no matter how many pills he prescribed. His department chair suggested that he sit in on one of Dr. Aaron Beck’s weekly cognitive therapy seminars.

At first, Burns thought Beck’s presentation sounded like “pure hucksterism”; still, he began using CBT methods if only to prove to himself that they didn’t work. Soon, many patients he’d been treating with drugs and “you talk, I’ll listen” therapy started to get better. A lot better.

Burns felt torn. He had just won a five-year grant to develop a brain serotonin lab at Penn. Yet he wasn’t convinced serotonin played a role in depression or any other psychiatric disorder. After three agonizing months, Burns decided he’d “rather spend my life doing something that works.” He left Penn and opened a private practice “in a storeroom with a window,” two stories below Beck’s Center for Cognitive Therapy.

Burns’s doubts were vindicated by a landmark 2002 metastudy conducted by psychologist Irving Kirsch, now at Harvard, of all trials submitted to the FDA by the manufacturers of the six most widely prescribed antidepressants approved between 1987 and 1999. Not widely publicized until a 60 Minutes report in February 2012, it showed only a slight difference in patient response between the drugs and placebos.

The above article includes Burns’ bumpy ride as a doctor in training, which included an aversion to blood (!) until a nurse ordered him to confront his fears head-on by scrubbing a patient’s gunshot wound.

In addition, a bonus article about Burns’ account of writing, publishing, and publicizing his seminal book offers a lesson in perseverance.   Burns’ book took 10 years to write and the testimonial of a reader’s mother to transform faltering sales into a best-seller:

After more than a year of rewriting, Feeling Good: The New Mood Therapy came out in 1980, then all but disappeared. The publisher consigned it to its failure list and put nothing into marketing. Burns would have to promote the book himself. A paperback edition, the occasional magazine story and interviews on “humble little” television and radio stations did little to boost sales.

Then in 1988, Burns got a call from a producer he’d met four years earlier on a Cleveland talk show. She’d just been hired by a show in New York and wanted him to appear in two days. The program was Donahue, the biggest daytime talk show of its time.

Donahue was in a melancholy mood the day Burns, a colleague and two patients arrived in New York to demonstrate the techniques they were using in Philadelphia. He let his guests run the show. During the Q&A, a woman stood up and said, “Dr. Burns, you saved my son’s life. He was going to commit suicide. We gave him your book and he turned his life around. I think everyone in the United States should read Feeling Good.”

The next day, more copies of Feeling Good were sold than in the previous eight years.

“It was like a miracle,” Burns says, 25 years later. “I just felt so grateful to that woman and the people in the audience. They changed my life. I’d wondered if anyone would ever care about [the book], if it would ever affect anybody. Then to see that something I had written had really changed the life of someone who was suffering”—Burns chokes up for a short moment before going on—“kind of brings tears to my eyes.”