- Combining psychotherapy and psychopharmacology can enhance the power of each.
- Anxiety often goes hand-in-hand with depression, and both need to be targeted in treatment.
- Only when depression is treated can you address underlying feelings of mourning and sadness.
I have worked as a psychiatrist in private practice in Manhattan for the past 35 years. I've treated patients between the ages of 18 and 98. Most suffer from depression and anxiety when they first come to see me. Many have tried antidepressant medication prescribed by internists or other psychiatric practitioners and complain that they have found little relief. Most enter my office with the miserable perception that "nothing works" and feel hopeless that they can be helped. Once treated, most, if not all, are indeed helped.
There is no cure-all for treating depression, and it can take some time to find the best formula. Too often, people who have not been prepared for what to expect in the treatment process become frustrated or anxious when they don't see instant results and quit psychotherapy and/or stop taking medication before it has reached its therapeutic level and become fully effective.
As a result, too many people suffering from depression feel lost. They not only experience dark feelings, but they are also in the dark about their condition, their treatment options, optimal ways to combine psychotropic medications and psychotherapy to address varied symptoms, and what the road to recovery looks like. Their sense of helplessness is tragic.
Depression is a hidden killer that is no less dangerous to a person's well-being than diabetes, heart disease, and cancer. It is the leading cause of disability worldwide. And yet, many people seeking help are given a pill with little or no explanation about their condition, the varied ways it can be treated, and what to expect on the road to recovery. It is like starting on a journey but not understanding how you are going to reach your destination. People being treated for a psychiatric (or any medical) condition deserve a roadmap.
Psychoeducation—understanding what depression is and how it manifests—is a key ingredient to successful treatment. Unfortunately, it is in short supply. There are not enough psychiatrists to meet the demand in the U.S., and the healthcare system is now designed so that medical internists and nurse practitioners are on the front lines of mental health treatment. One study showed that half of the 8 million doctor's appointments for depression each year are made with a primary care physician. In that same study, it was found that less than 10 percent of primary care physicians who treat depression educate patients about their condition or track their patients' progress after prescribing psychiatric medication.
Knowledge is empowering. It can make those suffering from depression feel calmer, less vulnerable, more in control, and hopeful. When one is suffering from depression, the importance of offering encouragement and providing hope should never be underestimated.
Here are some key points to demystify the treatment of depression:
1. Almost all depression is treatable.
Psychiatry has made great strides in treating its major biological conditions over the past 30 years. We have an array of psychopharmacological agents which can target individual components of the mental apparatus, including mood, cognition, memory, sleep, and appetite—all to great effect. Frequently we can do this by mixing and matching medications with few to no side effects. There are numerous psychotherapeutic strategies that can be used in combination with psychopharmacology to boost its effects and a vast array of psychiatric medications that can be used to enhance the effects of psychotherapy. You could say they both enhance the power of the other in treating depression.
No one should feel hopeless. Newer alternate treatments, like ketamine, transcranial magnetic stimulation, electroconvulsive therapy, and, most recently, psychedelic therapy, which is a new area of research, are other routes that can be used to achieve recovery. Those who aren't satisfied with the treatment they are receiving should look for another health practitioner. There should be no room for the concept of giving up. If you are not experiencing treatment success, you just haven't found the right therapeutic combination.
2. Treatment for depression is not an either/or proposition.
No one needs to choose between psychotherapy, antidepressant medication, body-mind practices like meditation and breathing exercises, or any other approach to relieving depression. Medication is frequently the essential starting point to relieve the most severe symptom, at which point psychotherapy, mindfulness, meditation, exercise, good nutrition, sleep, and other positive lifestyle habits all work to create a positive therapeutic response and boost a positive sense of self.
3. Depression is different from "the blues."
Many people casually tell friends, "I'm depressed." But temporarily feeling down, disillusioned, or listless is not the same as having clinical depression. Situational depression is a reaction to a recent unpleasant experience or temporary feelings of loneliness or unhappiness. Generally, these feelings can be talked about with friends, family, or a psychotherapist, and with some problem-solving skills, determination, and creativity, they can be overcome.
Major depression is when an individual is so paralyzed by a sense of gloom, indecision, fatigue, irritability, or other symptoms that they can't function. Relationships at home, work, and with friends are suffering. Without seeking help, their lives begin to spiral downhill.
4. Depression is never the inevitable response to adverse life events.
Many people rationalize their depression. They point to having been fired from a job, going through a divorce, being diagnosed with cancer, or suffering a loss as the reason for their depression. And, yes, sadness, fear, worry, loss, and regret are normal reactions to tough times. But no situation necessitates becoming paralyzed with despair and negative rumination. Sadness, mourning, anger, rejection, fear, and loneliness are emotionally challenging but can and should be addressed in psychotherapy. Major depression and dysthymia (mild-to-moderate depression, also called persistent depressive disorder) are often due to psychobiology and are caused by hormonal, genetic, or medical factors. Major depression affects one emotionally, physically, and cognitively and is too risky to ignore.
5. Only when depression is treated can you address underlying feelings of mourning and sadness.
Depression causes a cognitive rumination that is incompatible with the "working through" of the problem essential to the psychotherapy of situational problems. Frequently it is only after treating the biological component of depression that people are able to process and address their feelings of grief and sadness.
6. Anxiety typically goes hand-in-hand with depression.
In fact, one's mood may be more anxious than depressed. Being depressed is anxiety-producing. We usually target both depression and anxiety in treatment, be it pharmacologically or psychotherapeutically.
7. Depression can be manifested in a wide variety of symptoms.
When patients first come to my office, they usually don't realize that their varied problems with mood, sleep, appetite, concentration, cognition, and other disturbances are all related to depression. Learning that their symptoms are tied up in one condition usually brings enormous relief.
8. Many people who are successfully treated for depression don't just become un-depressed; they become the happiest, most fully actualized people they have ever been.
It's not unusual for individuals treated for depression to realize that they have had dysthymia for years. People who suffer from this less severe form of depression are functional but "downers." They tend to be described as those who "see the glass half full." It is assumed that this sour, chip-on-the-shoulder attitude is a personality characteristic. But when their mild-to-moderate depression becomes severe, perhaps because of a particularly challenging situation, and they then get treated with antidepressants, they often discover they feel better than ever before.
9. A good patient-health practitioner relationship is key to treatment success.
In our time-pressured medical system, most healthcare practitioners don't have or take the time to build a strong bond with patients. Yet cultivating trust and good communication can be crucially important in ensuring that a person sticks with treatment and doesn't unravel into a spiral of pessimism. Everyone deserves to have the best chance for a successful treatment outcome and enjoy their best life. Having a health practitioner who maps out what the course of treatment will look like, what roadblocks and detours may crop up, and how they can be prevented and addressed will ease the road to recovery.
10. Many people have an internal "resistance" to getting well.
It's a form of depression we call "masochism." Sometimes this tendency for self-punishment has to be discussed and interpreted in the psychotherapeutic beginning part of treatment in order to clear the way for accepting the help that will make for true, deep, and lasting change.
To find a therapist, visit the Psychology Today Therapy Directory
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