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Now What?

Question:

I saw a psychotherapist, an MFCC, for 13 years, beginning at the age of 22 and ending this past June. I had been suffering from depression and suicidal thoughts since at least the age of 10. Nevertheless, I had managed to become a University student, where I eventually got bachelor’s and master’s degrees in English literature. The talk therapy helped right from the beginning, but the Prozac I began taking a few years later had a more profound effect. Over the years I had mixed success with antidepressants, trying various dosages and combinations of Desipramine, Wellbutrin, Zoloft, Paxil, and perhaps others. I’m now taking a combination of Effexor (300 mg/day) and Dexedrine (30 mg/day), and it seems to be working — I think. For the last few years of therapy I probably wasn’t clinically depressed. At least, when I was depressed, I got out of it quicker. A year ago I had been feeling good enough long enough that for the first time I imagined that therapy was something that could be completed. My therapist agreed, and we set an end date. During the final six months of therapy, though, I lost some of the sense of well-being I had had. I didn’t know why I wasn’t feeling as well, but I thought perhaps it had something to do with the impending separation from my therapist. Still, I didn’t think it would help if I stayed in therapy. After 13 years in therapy I believed I had to experience what it was like to be out of therapy. I was surprised that I didn’t miss therapy or feel like I needed it. I continued to feel varying degrees of lousy, and I think I’ve lacked motivation and enthusiasm. I continue to see my prescribing psychiatrist every six months or so, but I don’t know whether a different prescription would help. I feel like I’m at a point at which I’m not depressed enough to be depressed, but certainly I’m not content and satisfied with how I feel, how I’m experiencing life. In short, I don’t know what my next step should be. I took a 12-week course in cognitive behavioral therapy for depression given by my HMO (Kaiser) and liked it a lot. I also felt a lot of resonance reading Judith Wallerstein’s “The Legacy of Divorce,” especially in regard to my persistent passivity. I really could use some advice, or perhaps you could pose some questions that might point me in the right direction. I could live out the rest of my life in my present state, but I really, really hope that I can do better. My life is not without pleasures but there’s also so much low-grade, low-down suffering. Dear Dr. Dombeck, I read your column and like the answers you give. Can you talk about something I haven’t seen in your column? That is, what to do when a person has done all the kinds of things you suggest but the depression overall doesn’t get better? I take medication and have been in therapy and even have been in the hospital. I work full time and try to do healthy things. But I still get so bad that all I do is cry when I’m alone, and have to fight tears even when I’m around other people. I pray for this problem to go away, in fact I think I would do anything to be more normal. But sometimes it is so bad I don’t know if I can go on. So what do you tell people when they feel like they’ve tried and tried and still can’t get better?

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  • Dr. Dombeck responds to questions about psychotherapy and mental health problems, from the perspective of his training in clinical psychology.
  • Dr. Dombeck intends his responses to provide general educational information to the readership of this website; answers should not be understood to be specific advice intended for any particular individual(s).
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Answer:

The short answer: Keep working to get better – but also accept that things may never be perfect.

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p> Like many mental illnesses, depression is (often) a chronic illness. While some people who experience a depression get and stay feeling better, a large proportion of persons experience only varying degrees of recovery. Some recover fully, only to relapse in the future (having been depressed in the past makes it much more likely that you will become depressed again in the future). Others never quite get ‘right’ again – although close examination will show that some periods of time are much better mood-wise than others. Despite the powerful medicines, psychiatric techniques and psychotherapies we have for depression today, it has to be acknowledged that there is no miracle cure. For many, depression can be lessened (to varying degrees) but not entirely removed.

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p> There are two things to take from this: 1) that there is a role for continuing to see what can be done to make what depression remains less and less a problem, and 2) that there is a role for acceptance of what cannot be changed here. These points are my restatment of the serenity prayer from Alcoholics Anonymous which I’ll quote here (as they have said it better than I can):

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p>

G-d, grant me the Serenity to accept the things I cannot change,
the Courage to change the things I can,
and the Wisdom to know the difference

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p> In essence my advice is that you should never stop trying to find better ways to lessen your depression.

  • Actively challenge your doctor – “I’m still not feeling as well as I’d like to – are there other medicines or combinations of medicines that might work better for me? Are there other treatments you can recommend?”
  • Exercise regularly (this has many many positive mood lifting effects)
  • Don’t allow yourself to become isolated. Find ways to be socially involved and committed (with church, family, friends, community, etc.)
  • If psychotherapy is not where you’re at for now – consider a support group (even an online support group is good)
  • Depression saps the meaning out of life. So find something that you can still connect with at an emotional level (helping others is a good one for many e.g., volunteer work) and find a way to do that work. For more on the importance of meaning read the classic work by Viktor Frankl

<

p> And at the same time – accept that things don’t have to be perfect in order for them to be okay. You may live your life with depression. That can be okay if you can accept depression as part of your human condition. Most people have something that they would change about themselves if they could – but for the most part people get by. The trick is to accept ones’ self as-is as a worthy person – as good as anyone else. Being depressed works against this sort of self-acceptance so it is good to be with others who are going through life challenges for mutual support.

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