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.

The Deadzone of Depression

There is a zone in a depressed person’s life where nothing seems to happen — except the pain of the absence of everything. 

Kay Redfield Jamison, M.D., in her book, Night Falls Fast, writes:

I wish I could explain it so someone could understand it. I’m afraid it’s something I can’t put into words. There’s just this heavy, overwhelming despair – dreading everything. Dreading life. Empty inside, to the point of numbness. It’s like there’s something already dead inside.

Such anguish is so overwhelming that every other concern is squashed in its wake.  Our capacity for willful actions seems to be gone; we can’t “figure it out.”  We are stuck.

I have learned a lot about the zone over the years and how to handle it.  It’s really like surfing a giant wave.  To handle these waves, you study them and prepare yourself for when the next big one rolls in.

When I feel I’m entering a Dead Zone, I start a deliberate and kind conversation with myself that is practiced and rehearsed.  I don’t let the toxic voice of depression drown me out.  It’s important to empower ourselves in whatever ways we can during these times because depression will lead you to falsely conclude that you’re helpless to lift your dark mood.  This conclusion is one of the central tenets of depression; one of its main “themes”.  We need to create – and we can – different and healthier themes for our lives.

Start with a three-by-five index card.  Use it to create your own deliberate and kind script of themes for yourself that day.  Here’s is an example of what I had written on one of my cards:

— This depression isn’t forever. It will pass.

— I have handled it in the past. I will handle it now.

— Get out of my head – don’t sit around and ruminate.

I usually write a new card out every morning.  When depression is absent (and there are long periods of time when it is), the theme of the card might be more celebratory or grateful:

— I appreciate all of the goodness in my life.

— Thank you God for all of the wonderful people you’ve put in my life.

— I am happy that I am not experiencing depression today.

According to psychologist, Deb Serani, Psy.D, there are both emotional and psychological reasons why this is so:

So, why do these gratitude experiences boost happiness and alleviate depression? Scientists say that these techniques shift our thinking from negative outcomes to positive ones, elicit a surge of feel good hormones like dopamine, serotonin and oxytocin, and build enduring personal connections.

The insight and reflection of counting these moments is what makes the practice of gratitude so powerful. But the key to combating depression is making these positive experiences part of the fabric of your life.

Try this for a while and see if it helps you. Don’t wait until you are in the zone of depression to construct the cards because your thinking during such times will be distorted.

Doing this is a healthy and self-empowering step that you can take today.

By Daniel T. Lukasik, Esq.

 

The Person I’m Supposed to Be: One Person’s Depression Journey

There’s a wretched place depression drags me off to after taking control of my thoughts and feelings. It’s the place where the longing for relief mutes every other desire, even the desire to wake up in the morning. There are days when I wonder if I’ll lose everything: my job, my relationships, my last stitch of sanity. It feels as though I’m breathing hot black smoke.

Yet I believe the same depressions that pin me to the mat so often also serve a bigger purpose in my life. They don’t come empty-handed. I believe the purpose of suffering is to strengthen us and help us understand the suffering of others.

At 16, my first episode hit me hard enough to think I’d literally gone to hell. Now, at 35, when I start dreaming of haunted houses and worrying uncontrollably about the future, I know another episode is looming. I’ve got a week’s notice, maybe two. And then it’s as if I’m drifting off to exile inside myself with only a shell remaining.

It used to be that rising from the ash after the depression cleared was like resurrection. The burial over, I’d catch myself laughing or looking forward to the next day. I’d pig out at my favorite deli. But now, when I look closely, I find mental illness leaving other significant gifts in its wake — things I didn’t discern when I was younger.

The discovery is like that scene from The Matrix when Neo finally comprehends his identity. Through the whole film, he’s been beaten up by evil agents. But the fighting transforms him into a warrior. And at the right time, he understands and uses his power. He’s peaceful, even when confronting an enemy. I believe my own years of struggling with depression have left me with similar gifts: inner strength and calm I can rely on, diminished fear and compassion.

I believe the painful nights that close in on all of us in some form are the cocoons from which we might shed our weaknesses. I believe pain tells us something critical about ourselves and life: that developing strength and empathy and bravery is more essential than our personal comfort. And when I think of it like that, I’m more willing to accept suffering on its terms.

That’s important, because if my pattern holds consistent, my next episode is due to arrive soon. I live with this reality, but I’m no longer afraid of it. The depression has, in the end, equipped me for its next visit — and that’s enough. Of course, I’ll take my medicine. I’ll talk to my gifted psychiatrist. But when the dark does come, I’ll stand up and breathe deeply, knowing I’m becoming the person I’m supposed to be.

 

By Andy Blowers.  This piece first appeared on National Public Radio’s All Things Considered.

 

 

Living a Passionate Life: An Interview with Gregg Levoy

Why did you write your newest book, Vital Signs: The Nature and Nurture of Passion?

