Aids to Depression Recovery

This site is meant to help those who suffer from depression -- and of course, family member and friends of those who suffer. We offer important information, but the person who's really depressed needs more help than any single site can offer. This usually means psychotherapy and/or antidepressant medication. Though either can help alone, the two together are much more effective. Newer antidepressant medications can be so helpful that they should always be considered. Competent psychotherapy can help one recover more quickly, and help keep them from relapsing. Unfortunately, it isn't always easy to get the two together.

Psychiatrists, who can both prescribe antidepressants and provide psychotherapy, usually do only one or the other, but not both. Physicians in other specialties can legally prescribe antidepressants but in most cases aren't sufficiently trained and don't have the time to do the necessary follow-up and counseling. Other psychotherapists, like psychologists or social workers, may have special training and experience in working with depression, but can't prescribe medication. It's best to find a psychiatrist and psychotherapist who can work together.

Psychotherapy

Psychotherapy is the process of talking out one's problems with a trained professional. There are many ways of conducting psychotherapy, but all depend on an open, trusting relationship. For some patients, the opportunity to disclose to the therapist all the guilt and shame accompanying depression without being judged is enough to start recovery. For others, the therapist will need to provide guidance in such areas as assertiveness, communication skills, setting realistic goals, relaxation, and stress management, which are problems that commonly interfere with recovery from depression.

Good psychotherapy can be provided by a psychiatrist (an MD specializing in mental disorders), a psychologist (PhD), a clinical social worker (MSW), a psychiatric nurse, a pastoral counselor, or a substance abuse counselor. But the fact is that someone with no qualifications at all can hang up a sign calling himself or herself a "therapist" or a "counselor"- these are terms that are not legally defined or regulated.

When you call a therapist or see someone for the first time, ask directly about the individual's professional background and training. Ask if he or she is recognized as reimbursable by health insurance-if not, consider finding someone else. You should also ask about the therapist's background, training, and experience with depression. And if after a few sessions you have any doubts or don't feel you're getting anywhere, tell your therapist about it and get a consultation with someone else. Because medications can be so effective for depression now, their use should be strongly considered along with psychotherapy. Nowadays a good therapist should be associated with a psychiatrist who can prescribe needed medications.

Psychotherapy for depression need not take a long time. Two short-term approaches that have been reliably demonstrated to be effective with depression are cognitive therapy and interpersonal therapy.

Cognitive therapy, based on the work of Aaron Beck, identifies a person's distorted thinking habits and attempts to recast them in a more accurate light. For instance, "If my husband gets mad at me, that means he doesn't love me, and I can't live without his love," becomes "If he gets mad at me, that's unpleasant but expected; he can be angry and still care about me."

Interpersonal therapy, developed by Gerald Klerman and Myrna Weissman, focuses on communication skills: learning to interpret accurately what others are saying to you (instead of assuming you know), and learning to voice your feelings, desires, and needs effectively. Many experienced therapists will use techniques from cognitive and interpersonal therapies as needed by the individual.

If you or someone you love is depressed and seeking a therapist, consider the following factors:

1) Your gut reactions. Is this someone you feel that you can like and trust? Do you feel at ease? Do you have any reservations? Psychotherapy is the one chance people get in modern life to tell the absolute truth about ourselves. Is this person someone you feel can bear that responsibility?

2) References. Talk to your friends, your minister, your doctor. A casual professional relationship isn't always good reference. You want to talk to someone who knows the therapist well-former patients are best.

3) The therapist's experience with depressed patients, including but not limited to familiarity with cognitive and interpersonal techniques.

4) The therapist's openness to medication as part of treatment.

5) The therapist's willingness to be active and directive when it's called for, not to assume that listening is curative in itself, or that the patient's needs for advice or reassurance are infantile and should be ignored.

These last three factors are things you should definitely ask directly of the therapist. If they are true professionals, they should not be offended by direct questions. If you find a therapist who is offended, then go find another one. In fact, it's best if you can see two or three people for an initial consultation and choose the one you feel can be most helpful. Because this is a much more important decision than buying a new car, you should put at least as much energy and time into selecting a therapist as you do when deciding on which make and model car to buy. Feel free to take a few therapists for a test drive.

Finding the right therapist for you may not be so easy to do with managed care. Many insurance plans will permit you to see only a small number of therapists who are affiliated with the plan. However, if you go through the trouble of checking out those therapists and aren't satisfied, many insurers will then allow you to go to someone who is not in the plan.

You should also investigate whether there is a nonprofit clinic or community mental health center in your area, which will probably charge on a sliding scale adjusted to your income, and will probably also let you see different therapists on the staff until you find someone you can connect with.

Medical Treatment

Antidepressants

Many people often have misconceptions about what antidepressants can do. First of all, they are not happy pills; they don't artificially bring on a feeling of bliss, euphoria, or unrealistic well-being. No medication can do that, except for alcohol and some illegal drugs, and their effects don't last. Nor do antidepressants insulate you from life, make you not care about important things, or make you insensitive to pain or loss. Tranquilizers can do that, for a while, but antidepressants can't. Also, antidepressants aren't addictive, nor does their effect diminish so that you will have to increase your dosage later on.

What antidepressants do is somehow prevent people from sliding down the chute into the blackest depths of depression when something bad happens. They can still feel hurt, pain, and worry, but they feel these the way normal people do-without depression. They also can help depressives sleep better, have more energy, and increase their ability to concentrate. Antidepressants seem to help people change their perspective or sense of proportion, so that they can appreciate better the good side of life and not be overwhelmed by the negative.

