The Upside of Depression and the Downside of Medication

https://i2.wp.com/upload.wikimedia.org/wikipedia/commons/thumb/d/dc/Depression.jpg/500px-Depression.jpg

Are there advantages to being depressed? Something good about something we think of as so bad? A recent New York Times Magazine article by Jonah Lehrer makes just that case: Depression’s Upside.

The essence of the argument is that some episodes of depression allow for and encourage a kind of analytic rumination that is productive. Put another way, the tendency in depression to focus on a problem, mulling it over to the exclusion of other thoughts, permits the sad person to find a solution to his difficulty and change his life in a positive way.

The counter-argument, however, is that the ruminative process is both painful and unproductive — that it often creates a kind of self-flagellating preoccupation with one’s trouble rather than a process that leads to something good; that unhappiness and focusing on pain and its concomitants simply feed on themselves to no helpful end.

In my clinical experience, therapy with people who are depressed over loss or injury often breaks down into two phases. The first of these is a grieving process, where the person expresses and processes (or sometimes purges) the feelings of anger, sadness, emptiness, desolation, and hopelessness that come with the loss of something of value — a love, a job, high social status, a capability, a fortune, etc.

The second phase involves learning from one’s painful experience about how to live differently, make different decisions, associate with different people, become more assertive, overcome fear; value things differently in life such as money, material things, status, accomplishment, friendship, and love.

Naturally, neither of these two phases is absolutely discrete — they blend into each other and overlap each other. As a practical example, someone who has had a series of bad relationships will typically need to grieve the unhappy end of the most recent one and, in the process, learn how he happened to choose a person or persons who made him so miserable; then changing whatever needs to be changed internally and externally so that different and more satisfying choices occur in the future.

People who are like the hypothetical individual just cited usually come into therapy in emotional pain and seek relief of that pain as promptly as possible. This desire is entirely reasonable — who wouldn’t want this? Some of them request medication, which is often the fastest way to “feel better.”

But many are leery of psychotropic drugs and see them as artificial, hoping that therapy will produce a more lasting fix without dependency upon a foreign substance. Indeed, while a good therapist will strongly encourage the use of medication for someone who is seriously depressed, i.e. suicidal, unable to work, sleeping away the day away (or almost unable to sleep); that same therapist will also know that medication sometimes serves to “de-motivate” the patient, giving him or her a relatively quick solution that allows that person to tolerate an intolerable situation. In the New York Times Magazine article mentioned above, Dr. Andy Thomson describes this problem eloquently:

I remember one patient who came in and said she needed to reduce her dosage. I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great. I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’

Clearly, this woman was aware that she needed to be in some amount of discomfort in her relationship with her husband in order to be motivated to get out of it. The drug made her feel better, but, it also reduced her incentive to change herself and her life. It was, in effect, a kind of band-aid, rather than a real cure. It anesthetized her and, in so doing, robbed her of something that was essential for new learning and behavior change to occur.

Unfortunately, most people who come to therapy are neither as courageous or insightful as the woman just described. Once they feel significantly better, whether due to therapy or medication, it is common for them to be less interested in continuing treatment. They have recovered from the event that precipitated their entry into therapy, but they might not yet have learned enough to avoid making the same mistakes that contributed to the problem in the first place.

Such a person can reason that the cost of therapy (both financially and in terms of time, effort, and the difficulty that comes with changing one self) is now greater than emotional pain from which they might still be suffering. Put another way, at this point, doing therapy “causes” more difficulty and pain than not doing therapy, just the reverse of what seemed true when they started the treatment process.

At this stage, those who continue in therapy have something that an old mentor of mine, Truman Esau, used to call “therapeutic integrity.” What he saw in some of his patients was an almost heroic desire to make themselves better regardless of how much the actual process of doing so was difficult, uncomfortable, or painful.

These patients didn’t shy away from problematic truths about themselves or others. They worked hard to stretch and challenge themselves, knowing that it was crucial to improve. They didn’t simply want a quick fix. Like the woman in Dr. Thomson’s example, they recognized that some pain was essential to being motivated. They knew that there was no such thing as “a free lunch,” and were willing to do whatever it took to repair and better their lives.

If you are in therapy now, it will be important for you to be sensitive to this shift from the often intense distress that brought you into therapy, to the point when the therapy itself might seem distressful. This can mean that the therapist is not skillful or that he is pushing you too much, but it just might also signal that some of the most difficult life changes you need to make are still ahead of you, even if the cost of making those changes seems greater than when you started treatment.

If you leave therapy because it is hard and unpleasant work, the problems you have won’t care. They will simply continue to reside in you, work on you, and trip you up. It is not enough to get over your last disappointment or unhappiness, but to change yourself enough to avoid future problems.

Few things that are worthwhile come to us for free.

The above image titled Depression is the work of Hendrike, sourced from Wikimedia Commons.

What Do Antidepressants Really Do?