Because it was a natural evolution from the book that preceded it, Callings: Finding and Following an Authentic Life, and because I’m just fascinated by how people manage to hold on to their vitality and life force against all the downward-pulling forces of life and culture.

In the Introduction to Vital Signs, you write that the book is geared towards “being in love with life” versus your first book, Callings, that addressed “doing what you love”. In what ways are the two the same thing? In what ways are they different?

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They’re similar in that doing what you love is among the active ingredients of being in love with life, and being in love with life is a mindset that lends itself to looking for ways to stay that way, and doing what you love is one of them.

As for distinctions between them, I look at the two books this way: Callings:Finding and Following an Authentic Life was more about finding a passion, and Vital Signs: The Nature and Nurture of Passion is more about living passionately. Developing the skill, the stance, of passion that can inform all arenas of your life, not just the vocational.

In your mind, can a failure to live a passionate life cause and/or contribute to true clinical depression? How so? Can you give us any examples?

I believe so, yes. For starters, if you’re not expressing your passion and vitality, whether in your work or love life, creative or spiritual life, then you’re probably suppressing it, or repressing it, or depressing it, which all mean the same thing: pushing it down. And whatever we refuse to express will either explode or implode, and I think depression is a form of imploding. Here’s an example from my own files:

I’m not generally prone to depression, but a couple of years ago I had a nasty bout of it. I was sleeping too much, feeling lazy, bored, disconnected from everything and everyone, lacking initiative but restless. I just felt profoundly off, and I couldn’t get to the bottom of it.

Until I had a dream of being chased by an enormous black dragon—the size of a T-rex with wings—and feeling like a rabbit who couldn’t find a hole to duck into.

I tried fighting off the dragon with a safety pin, and finally, out of sheer fright (and, I remember, a distinct sense of incredulousness that I wasn’t going to be rescued at the last second, like in the movies), I woke up. Literally woke up from the dream.

My interpretation of the dream was that the dragon was my writing. My real writing. Not the academic-style stuff I’d been doing a lot of at that point, but the freewriting practice I meant to be doing alongside it, and wasn’t. In a sense, I was playing it safe with all that cautious, academic writing—thus the absurdly inadequate safety-pin defense—when I should have been doing more passionate, intuitive writing.

But the dragon woke me up, literally and figuratively, and over the next few months I started doing my real writing again—and here’s the punch line: the boredom and depression lifted.

That experience reminded me how closely related depression and repression can be.

In your experience, what are some of the reasons people don’t follow their passions?

One reason is that people often put security before passion. There’s nothing wrong with security, but when it routinely takes precedence over your passion and aliveness, you’re courting disaster (a word that means “against one’s stars.”) I once heard it said that heroism/heroinism can be redefined for the modern age as the ability to tolerate paradox. To hold two seemingly contrary ideas/impulses/energies/beliefs inside you at the same time and still retain the ability to function. In this case, passion and security. Which don’t cancel each other out. They’re both true. We need both of them. And they both need to be brought to the bargaining table to hammer out a treaty that’s going to serve them both, rather than trying to stuff one or the other under the floorboards just to be rid of the tension.

Another reason involves the kinds of suppression and repression that are common to certain styles of parenting, schooling, gendering, bibling, and corporate enculturation, where you’re encouraged to leave maybe the best parts of you out in the parking lot when you punch in, like your emotional life, your personal life, even your spiritual life. I recently consulted with a woman who told me that when she was growing up, her parents sent her to her room for any displays of “negative emotions,” like tears, anger or frustration. That is, punished her. Banished her.

So it’s no surprise that at 40, after a lifetime of repressing half her emotional

repertoire, she’s feeling blocked from being her full powerful self, the one she’s going to need in order to be the healer she intuits herself to be. She quite rightly refers to her mission at 40 as “soul retrieval.”

What tips can you give our readers about how they can begin to follow their passions?

For starters, it might be useful to begin identifying where you lose it. Where it leaks out of your life. Which routines, relationships, involvements or beliefs drain your energies, and which ones revitalize them. Maybe it’s a job that sucks the life out of you, or a relationship in which you feel like a ghost of your full vital self, or your eager, capable mind being put in dull circumstances, or any involvement that’s literally de-meaning. Lacking in any sense of meaning or purpose.

Maybe it’s socializing out of guilt or obligation, driving in rush hour traffic when you don’t have to, television, letting yourself be trapped by talkaholics, or doing your own taxes rather than farming it out.

Secondly, it’s important to understand that passion can be cultivated.

Turned on as well as turned off. It’s not one from the “either you’ve got it or you don’t” department. And cultivating it happens most readily at the level of the gesture and the moment, not the 5-year plan or the extreme makeover. Though even at the micro-level, action is ultimately required. Especially spontaneous action. The equation is: ready, fire, aim.