The way antidepressants work is interesting. There are two chemicals, serotonin and norepinephrine, that have to do with the transmission of impulses between nerve cells in the brain and seem to be associated with depression. It seems as if depressed people use up these chemicals more quickly than other people. Antidepressants help to maintain these chemicals, apparently leading to feelings of reduced anxiety, more security, increased self-worth, assertiveness, and resilience.

One major drawback to all antidepressants is that there is no evidence that their use can prevent future episodes of depression. When a person recovers and goes off their medication, they remain as susceptible to future episodes of depression as if they were never treated. That is why many people choose never to stop taking medication.

Older medications include tricyclics, MAOIs, and lithium. Newer medications include hetereocyclics and Prozac and related drugs.
Tricyclics

Until rather recently, tricyclics were the standard treatment for simple depression. These medications include imipramine (Tofranil), amitriptiline (Elacil), Vivactil, Norpramin, Pamelor, and Sinequan. In common use today, 40 to 70 percent of depressed patients improve substantially with tricyclics. Although they are quite effective medications, there are several drawbacks to their use. They usually take several weeks of faithful administration to be effective, which is difficult to handle when people are really distressed.

In addition, it is fairly easy to take a fatal overdose. Some tricyclics are rather sedating, which is a disadvantage for most people, but they can be used at bedtime for patients with difficulty sleeping. In general, tricyclics should only be used on a short-term basis, unless the person has a long history of severe mood disorder. They are not addictive and there is no perceived high with their use. They must be used with care with people who have cardiovascular disease.

MAOIs

Monoamine oxidase inhibitors - Marplan, Parnate, and Nardil - are a different class of drugs and have a different action in the brain. These drugs are useful from some people who do not respond to tricyclics. In Europe, these are generally considered the first line of treatment, while in the U.S., they are often resorted to only when others have failed. They have some unpleasant side effects, but the main disadvantage of MAOIs is that they may cause a stroke if certain foods containing the compound tyramine (cheese, red wine, pickles) are consumed while they are being used. However, they are so effective with some people that the disadvantages are far outweighed by the relief they provide.

Lithium

Lithium is generally the treatment of choice for bipolar disorder, the cycle of manic highs with depressed lows. In the correct dose, lithium reduces by about 50 percent the chances of another manic episode within a year. Mood swings become fewer, shorter, and less severe. The success rate for lithium treatment is 70 percent, and 20 percent of people become symptom-free. It is generally seen as a maintenance drug-once on, the patient is on for life. Compliance is an issue for many people, partly because they miss the manic highs that come with the disease.

Side effects, including weight gain and skin rashes, also make it difficult for some people to follow their prescriptions. Lithium can be toxic and must be used carefully. It should be dispensed only by a psychiatrist who is familiar with its use, not by a general practitioner. Because it can gradually build up to toxic levels, patients must have the amount of lithium in their blood checked monthly. These factors make it difficult to use lithium effectively with patients who are disorganized or impulsive, a frequent problem with bipolar disorder.

Prozac and its Cousins

One of the most well-known drugs of today is Prozac. It has been followed into the marketplace by many other new antidepressant medications like Zoloft and Paxil, two near cousins, Effexor and Serzone, and some more distant cousins, notably Wellbutrin, Desyrel, and BuSpar. Unlike tricyclics, which affect the levels of both serotonin and norepinephrine in the brain, Prozac, Zoloft, and Paxil affect only serotonin. Hence they are known as "selective serotonin reuptake inhibitors," or SSRIs, meaning that they prevent or slow down the reabsorption of serotonin.

Effexor and Serzone affect both serotonin and norepinephrine, and the others have more complicated effects. All, however, have been shown to be effective in the treatment of depression. The choice of which of these medications to use for a particular person has to do with their dosage and side-effect profile. Paxil, for example, seems to have a soothing effect on anxiety that Prozac lacks. Effexor has the reputation of being more energizing than Prozac.

Compared with tricyclics, the side effects of Prozac and its cousins are usually slight. Tricyclics can give you dry mouth, make you constipated, and actually slow you down, whereas Prozac has none of these problems and gives you a little more energy. However, there are some side effects with the newer antidepressants which should be mentioned. Most notable among these is a reduction of interest in sex and difficulty maintaining an erection. Although the male performance problems usually go away after a few weeks, many people on SSRIs report a continued diminished interest in sex, which can certainly add to marital problems.

Family Support

Living with someone who's depressed can be one of the most frustrating experiences there is. We want to help the sufferer but we don't know how. Often it seems that whatever we do makes it worse. Sometimes we get angry at the depressed person, but feel guilty afterward. So many of the interpersonal habits of depression are self-defeating: socially, depressed people have an intense need for love and acceptance, but are unable to reciprocate in a way that reinforces others. Their tone of desperation may turn people off. They may be very uncomfortable in social situations because of the intensity of their need for acceptance but their persistent expectation of rejection.

The depressed person often has little energy left over to think about others, so may appear overly self-absorbed, often with a variety of minor physical complaints. Anger seems to accompany depressed people like a dark cloud overhead. Sometimes they feel it themselves. They may feel that life isn't fair, or they may feel bitterly that they've been deprived of something they deserve. Or they make others around them angry with their self-pity and pouting. Typically, others may experience anger but refrain from expressing it out of fear of hurting the victim.

Clearly, people like this can be very difficult to live with. Something that can be of great help to a friend or loved one is to get an accurate diagnosis. It's much easier to put up with difficult behavior from someone we love if we understand that he or she is in the grip of a major illness and not provoking us deliberately. Depression is an illness; it can develop very gradually or very quickly. It can come in response to life events or as a result of changes in body chemistry. Depression can strike anyone regardless of age or sex, wealth or poverty; but it is an illness and it can be treated.