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Depression: Major Depression & Unipolar Varieties
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Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression

Mark Gorkin, LICSW

Summarizing key issues raised in the popular series on depression and his own meds trial, the Stress Doc provides a glimpse into the future: a sidebar from the forthcoming book, Practice Safe Stress with the Stress Doc, published by AdviceZone.com.

1. Recognize the Reality of Depression. Your depressed phase has lasted too long, with too many disruptive or intense symptoms - erratic sleep and eating patterns, frequently on the verge of tears, chronic procrastination and difficulty completing projects. You "just want to disappear" (as a client recently expressed), and there's a generalized loss of interest, pessimism, distrust and disorganization. The problem is likely more than just extended grieving or having "a sad personality," as one therapist told her client. The client had asked for a second opinion when, despite nine months of therapy, good insight and vigorous daily exercise she still felt on the verge of exhaustion. This woman still had to strain continuously to just keep up.

2. Begin to Let Go. Normal ways of coping wont work in this existentially and biochemically troubling period. You're not just grappling with depressive symptomatology, but also likely struggling with denial and shame; one must admit that will power is not sufficient. This can be particularly confusing with moderate chronic depression. In the past you were able to get yourself out of your depressive box or cave. Alas, as we age, ongoing stress can impair the effectiveness of our biochemical and hormonal systems. In fact, just using will power, thrashing about to break the depressive bonds will probably exhaust you further. You feel trapped in that black hole or have a heightened sense of whirlpooling madness.

3. Acknowledge Shame and Ignorance. Too many people associate depression with cocooning under covers for hours on end or covering up through various addictive tendencies compulsive eating, drinking and sexing, TV watching, video game playing, out of control shopping, etc. And, in fact, these may be accurate warning signs. However, many Type A achievers also struggle with depression. (Don't let resume size blind you to the possibility of depression.) For such hard-driving folks, shame and inaccurate information often impede getting the needed psychological and medical help. Especially if there's family history of mental illness or mood disorders, acknowledging that one hasn't fully escaped a genetic legacy can be a difficult step. And if you were or are the family standard bearer, the one who exemplifies "improvement in the generations," then giving in to depression becomes a sign of failure, of letting others down.

4. Beware Drug Reaction. Despite the widespread use of SSRIs, many are still resistant to exploring the use of antidepressant medication. These include individuals who: a) erroneously see medication as a crutch or as a means of simply numbing or masking emotions, b) had a troubling trial with the older generation of antidepressant meds tricyclics or MAO Inhibitors, c) had an unsuccessful brief trial with an SSRI, including troubling side effects and dont understand that a meds trial is as much art as science; for some Zoloft works better than Prozac or Wellbutrin may interact differently than Serazone with other prescription drugs and d) have psychological if not medical scars from previous drug or alcohol history; folks with family members who've struggled with substance abuse also may be guarded.

Warning: If you are using alcohol in anything but very strict moderation, taking antidepressant medication is inviting trouble. In fact, alcohol is contraindicated. And remember, alcohol is a depressant drug.

5. Admit Dread of Losing Your Edge. For individuals with an agitated depression as well as cyclothymic (a cycle of mood swinging) or bipolar tendencies with pronounced highs and lows, especially where the agitation-mania fuels productive efforts or creative outbursts, there may be understandable resistance to a meds trial. There is a natural fear that ones existential and emotional range, post-Prozac, will extend from the mediocre to the tapioca, that is the blandly normal. While there is an adjustment period, with the proper medication and dosage, over time my bias supports the likelihood of more energy being freed for creative endeavor. Performance may take on a somewhat different hue, but will still have your distinctive quality. (Email stressdoc@aol.com for a provocative, counter-intuitive essay on "Van Gogh, Prozac and Creativity.")

6. Find a Psychiatrist. A common medical mistake, if not a professional abuse, is the numbers of GPs, internists, gynecologists, etc. who prescribe antidepressant medication for patients without psychotherapeutic follow-up and sufficient monitoring of side effects. The professionals best trained in the realm of mood medicine are medical doctors with degrees in psychiatry and psychopharmacology. Alas, even consulting with the latter specialists does not guarantee proper meds dosage or regular supervision. The medical field is still in the learning curve stages of understanding the bio-psycho-social dynamics for overcoming mood and mental disturbance. As mentioned, finding the right medication is as much art as science and must take into account individual difference.

7. Integrate Psychotherapy. Upon completion of a proper diagnostic and medication evaluation and the start of a supervised meds trial, if you cant afford to see a psychiatrist on an ongoing basis, search for a mental health professional experienced in the depression field. For chronic depression, look for a therapist who is open to exploring the best biochemical and psychotherapeutic intervention mix as opposed to a clinician whose bias pits one approach against the other. The problem isnt just hair-trigger prescriptions. Too many therapists still misdiagnose clinical depression as "deep sadness" which can be overcome by "intensive working through."

