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Overcoming Depression

Psychologist James Overholser and his colleagues combat an upsurge of hopelessness

By Alexander Gelfand

Spring | Summer 2019

James Overholser, a member of the psychology faculty since 1988, devoted his latest book to the use of the Socratic method in psychotherapy. Photo by Mike Sands.

Once a week, Professor James Overholser takes a train from University Circle to the W. 25th Street–Ohio City RTA station and walks the remaining eight blocks to a charitable mental health clinic. There, in a small office on the third floor of an old school building, he provides psychotherapy to clients who are struggling with depression and anxiety.

Overholser likes the clinic because it sets fees on a sliding scale, making care available to anyone regardless of financial status. His clients benefit from the expertise he has acquired during a productive career as a clinician, researcher and teacher.

Since 1988, Overholser has been a faculty member in Case Western Reserve’s Department of Psychological Sciences, where he devotes much of his research to depression and suicide risk. He is involved in a decades-long, multidisciplinary effort to uncover the psychological and biological causes of depression and other mental disorders. And he has partnered with the Louis Stokes Cleveland VA Medical Center on a variety of studies that seek to identify risk factors for depression and suicide.

Unfortunately, the need for better screening tools, treatments and preventive measures for these disorders has only grown more urgent over the years. The Substance Abuse and Mental Health Services Administration reports that more than 16 million American adults had at least one major depressive episode in 2016, and multiple studies reveal steep increases in overall rates of depression over the past decade. Meanwhile, according to the Centers for Disease Control and Prevention, the suicide rate climbed 24 percent between 1999 and 2014, making suicide the 10th leading cause of death in the United States and the second leading cause for people ages  15–24. The numbers are even worse for military veterans, who are four to six times more likely to die by suicide than members of the general population.

Overholser points to several possible culprits for these trends, including an overreliance on drugs (prescription and otherwise) as a means of managing anxiety and depression; the social isolation fostered by technology; and the financial pressures affecting his own clients.

“With high rates of unemployment and housing foreclosure combined with wage and salary disparities, I see many people who struggle to pay their basic bills,” he says. Such financial burdens, he explains, lead to greater stress and conflict.

As mental health professionals confront this upsurge of hopelessness, Overholser’s work is more vital than ever. His research into the etiology of depression and suicidality has led to advances in assessment, prevention and treatment. And in publications informed by his clinical practice, he has shown that the Socratic method—modeled on the systematic questioning that the philosopher Socrates employed to demolish flawed arguments and reveal universal truths—can empower clients to change the way they think, feel and behave.

Not surprisingly, Overholser also uses the Socratic method as a teaching tool in his undergraduate classes and with his graduate student advisees.

“It all spins together,” he says, reflecting on his interrelated activities. “The research and the clinical service help improve my teaching, while my teaching keeps me on top of a broad spectrum of literature that is good for my research and good for my clients. They’re all helping to stimulate new ideas and new approaches.”

Showing Persistence

“I’ve always felt that I was born to be a psychologist,” Overholser says. Nonetheless, becoming one wasn’t easy.

Overholser grew up in a blue-collar family in St. Paul, Minn. His father, who worked at a local meatpacking plant, was laid off for a lengthy period when Overholser was a teenager, leading to hard times—and serious doubts about Overholser’s career plans.

“I was repeatedly asked, ‘What can you do with a psychology degree? Why don’t you just go out and get a job?’” recalls Overholser, who suspects that his long-standing interest in helping disadvantaged populations stems in part from his own family’s financial struggles. Over the course of his career, he has studied the emotional effects of financial misfortune; developed psychotherapeutic strategies tailored to people who live below the poverty level; and conducted research indicating that depressed individuals who are dealing with financial problems or job-related stress are at greater risk of suicide. This same interest motivates him to see low-income clients at that West Side mental health clinic, which is run by Catholic Charities.

“As faculty members at a well-respected university, I feel like we have an obligation to give back to the local community,” Overholser says. “Not just to leave campus to make more money, but to make a connection with some of the local agencies and to provide a helpful service in whatever field we might be trained in.”

