A reader emails that her doctor wrote her a prescription for depression and tells her that it’s a “disease.” But she tells me that her problem is more emotional than medical, and she hates the way the pills make her feel.
Depression is a condition often characterized by a combination of low energy, low self-worth, a sense of hopelessness, sleep disruption, sudden changes in appetite, lethargy, and just plain negative thinking.
Depression can certainly manifest itself as physical symptoms. However, it’s impossible to arrive at a diagnosis unless the patient is experiencing negative feelings. Depressed people feel depressed regardless of the cause. These negative emotions are not always the result of an overactive imagination. For example, a parent whose child dies in a terrible accident will experience symptoms of depression, clearly derived from the 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. For example, a man might hastily conclude that an argument with his wife means they will break up. Or, an adolescent might overgeneralize a rejection by a romantic interest to mean that he is never going to find a girlfriend. Hasty conclusions and unfounded generalizations can, over time, lead to disorders such as clinical depression.
Depression can also be the psychological consequence of thinking and acting in self-defeating ways. 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 might sense (perhaps correctly) that her parents are having marital problems that escalated when she went away to college. Torn between her goal of pursuing her academics 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, for the sake of her parents — when they clearly should be taking responsibility for their own issues.
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 cannot change the basis for her outlook. Other than dulling her perceptions and sensations, no amount of medical treatment can permanently relieve the source of this young woman’s depression. To really change and get better, she must understand the futility of what she’s doing.
Depression always involves a psychological component, and 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 practice, I do not refer individuals for antidepressant medication unless their problem is so debilitating that psychotherapy alone is not enough. Furthermore, antidepressant medication will not solve their cognitive problems, i.e., the processes of reasoning, memory, judgment and comprehension. 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 on the sidelines as their coach.
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 that certain physical conditions can coexist and interact with depression.
Unless a person’s condition is so unbearable that they can’t get out of bed or leave the house, I suggest therapy and behavioral change first. 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 only the last resort.
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