I believe that the oldest reference to an antidepressant medicine comes in Homer’s Odyssey, which “could not have been completed much before the end of the eighth century B.C” according to Richmond Lattimore. The reference occurs when Menelaos (brother of Agamemnon),  Telemachos (son of Odysseus), and others are grieving the loss of friends and relatives in the Trojan War. Helen, the wife of Menelaos, is also present. It was her departure to the walled city of Troy with Paris that triggered the assault on that fortress to retrieve her. Having since returned to her husband, she wishes to salve the emotional pain of the men who are gathered at her home. The passage reads as follows in Lattimore’s translation:

“Into the wine of which they were drinking she cast a medicine of heartease, free of gall, to make one forget all sorrows, and whoever had drunk it down once it had been mixed in the wine bowl, for the day that he drank it would have no tear role down his face, not if his mother died and his father died, not if men murdered a brother or a beloved son in his presence, with the bronze, and he with his own eyes saw it.”

That would be a potent brew indeed. But the idea of it prompts me to say a few words about what an antidepressant can and cannot do, for there is much misunderstanding on this point. And, by the way, the first real antidepressants only became available in the 1950s.

An antidepressant does not make you giddy about your life or impervious to emotional pain; it doesn’t make you forget bad things. In other words, it is not what Helen of Troy administered. If an antidepressant is working well, it helps put a floor under you. That is to say, many people with depression feel as though there is nothing holding them up (metaphorically speaking), no bottom to their suffering.

An effective medication creates that bottom, relieving them of the sense that they are without any support underneath them. It reduces their suffering too, makes them less prone to crying, less exhausted, and less subject either to over-eating or having no appetite, and usually able to sleep better. In other words, the medicine helps you tolerate life and helps normalize that life.

Some people, including quite a number who shy away from psychiatric medications or medication or any kind, actually are attempting to “doctor” themselves with drugs or alcohol.

There is danger here, naturally.

You probably know some of the dangers, but one I want to mention in particular is the depressant-effect of alcohol. It might make you feel better in the short-run, but in the long-run it is likely to fuel your depression, not to mention create a dependency.

As the old Chinese expression goes, “First the man takes the drink, then the drink takes the man.”

I suspect that you know someone who believes that psychotropic medication (and perhaps psychotherapy too) is a crutch. There is no denying that being treated for emotional problems can produce negative judgments and a stigma. Moreover, historically speaking, insurance companies have paid less well for therapy and psychotropic medication than for “physical” illnesses. That has just changed in 2010, but the stigma won’t be legislatively erased by the US congress, as was achieved by “parity” legislation that now requires equal insurance coverage of both physical and “mental or nervous” conditions.

Yet some categories of depression are certainly just as “physical” as an imperfect gall bladder is, for instance. Specifically, Bipolar Disorder, also called Manic-Depressive Disorder, is one such biologically-based psychiatric category where medical intervention is often enormously helpful, if not essential.

Would you want your severely diabetic loved-one to avoid the “crutch” of necessary medication? If your answer is “no,” then you shouldn’t be put-off by treating a biologically-based depression with a proper medication to stabilize his mood.

Nonetheless, it is true that many depressed individuals do not have any biological flaw or chemical imbalance, but rather are reacting emotionally to difficult life circumstances such as repeated losses (e.g. divorce, job loss), unfinished grief, or abuse of one kind or another. Very often psychotherapy is able  to successfully treat these people without the benefit of medication. Indeed, sometimes patients are too quick to obtain antidepressant prescriptions which take the edge off their feelings enough to reduce their motivation to address difficult life circumstances, including repetitive patterns of behavior that lead to unhappiness.  In that event, they will risk having to stay on antidepressants lest they fall back into depression.

For those patients, on the other hand, who successfully address their issues in psychotherapy, antidepressants may never be needed or, if they are used, might be required only temporarily.

If you are seeing a therapist for depression, talk with him about medicine for your condition, especially if you feel that you need immediate relief or are having suicidal thoughts. Beware equally of therapists who never want their patients to go on medication, as well as those who always do.

I should mention that while many depressed people obtain medication from their family or primary-care physician or general practitioner (GP), this isn’t always the best source of psychotropic mood-altering substances. While some GPs are both comfortable with and experienced in prescribing such medication, some are hesitant or unsure. The latter group may be less adept at identifying the precise antidepressant which is best for you given your particular symptoms; moreover, their hesitation can cause them to give you too low a dose to obtain a therapeutic benefit.

A good psychiatrist, by contrast, is absolutely up-to-date on everything about the medications available to treat you, adept at identifying which of the available antidepressants is the best fit for your particular situation, and knows how to get you to a therapeutic level of the medicine as quickly as possible. Since those in pain so often feel as if there will be no end to their suffering, and since antidepressants often take a several weeks to produce relief, getting the medicine right as quickly as possible is very important.

If you do choose to obtain medication, be sure to educate yourself about your condition and the possible side-effects of the medication being suggested. Not all physicians are good about describing those side-effects before-hand, even including the sexual side-effects produced by some antidepressants. Be your own advocate. Don’t be passive in treatment. It is your body, it is your life.

Last I heard, you only get one of each.