Despite the obstacles he faced in his youth, Overholser made his way to the University of Minnesota, where he completed an undergraduate honors thesis under the guidance of the renowned child and adolescent psychologist Philip Kendall. His topic, appropriately enough, was persistence among children.

“He thought it was a great project for me because of the persistence I displayed,” Overholser says.

Kendall was also an early proponent of cognitive-behavioral therapy, which Overholser readily embraced. CBT is the most widely practiced form of psychotherapy in use today, and with good reason: It has been shown to achieve positive results over relatively short time periods for problems ranging from anxiety to obsessive-compulsive disorder. The approach grew out of the broader field of cognitive therapy, which posits that psychological problems and negative emotions emerge from irrational thinking and flawed assumptions about ourselves and the world around us.

“If we change what a person is thinking, it’s likely to have an effect on their behavior and emotions,” says Overholser, who adds that even small adjustments can lead to significant improvements in attitudes and habits.

Overholser initially envisioned a career as a full-time clinician. But graduate school at The Ohio State University opened his eyes to the value of teaching and research—and to the power of the Socratic method.

Overholser is an active mentor to his students and research staff, and a longtime collaborator with health professionals at the Louis Stokes Cleveland VA Medical Center. Front row, seated in chairs, from left: undergraduate Saisha Nayak; Josephine Ridley, a psychologist at the VA Medical Center; graduate student Eleanor Beale. Second row, beginning in front of the windows, from left: graduate students Jennifer Lehmann, Alison Athey and Jalessa Perez; research assistant Connor Bargar; Kristie Phillips, a retired VA nurse who serves as the primary recruiter for the research group’s studies at the VA Medical Center; graduate student Silvia Hernandez; James Lavacot (CWR ’19); James Overholser; research coordinator Lesa Dieter; graduate student Liliana Varman. Photo by Mike Sands.

Overholser first encountered this approach in the classroom, and he soon learned that many psychologists—including Aaron Beck, one of the founders of cognitive therapy—regarded it as a useful psychotherapeutic technique as well. But while clinicians had praised the method in general terms, it was rarely discussed in the research literature, and no one had offered therapists practical guidance on how to implement it.

So, in the late 1980s, while working in the Department of Psychiatry and Human Behavior at Brown University’s Warren Alpert Medical School, Overholser began filling that void himself. In a series of seminal articles and most recently a book (The Socratic Method in Psychotherapy), he has delved into the method’s philosophical roots and drawn on his own clinical experience to explain how it can lead patients to correct errors in their thinking, sort through their goals and values, and cultivate healthier ways of interpreting and responding to life’s events.

Overholser says that studying and writing about the method has helped him incorporate it into his own clinical practice.

“When I’m working on a paper on the Socratic method, I’m a better therapist,” he explains. “I think it’s a little bit too easy to fall into the role of the expert who can solve problems for other people. In reality, it’s better if I go slow and ask a series of questions to help the person figure out ways to solve their own problems.”

Consequential Findings

Overholser’s major work on the causes of depression began in 1988, shortly after he joined the Case Western Reserve faculty. That year, he met neurobiologist Craig Stockmeier, then a professor at the CWRU School of Medicine, and psychiatrist Herbert Meltzer, a professor at Northwestern University’s Feinberg School of Medicine and a pioneering figure in the study and treatment of severe depression.

At Meltzer’s urging, Stockmeier had begun acquiring brain tissue samples from the Cuyahoga County Coroner’s Office in order to explore the biological factors underlying depression and suicide. Overholser became the clinical psychologist on the project, now known as the Postmortem Brain Collection; and for the past 30 years, he has performed so-called psychological autopsies on its subjects. While Stockmeier and other colleagues study the samples in the collection using a variety of imaging technologies, biochemical methods and genetic techniques, Overholser draws on medical records and interviews with relatives to diagnose whatever psychological disorders the donors may have had in life. (Meltzer also initially contributed diagnoses, a role since taken on by VA Medical Center psychiatrist George Jurjus.)

By combining the results of the neurobiological studies and psychological autopsies, Stockmeier has uncovered relationships between various brain structures, neurotransmitters and genetic factors, on the one hand, and mental illnesses such as schizophrenia and major depressive disorder, on the other. The team’s ongoing efforts, in turn, have enabled physicians to better target transcranial magnetic stimulation to treat depression. Eventually, the research could lead to better antidepressant drugs.

