One of the first questions new patients ask is whether or not they need to take medication for their depression? What a loaded question! And an important one.
Before prescribing anything—be it psychotherapy, medication, or a combination of both—I tell patients what they need is a relationship with a doctor they can trust.
The first thing to establish is the diagnosis: to what degree is the depression pathological, or is it the normal emotional response to disappointment. In psychology, the term depressive position refers to the discrepancy between what one expects and what one gets. Think of it like a bruise; even though bruising is a common phenomenon, that doesn’t make it any less painful; and, some bruises are much worse and take longer to heal. With respect to emotional bruising, many people know exactly how they sustained the injury: they lost their job; or an important relationship broke up; or they moved and lost contact with sources of support. “I know why I’m depressed,” they say, “but I don’t know what anyone (including the doctor) can do about it.” Others report ongoing disappointment stress: “I keep getting passed over for promotion,” or “My kids are driving me crazy.” Many arrive as if they awakened bruised, saying, “I don’t know why I’m depressed. It seemed to come out of the blue,”
“Normal” depression is distinguished from its pathological counterpart by persistence and functional impairment. For just as “normal” bruises resolve spontaneously, so do emotional bruises—we call that resilience. The responses people employ (be they conscious or unconscious) to recover from adversity we call coping. Long before people consult a psychiatrist they have had experience dealing with disappointment and adversity; some people arrive for treatment needing more help than others in developing healthy coping skills, and one cannot have too many healthy ways to cope.
Although the DSM is not scripture, it does present valid criteria for diagnosing clinically significant depression—persistence and intensity of symptoms as well as the impairment in function which follows therefrom—which differentiates “normal” depressive reaction from a state that doesn’t resolve spontaneously. The pathological state is called clinical depression, also known as Major Depressive Disorder (MDD), whose symptoms include persistent lack of pleasure (anhedonia), decreased energy (anergia), sleep disorder (insomnia), compromised and depressed thinking, (cognitive impairment and global negative feelings), appetite disturbance (weight gain or weight loss), decreased self-esteem (feelings of helplessness and hopelessness), anxiety (excessive worry and physical tension), and thoughts about death or dying (suicidal tendencies ranging from the wish to be dead to taking action to end one’s life).
MDD is very common. At any given time 5 to 10% of the population in the United States is suffering from a depressive episode. The lifetime likelihood of having MDD–17% overall, twice as high in women as in men–is almost the same as the lifetime likelihood of having a heart attack. 50% of MDD episodes remit spontaneously in 6-18 months–which is why no reasonable clinician (be it MD, PhD, MSW, NP, or APRN) would tell someone with MDD to come back in a year to see if they got better! More than half of those who don’t get completely well, enter a chronic depressive state, while the remaining 10% descend a downward spiral that includes disability, substance abuse and suicide, in some studies as a high as 10%. If that sounds serious, it is!
Years ago, psychiatrists were taught that MDD was a progressive disorder with episodes increasing in frequency and intensity as people age, Now we know that that a single episode of depression increases the brain’s sensitivity to stress, setting the stage for more significant depressive responses to future stressors. This has become clear: depression is not only bad for one’s life and one’s relationships; it’s bad for one’s brain!
Enter the role of treatment: the abiding principle of psychiatry in treating MDD is to bring about complete remission of symptoms as soon as possible. We want patients to do more than feel better; we want them to get and stay well. The first imperative is to differentiate bipolar from non-bipolar depression, because treatment is different. Nearly fifty percent of patients who present with MDD have some underlying bipolar diathesis. Milder forms of Bipolar Disorders (BD) are not epidemic; it’s not a fad diagnosis. Rather, BD simply went un- or underdiagnosed until recently, the average delay between onset (usually an index episode of MDD) and proper diagnosis being 10 years.
Effective treatment for MDD shortens the duration of illness, on average from twelve months to three or four; thereafter effective treatment prevents recurrence, hopefully for a lifetime. There is a robust literature about the effectiveness of psychotherapy alone or in combination with psychiatric medications in bringing an episode of MDD to an end. Large meta-analyses support the conclusion that psychotherapy alone (the most studied therapy is Cognitive Behavioral Therapy) works well for mild and moderate MDD but must be continued for months after symptoms remit; other psychotherapies including Interpersonal Psychotherapy (IPT) and Brief Psychodynamic Psychotherapy (BPD) have documented their usefulness as well.
When they do respond to psychotherapy alone, moderate to severe forms of MDD take longer and are more likely to recur; whereas adding medication to psychotherapy for moderately severe to severe depression brings episodes to a close quicker, which is important in considering the long-term impact of the brain’s sensitization to stress.
Medicines most definitely are not the cure-all, but combination of medication and psychotherapy for moderate to severe depression works faster.
Does one absolutely need medicine to recover from MDD? It depends on the individual and the length and depth of his symptoms. Interestingly, long term studies indicate that antidepressant medications per se do not predispose to future episodes of depression; and rather than interfere with psychotherapy for depression, medication enhances therapy’s effectiveness.
For myself, my family and friends, I recommend the treatment that works the quickest. The reason I think combination treatment for moderate to severe depression works best is that it helps patients use therapy more effectively to reinforce and develop healthy coping. Medicine for depression lubricates synapses and supports nerve cell growth, but nothing will replace the powerful interactional component of psychotherapy which activates brain circuits, reinforcing and modeling healthy coping in a way no medicine ever could.
Man with pills photo available from Shutterstock