7 Thoughts From a Chronically Unhappy Person

From The New York Times, Diana Spechler writes, “My depression habits include avoiding pain and courting diversion.  During every bout of depression, I grasp – at yoga, therapy, medication, romance – and hope that my tiny firefly of pleasure won’t wriggle from the cup of my palms.”  Read the News

When Medication Isn’t Helping Your Depression

As many people know all too well, clinical depressions do not always improve after the first attempt at treatment. One in three people with depressions (I’ll explain the plural in a bit) find they have not gotten back to “normal” even after four different courses of standard treatment.

Depression is considered “treatment-resistant” if symptoms have not improved after two or more courses of well-established treatments of a sufficient dose and length of time, whether those treatments are evidence-based medications, psychotherapy, or other therapies that have been proven effective.

That “or more” can be problematic. The longer your depression persists, the greater the risk of financial costs, job loss, family stress, marital problems, and even possible brain changes. That’s why it’s a good idea to discuss a diagnosis of treatment-resistant depression with your practitioner after two failures of treatment. The earlier you address it, the better.

There are a number of reasons why your depression might not respond to a particular treatment. For one thing, there is no single type of depression; there are multiple causes.  That is why it is actually most accurate to use the plural term (depressions), and why “one-size treatment” will never fit all.

For another, effective treatments that are not followed cannot work. If a person is not taking the doses of medication as prescribed or doesn’t stick with the recommended treatment, a depressive episode should not be considered “resistant.”

 If my depression resists treatment, what are my options?

It’s easy to get discouraged when the treatments you’ve tried haven’t helped you reach recovery. (And remember: Better but not well is not good enough.) Above all, don’t give up hope. Here are some things to consider.

  • Simply switching from antidepressant to antidepressant may not be useful. As shown in the STAR*D study, the largest American study of treatment-resistant depression, more proactive steps appear to be needed once treatment resistance has developed.
  • Returning to a medication that worked in a previous depressive episode may be more effective than switching to a new one. If it doesn’t work as promptly as before, remember that it may do the job at a (safe) higher dosage taken for a longer time period.
  • Give treatments a chance to work. While the typical time frame for good response to a medication is stated as four to six weeks, for many people it can take 8 to 12 weeks to see improvement.
  • If medications or psychotherapy have been ineffective on their own, consider trying them in combination. Medications plus cognitive behavioral therapy, interpersonal therapy or dialectical behavior therapy traditionally outperform either treatment used alone.
  • Augmentation of your antidepressant with an adjunct or “add-on” medication, often an atypical antipsychotic, may be helpful if you’ve had partial response to a treatment.
  • Other “augmentation” agents that pro-vide benefits for some people include nutrition supplements such as Vitamin D, Omega 3, and folate.
  • Electroconvulsive therapy (ECT), commonly known as shock therapy, has long been stigmatized in popular culture. It is an extremely safe procedure, acts rapidly, can be life-saving, and is sometimes the only effective treatment. It does produce memory problems for some.
  • Other “neurostimulation” treatments, such as Transcranial Magnetic Stimulation (TMS), are coming into wider use. TMS is a non-invasive procedure that typically can be delivered in about an hour each day in an office setting.

Once you find something that works, don’t change a thing. Just as someone with diabetes requires ongoing treatment, most people who have developed chronic, recurring depression need to continue treatment indefinitely.

By John F. Greden, MD.  Dr. Greden has been practicing psychiatry for 35 years. His clinical specialties include treatment-resistant depression and maintenance of wellness. The Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences at the University of Michael Medical School, he is also the founder and executive director of the UM Comprehensive Depression Center (depressioncenter.org) and the founding chair of the National Network of Depression Centers.

Building Your Depression Toolkit

One study found that as many as eighty-percent of all people in this country that suffer from clinical depression don’t get any treatment.

Given that depression is the leading cause of disability in the U.S. and that over 20 million people are afflicted with it, that’s a lot of people – about 16 million.

However, many of the law students, lawyers and judges with depression that I’ve met tell me that they don’t need to be told to get help because there are already getting it. They’re already in therapy, taking medication or both. They get it. They know that depression is an illness and they have to deal with it.
Some of them have been coping with it for a very long time. I call these people “depression veterans”. I have met many such veterans and their courage and determination to recover and stay well inspires me.

As I wrote in a prior blog, these people are really my “heroes”.

I also have met many in the legal biz who say they’re at the end of their rope. They’ve been in and out of therapy over the years with little or negligible improvement in their depression. Others have started and stopped a number of antidepressant and/or other mood stabilizing medications tired of to little impact on the mood and too many side effects. But the depression always returns for them.

For most of them, it’s not a relapse into major depression. Rather, a mild or moderate depression interspersed with fatigue, a lack of pleasure and a glum outlook on life. What they are experiencing is a fact about depression and its course. That it often a chronic and life-long illness for those so afflicted.
Then there are many who go through long stretches of feeling pretty well most of the time, but still have pockets of depression.

I put myself in this camp.

Most days, my depression, on a scale of “1” through “10” is a 1 or 2, if it’s present at all. If it gets worse, it’s less often, not as strong and has a much shorter duration is much shorter – maybe a 3 or 4. This seems to be especially so during the dark days of winter.

What worked for me to reign in the beast of depression was a change in lifestyle, which included regular therapy, medication, a support group, prayer and exercise. While there is no one thing that is a panacea for depression sufferers, I am convinced that such the positive changes have a direct, lasting an significant alleviation of depression’s worst symptoms.