“I am so grateful for Jim’s continued interest in this,” Stockmeier says. “Having the brain tissue is meaningless unless we have the mental health information to go with it.”

Data from this project has also figured in studies that Overholser has conducted with his doctoral students at Case Western Reserve. For example, he and Timothy DeJong (GRS ’07), now on the faculty at Western Michigan University School of Medicine, conducted a study in 2007 that challenged a potentially dangerous assumption about suicide risk.

Experts have long believed that suicide attempters are a completely different breed from suicide completers and are at relatively low risk of dying by their own hand. Overholser and DeJong, however, tested this assumption by comparing information about two groups: suicide completers from the Portmortem Brain Collection and suicide attempters from a Cleveland psychiatric hospital. To Overholser’s surprise, they found that members of the two groups had very similar scores on measures of depressive symptoms. The results led Overholser to reconsider the significance of unsuccessful suicide attempts, which are sometimes dismissed as nothing more than a cry for help.

“I think that’s a huge mistake, and it can be a deadly mistake,” he now says.

Overholser’s collaboration with the VA Medical Center, now in its 14th year, has yielded equally consequential findings. The goal of the partnership is to untangle the complex web of social, behavioral and psychological factors associated with suicide and to determine which of these factors are most salient. Through their efforts to date, Overholser and his colleagues have enhanced mental health professionals’ ability to identify high-risk individuals and intervene effectively.

For example, in a series of studies conducted at the VA over the past decade, Overholser and several of his students have demonstrated that the perception that one is a burden to others is highly correlated with depression and suicide risk—a discovery that led Nicole Peak (GRS ’10), now a licensed psychologist in Colorado, to develop a scale for measuring an individual’s sense of “perceived burdensomeness.” Current doctoral candidate Eleanor Beale is exploring the relationship between the social support that people receive from family and friends and their risk of depression or suicide.

Overholser and Demaree

From left: Professor Heath Demaree, chair of the Department of Psychological Sciences, says that Overholser is creating “a new wave of therapists and researchers” whose work will lead to improved treatments for depression. Photo by Mike Sands.

According to Josephine Ridley, a clinical psychologist at the VA who works closely with Overholser and his students, insights from such research have found their way into the Comprehensive Suicide Risk Evaluation that is now being rolled out across the country by the Veterans Administration’s Office of Mental Health and Suicide Prevention. They are also reflected in the various programs the VA provides to depressed or suicidal veterans (social clubs, group activities, family therapy) to help foster a sense of social connectedness, which has been shown to reduce the risk of depression and suicidality.

As happened with the study on suicide attempters, research conducted through the VA partnership has undermined some of the conventional wisdom about suicide risk.

In 2015, for example, Overholser and Christine May (GRS ’15), now on the faculty at Springfield College in Massachusetts, completed a study of passive suicidal ideation—thinking about suicide without formulating a concrete plan to harm oneself. Traditionally, this kind of thinking has been viewed as a much less significant predictor of suicide completion than active suicidal ideation, which involves drawing up a plan with the intention of carrying it out. But Overholser and May found that with respect to depression, hopelessness and suicidal behavior, veterans experiencing passive suicidal ideation looked very much like those engaged in active suicidal ideation.

“I approached that study believing that passive ideation was no big deal, but I came out of it convinced that it is,” says Overholser, who adds that this conviction now informs his own work with clients.

It’s telling that when Overholser mentions such discoveries, he is often referring to research he undertook with his students.

By now, Overholser has advised more than one generation of graduate students and supervised scores of trainees as they honed their psychotherapeutic skills in the CWRU Psychological Clinic and elsewhere. For this reason, says Heath Demaree, professor and chair in the Department of Psychological Sciences, no account of Overholser’s influence on his profession would be complete if it did not acknowledge his contributions as a teacher and mentor.

“Not only is Jim extremely important in evolving our understanding of the etiology and treatment of depression, but he’s also creating a new wave of therapists and researchers who are experts in this field,” Demaree says. “His impact will last for decades to come.”

Page last modified: May 17, 2019