Pills aren’t the answer

Dear Dr. Hurd,

I’ve been down and depressed for a while now. My doctor wrote me a prescription for some pills, and says my depression is a disease. But I feel that the problem is more emotional than medical. I hate the way the pills make me feel. In short, is depression a physical or mental problem?

Dear Reader,

Depression is a condition usually characterized by some combination of low energy, low self-worth, a pervasive sense of hopelessness, sleep disruption, sudden changes in appetite, lethargy, and just plain negative thinking.

Depression can, and often does, manifest itself in certain physical symptoms. However, it’s impossible to arrive at a definite diagnosis unless the patient is, in fact, experiencing negative feelings. Depressed people FEEL depressed, regardless of what may be causing the feelings. These negative emotions are not necessarily the result of mistaken ideas or an overactive imagination. For example, a parent whose child dies in a terrible accident will experience symptoms of depression, clearly derived from the observation and experience of objective reality. In cases like this, there is no doubt as to the source of the feelings.

A depressed person is not ‘crazy;’ he or she just feels more despondent than there’s reason to feel. Depressed people tend to jump to conclusions and form negative outlooks about people and situations around them. For example, a man might hastily conclude that an argument with his wife means they are no longer in love and that they will break up in the near future. Or, an adolescent might overgeneralize a rejection by a potential romantic interest to mean that he is never going to find a girlfriend. In some individuals, poor thinking habits such as hasty conclusions or unfounded generalizations can, over time, lead to disorders such as clinical depression.

In more serious cases, depression can be the psychological consequence of thinking and acting in self-defeating ways — day after day, year after year, decade after decade. In my experience, the most common example of this is the mistaken notion that we should sacrifice our personal happiness and well-being for the sake of others. For example, a young woman caught up in such thinking might sense (perhaps correctly) that her parents are having marital problems that got worse when she first went away to college. Torn between her goal of pursuing an academic career and her need to emotionally support her parents, she drops out of school to be with them. After several weeks of this, she becomes listless, resentful and depressed. And no wonder! She sacrificed her happiness and, quite possibly her future success, for the sake of her parents — when they should be taking the responsibility of solving their own problems.

A therapist or counselor who understands the impact that self-defeating thoughts have on behavior and emotions can help this young woman get better. Prescriptions will not change the basis for her outlook. Other than dulling her perceptions and sensations, no amount of medical treatment — not even state-of-the-art antidepressant medications — can permanently relieve the source of this young woman’s depression. To really change and get better, she must come to understand the futility and self-destructiveness of what she’s doing.

Although depression always involves a psychological, as opposed to a medical component, considerable evidence suggests that some antidepressant medications can bring a certain degree of relief to depressed people, as long as they continue to take the drug. In my own practice, I typically do not refer individuals for antidepressant medication unless their problem is so debilitating that psychotherapy alone will not be enough. In addition, they must be made to understand that antidepressant medication will not solve their cognitive problems. ‘Cognitive’ refers to the processes of reasoning, memory, judgment and comprehension, as opposed to purely emotional reactions. Self-generated, therapeutic work, both in and out of the counseling office, remains an absolute requirement for improvement. I tell patients, metaphorically, that if the antidepressant actually works, they will at least be swimming with the current instead of against it. But either way, they still need to swim — on their own, with the therapist working closely as their coach.

Philosophically, man is a combination of both mind and body. Cognitive therapists help people figure out where they went wrong in their thinking and actions, and how they can become less self-defeating and more positive in their outlooks. But it’s also reasonable to assume (especially with today’s expanding knowledge of brain function) that certain physical conditions can coexist and interact with the psychological state of depression.

Unless a person’s condition is so unbearable that they can’t even get out of bed or leave the house, I suggest trying therapy and behavioral change first. A skilled cognitive therapist can often be invaluable in this process. Though the great majority of medical doctors are sincere in their desire to solve problems with their prescription pads, medication should never be the knee-jerk reaction to the symptoms of depression. It should be the last resort.