To make a lifestyle change, I develop a depression “toolkit”. A game plan that I’ve pretty much stuck to for a number of years. The value of such a toolkit is that it provides a map for us to stay on course. It gives us a sense of structure and a sense of hope.

If you thinking about how to really recover from depression stay healthy, it’s important to come up with your own depression toolkit. There are lots of ways to go about it. The two best examples of depression toolkits I’ve found come from the University at Michigan’s Depression Center and the Depression and Bipolar Support Alliance.

So pick up your pen and start building your own toolbox today.

Copyright 2014 by Daniel T. Lukasik


Regain Motivation With A Depression Action Plan

Everyone feels down at some point in their lives. But if you have major depression (also called major depressive disorder), you likely feel depressed every day for most of the day, especially in the morning. You might wake up and have no energy to get out of bed. And even when you do get up, deciding what to do first can feel like a mountainous task.

At those times of inertia, it’s easy to get discouraged. But giving up the idea of getting anything done can make you feel powerless and perpetuate feeling depressed. Instead, fight back with an action plan that propels you ahead, even when you’d rather lag behind.

Creating a Depression Action Plan

A depression action plan can help take the guesswork out of where to get started each morning. It can also empower you to see just how much you can do, which is important because people with depression tend to compare their current levels of activity to past ones.

“For an action plan to be effective, you first have to understand that major depression is an illness, not a weakness,” says Stephen J. Ferrando, MD, a professor of clinical psychiatry and clinical public health in the department of psychiatry at the New York-Presbyterian/Weill Cornell Medical Center in New York City. Stop comparing yourself to the past. “It’s not your fault you have depression,” he says.

To get started creating an action plan, it’s best to work with your doctor or therapist. “When you’re depressed, it can be difficult to determine where to begin,” says Randy Auerbach, PhD, ABPP, a researcher, an assistant professor in the department of psychiatry at Harvard School of Medicine, and the director of the Child and Adolescent Mood Disorders Laboratory at McLean Hospital in Belmont, Mass. Your doctor or therapist can help you identify both short-term and long-term goals to work toward.

Consider these steps you might want to include in your daily action plan:

Tasks you need to do

Make a list of four or five things you need to get done today, such as work and chores. To avoid getting overwhelmed, break down each goal into small parts. For example, instead of making cleaning the entire house your goal, decide to clean just one room today, says Brian Iacoviello, PhD, an assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai Hospital in New York City.

Activities you enjoy

If depression has taken the enjoyment out of all activities for you, write down what you once found pleasurable. Working toward doing the things you once enjoyed can help you slowly regain momentum. You can also try adding new activities, such as soothing stress-coping experiences (e.g., meditation, yoga, and tai chi).

Time with your support network

Research shows that a support network is critical for depression recovery. Make plans with friends and family and show up even when you don’t feel like it. It helps to have a friend who will hold you accountable. “Social support can be an enormous ally when you’re in dealing with depression,” Dr. Auerbach says. A local or online depression support group can also be a good resource.


In a review published in in 2013 in the American Journal of Preventive Medicine, researchers reported that even low levels of physical activity, such as walking or gardening for 20 to 30 minutes a day, can help ward off depression. If you’ve stopped exercising, set reasonable goals to allow yourself to slowly get to the level of physical activity you want to reach. You might even combine exercise with socializing by picking a workout activity to do with a friend.

Healthy meals

Eating a balanced diet may help alleviate depression symptoms. Include steps in your depression action plan to create healthy meals each day. To maximize benefits, aim for three meals that include whole grains, fresh fruits and vegetables, beans, lentils, nuts, seeds, lean meat, fish, eggs, and low-fat or fat-free diary. Never skip breakfast. Be sure to drink plenty of water because even mild dehydration can affect mood. Limit your alcohol intake.


If you’re taking medication, include specific times to take it in your depression action plan. Sticking to your prescribed treatment plan is the best way to speed recovery.


Your entries can provide insight for you and your doctor or therapist to review together to determine patterns of behavior that may be holding you back from doing everything you want to do. Record behaviors such as what you’re doing, how successful you’re being at doing those things, and what you think about when you’re doing them. Once you’ve identified any negative patterns, you can work with your doctor or therapist on how to let them go.


Implement a system of rewards to give yourself when you’ve accomplished a goal in your depression action plan. Self-care activities — such as a massage, a new haircut, a movie, or any other activity that makes you feel good and follows your plan for recovery — make good rewards.

How to Stick to Your Depression Action Plan

When the temptation to do nothing crops up each morning, realize that you’ll have to push yourself to take the first step to get started. Once you do that, know that your level of motivation will likely increase. To stay on track, be sure to schedule activities at specific times so you don’t get overwhelmed about what to do next or how much you have to get done. Post your depression action plan in a visible place, and set up reminders by programming alerts on your phone.

Also, remember that your depression action plan may not follow a straight path. There may be setbacks, and that’s okay — just do your best to keep going. Then at your regular doctor appointments or therapy sessions, you can discuss your progress and work together with your doctor or therapist to identify what may still be getting in your way and figure out what to do to change it.

At the end of each day, focus on what you’ve accomplished instead of what you haven’t. “The greatest challenge for a person with depression is to overcome pessimistic thinking, helplessness, and hopelessness,” Auerbach says. “But with proper treatment and a good action plan, depression can be conquered.”

By Barbara Sadick

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