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Depression Treatment

Question:

I am a 48 year old female who is very depressed. My father was an alcoholic and my mother was an enabler. There was no love or affection ever shown in my home. I was constantly put down and degraded. I seemed to be handling all this quite well until I was twenty. The night before my brothers wedding he got into a car accident where his fiancee died and he lived. Because he had a couple drinks and lived in a dry state he was being charged with manslaughter. I handled a lot of the legalities and my brothers issues since my parents couldn’t. He ended up committing suicide 5 months later. AT first I hid my feelings as I always did. A year later I couldn’t get out of bed. I did finally conceded to counseling and medication. That really helped. My therapist moved out of state and since then I have gone to a few but I never seem to stick with it. I really connected with that first one and can’t seem to connect with any other. I took Effexor for several years until that became ineffective. Both my parents are deceased and the depression has worsened. I have not taken an antidepressant in four years and need to find a good therapist and antidepressant. I seem to cycle with being angry and overstimulated to not being able to get out of bed. One psychiatrist diagnosed me with manic depression disorder and I believe that. Please direct to proper therapy and specifically some medications. How long do I need to wait for the meds to work? Thanks …Sandy

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  • Dr. Dombeck responds to questions about psychotherapy and mental health problems, from the perspective of his training in clinical psychology.
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Answer:

There isn’t any advice I have to offer you regarding treatment that you don’t already know. Given your worsening condition, it would be reasonable for you to seek the help of a psychiatrist and a psychotherapist. There are many antidepressant medications out on the market today, and if Effexor doesn’t work for you, some other one (or some combination of drugs) quite likely will. Most antidepressants on the market today are thought to work by manipulating the way neurons in the brain are sensitized to neurotransmitter chemicals, specifically to serotonin and norepinephrine. This sensitization process takes several weeks to occur, so the general recommendation that is made is that you will need to wait about four (and sometimes six weeks) before you can conclude that something is helping or not. Then there are dosing patterns to think about, and drug interactions if more than one drug is used at a time. It’s complicated actually, and something best left to a good psychiatrist to figure out.

If no medication works for you ever again, there are still other solutions to pursue, including electroconvulsive therapy (ECT) which, contrary to its reputation, is a safe and quite effective treatment for protracted, treatment-resistant depression. There is short term memory loss associated with ECT, which isn’t good, but many patients would rather have some memory loss than endure the pits of their depressive symptoms.

Physical medicine can help raise the floor of your symptoms, helping to provide you with greater energy and a better mood, but it can’t address the difficulties and traumas you’ve endured in living your life. Psychotherapy is far better of a modality for addressing these sorts of problems. If you’re at all typical of adult children of alcoholics, you experienced neglect alternating with chaos while growing up. You are likely to have some attachment issues (meaning, it is probably difficult for you to become emotionally intimate and to trust others). You may have some control issues, particularly so if you were parentified (e.g., thrust into the parental caregiver/organizer role before your time). You’ve also had your share of quite stressful grief and loss in your life, and some of that grief may have become a chronic condition. Psychotherapy can help you to unpack and deal with these difficult situations, as well as teach you ways to identify and alter self-defeating thoughts and in general how to cope better. That is, psychotherapy can help you accomplish these goals if you can connect with a good therapist. There is some chemistry involved, as you are aware, and rapport between therapist and patient is not assured.

How can you find a therapist with whom you can connect? I don’t think there is a magic trick to it. You need to get the best referrals you can come up with (from doctors you trust; from friends or acquaintances who have dealt with similar problems; from the yellow pages if necessary, or an online directory (such as Mental Help Net’s Therapist Database, or this one is good too), and you need to think about what it was about your first therapist that made that therapy work for you where the later therapists didn’t stick. And then you need to simply call and make appointments with one or more therapists and have a meeting with them (in parallel or in serial sequence, whatever works for you) until you find a therapist with whom you can work. It is likely that you will have to wait for a while until an appointment opens up, and/or drive to some place that isn’t as convenient as it could possibly be. That is the nature of the beast and something you’ll have to make peace with if you want it to work.

You will also need to be realistic about what you can expect from a therapist, as well. Each therapist (each person) is unique. You will never replace your first therapist; your option is only to grow a new therapist relationship, and for that you will need to invest the time necessary for this to occur, and be brave enough to talk about the things that you need to talk about, and keep an open mind and heart when judging the therapist’s responses to you. If you are prejudiced to reject him or her before you go into the therapy room, you can be sure you will find a reason to reject. If you know you need particular handling (if for example, you know you need to be treated gently because your skin is thin and you can’t take criticism), tell the therapist about your needs up front so he or she has a fair chance to try to accommodate those needs.

It is really quite important that you start your renewed treatment journey with a visit to a competent psychiatrist. The reason for this is that you need to have a definitive diagnosis made for you. Diagnosis drives treatment. If the diagnosis isn’t right, you are likely to not get the medicines and other interventions that are most likely to help you. You’ve been told you perhaps have a bipolar condition, for example, but keep in mind that shifting between extremes of anger/energy and withdrawal/fatigue is also characteristic of an agitated form of major depression, or even of a grief process that has gotten stuck for one reason or another. At this point in your life you’ve lost your brother to a rather tragic suicide, your parents are dead and the one therapist you’ve connected with left the state years ago, so you’ve had your share of losses. It is important that you and your doctor figure out which of these scenarios is most likely to be true so as to set you on the best treatment path.

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