I was sitting around with some friends one evening recently when one of them said, “You know what the problem is? We’re not outrageous enough.” When I asked him what he would do if he were to be more outrageous, he thought for a moment, then reached up and swept his hair from middle-parted and slicked back to side-parted with a cowlick dangling from his forehead—instantly transforming him from Richard to Ricardo. And he said, “I’d come into work like this.”

The point is: start with the subtlest impulse to express yourself and act on your passions, and build from there. Begin identifying little moments of choice that lead you either toward or away from your sense of aliveness.

I think it’s important to distinguish, also, between healthy and unhealthy passion. In other words, there’s a difference between being called and being driven, and not all passions should be acted on. There’s something called harmonious passion (flexible persistence toward an activity and more of a flow state) and obsessive passion (persistence at any cost, the passion controlling you rather than the other way around, and self-esteem and identity all wrapped up in performance).

There’s also primary and secondary motivation. Doing something for it’s own sake—for the charge or challenge of it—and doing something for a payoff (whether money, power, sex, fame, or attention).

And there’s a pretty simple test to determine which one is in the driver’s seat: when the payoffs dry up, do you still do the work? Are your passions still intact?

Gregg Levoy  is the author of Vital Signs: The Nature and Nurture of Passion, and Callings: Finding an Authentic Life – rated among the “Top 20 Career Publications” by the Workforce Information Group and a text in various graduate programs in Management and Organizational Leadership.

He is a lecturer and seminar-leader in the business, educational, governmental, faith-based and human-potential arenas, and has keynoted and presented workshops at The Smithsonian Institution, the EPA, Microsoft, and Amerian Express, to name a few.  He is also a frequent media guest on ABC, CNN, NPR, PBS, and others.

 

 

Perfectionism and Depression: Nobody’s Perfect

We often mix-up a drive to excel and perfectionism; they’re not the same thing. A drive to be your very best can leads to a sense of self-satisfaction and self-esteem. It feels good to give it all we got. Perfectionism? It’s a horse of a different color. People who feel driven in this direction tend to be more motivated by external forces – such as the desire to please others rather than themselves. Common and recurring thoughts of perfectionists include:

  • Anything short of excellent is terrible
  • I should be able to do/solve this quickly/easily
  • I am best handling this myself
  • I must find the one right answer
  • Errors, failure, and mistakes are unacceptable
  • I have to do it all at once

One depression/perfectionist suffer writes:

My name’s Paul and I am a recovering perfectionist.

I am also recovering from depression. The two are connected.

I’d been trying to do too much, too well, trying to please too many people, expecting too much of myself for too long, putting too much pressure on myself, creating too much stress. That’s a lot of ‘too muches’ for one person. My self-esteem took a battering, I stopped looking forward to anything and I felt like I was useless and hopeless.”

Psychologist Dr. Gordon Flett has studied perfectionists and found that they set excessively high personal standards for themselves and others then harshly evaluate their performance on these benchmarks. Often, perfectionists believe it’s their parents, bosses, or spouses who expect them to be perfect. They believe that such people will value them only if they’re perfect. The constant demand to appear as if they have it all tougher is draining.

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Others tend to see them as harsh and unforgiving – rigid and unkind – though the truth on the inside is they are vulnerable people who lack resilience. Flett fund that physicians, lawyers, and architects, whose occupations demand precision, are at higher risk for perfectionism, depression and suicide.

Causes of perfectionism run from parenting to a genetic link, but whatever it’s origins, try these fixes:

Separate self-worth from the requirement to do things perfectly.

Dr. Nicholas Jenner writes: Perfectionism is addressable by using and applying cognitive tools. Positive change can be had when thinking is changed and self worth is separated from the requirement to do things perfectly. If you constantly hear your inner critic berating you for not getting or doing that extra 20%, you have noticed your perfectionist beliefs. Discrediting and disputing these values and finding realistic evidence to prove them wrong is a key part of recovery. As humans, we are inherently imperfect. We have the ability to fail without ever being a failure. We sometimes just need to think it and believe it.

Put people first.

Before tasks and “stuff,” put your heart into connecting with the people you love.

Come out as a human being.

Authenticity, although messy, is required for the pleasure of love, joy, fun and overall happiness.

Pay attention to your own signs of trouble.

Perfectionists get more anxious and rigid when they are hungry, angry, lonely or tired. Use prevention strategies to manage this tendency.

Let go of high expectations. Try to accept people as they are. We are all unique and flawed as human beings.

The great songwriter and poet Leonard Cohen once wrote and sang, “Ring the bells that still can ring. Forget your perfect offering. There is a crack, a crack in everything. That’s how the light get’s in.”

We’re cracked open when stress, anxiety and depression become just too painful and perhaps begin to see this eternal truth about others and ourselves:

Nobody is perfect.

 

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