8. Assess Initial Symptomatology. Conventional medical wisdom says it often takes from two to six weeks for the therapeutic effects of antidepressant medication to kick in. If you are so predisposed, that is, you react sensitively to medication, be prepared to notice a mind-body difference in two-six hours. This is an "N of 1" experiment and you are the star subject. Early side effects may include sleep disturbance restlessness or a slothful lying in bed, vivid dreams, having more energy, including aggressive energy and phases of hypomania (a rash of impulse shopping, for example) and diminished sex drive. Your mind-body system is adjusting to a biochemical sea change. As you adapt to the meds and your depressed mood begins to lift, these symptoms may diminish or your tolerance for them may increase. (Hey, with Prozac I had some unprecedented and not totally undesirable side effects: I started grooving on chocolate and my mildly diminished libido -- slowed ejaculation time yet without impeding erectile functioning -- certainly drew no complaints from the ladies. ;-)

Sometimes side effects may be double-edged, e.g., some restlessness during sleep opened wider the window to my dreams. Or even the drowsy morning haze (once meds dosage was properly adjusted) became more a maze for mentally meandering through dawning levels of consciousness.

Clearly, if the symptoms feel troublesome or confusing, do not suffer in silence; you dont have to tough it out. Call your therapist and psychiatrist for a medication consultation.

9. Assemble the Cumulative Evidence. In two-three months, with effective medication and psychotherapy there should be noticeable improvement: more energy, better eating and sleeping patterns, sharper mental focus, crawling out from the barrel bottom, the return of laughter and a less generalized sense of emptiness and teariness. In fact, the lack of reflexive crying, despite feeling empathy at a traditional tear-jerker movie scene at the three month meds trial mark opened my mind to the correlation between biochemistry, overt emotionality and my inherent "sensitive nature." I could now be moved without necessarily being flooded.

Much past and present jarring life experiences and behavior patterns are open to reexamination and reinterpretation. From chronic procrastination and profound shyness to impulsive or addictive tendencies ("recreational" drug use as self-medication, for example), all may be influenced by a mood disorder or be depressive adaptations. Your existence and essence was and is not simply a byproduct of an intrinsically or intractably deficient moral character and demotivated nature.

10. Use Self-Accepting Analogies and Self-Energizing Rituals. An important part of integrating the depressive experience and being able to share it with others is having accessible and vivid analogies and illustrative examples at your command. For example, the feeling that one has been running with an invisible 30-pound weight tied to ones ankle. Another way of framing the problem: imagine yourself as a car that's slowly leaking oil and power steering fluid. You're a quart low on oil. Can you still get around? Sure, but increasingly, as the miles mount, there will be wear and tear on the engine, transmission, steering, etc. If you don't plug the leak, major damage lies ahead!

Also, integrate new rituals to aid your depression recovery-meds adjustment process. If a slow starter, try some morning exercise. Personally, thirty minutes of answering email after rolling (or crawling) out of bed is like a warm-up for the creative writing looming ahead. If self-employed, for example, find a coffeehouse that gets you out of the computer cave and that allows for work and some socializing. Learn to take a rejuvenating post-lunch or dinner, 10-20 minute nap. (And now you realize the effects of depression, not just "low blood sugar," may make this a necessity, not just a luxury.)

11. Confront Approach-Avoidance Conflict and Impatience. While mood uplift and enhanced role performance is likely to seem remarkable, the challenge now is not to shortchange longer-term growth for newfound chemical balance. In other words, there's a lifetime of depressive ways of perceiving, interpreting, relating, reacting and defending that need to be acknowledged. Old assumptions will be put to the test. Much unfreezing and new learning must occur for ongoing mind-body and interpersonal maturation. At the same time, all childhood emotional or perceptual sensitivities and sensibilities need not be thrown out with the darkened depressive waters. This process may be scary, though. Long-term survival (albeit, self-defeating) coping patterns must be gradually dismantled. Untreated depression is like being stuck with a 486 computer when the world keeps changing at a dizzying pace. You cant or, more likely, are afraid of or feel overwhelmed by upgrading.

The other concern, of course, is impatience, when your mood state and energy levels aren't improving fast enough. Again, proper supervision for medication and commitment to ongoing therapy strongly increase the chances of building over time a solid foundation for recovery. Medication is not a crutch. Neither are depression support groups, mens or womens groups, 12-step groups, etc. The latter are normative resting, retreating and refueling stations on the challenging journey of life.

12. Is It Forever Prozac? How long do you stay on Prozac or its chemical cousins? I'm not sure there is a definitive answer. Each meds trial is as distinct as the patient's genetic and life cycle history, along with current resources, sense of affiliations and accomplishments, strength of self-identity and future possibilities. Carefull supervised experimentation is the password. Biochemical and emotional stability along with positive functioning over time, yet still accompanied by some moderately disconcerting side effects, may signal a window for trying a new antidepressant medication or for reducing your current dosage. Regarding the latter, with strengthened attitude and activity levels, less medication (thereby further attenuating side effects) without diminishing therapeutic benefits is possible.

Some may choose to be meds free. I recall a woman artist in her 40's, after a successful meds trial, announcing in a bar: "Prozac for the house!" Yet she decided to stop taking Prozac upon basically overcoming her dark period. She didn't mind feeling "a little blue on Sundays." Though I've encountered more people who regretted or had second thoughts about stopping their meds trial.

The combination of biochemical intervention and psychosocial maturation seems to make some lasting repairs in neurotransmitter functioning. While long-term research results for the SSRI meds family and its offspring are still in transit, until there's contrary scientific evidence, I'm taking that "serotonin supplement" (10mgs/day). This regimen is part of my natural path, one still filled with passion and pain. And it's a path for recovery, resiliency and rejuvenation. Amen!