To Medicate or Not to Medicate? A Very Good Question!

Patients who are experiencing strong emotional distress will often ask about taking medication.  Questions about depression or anxiety medications are often accompanied by strong ambivalence:  patients recognize that something is wrong and want to feel better, and at the same time express doubt that a pill will be effective.  Others would rather take a pill and be done with it; they believe that talking about their problems is ineffective, that therapy is a waste of time.

Medications can help.  But there are a number of questions that need to be explored before making decisions about trying a psychotropic medication.

·         How long have you felt the distress? 

·         How intense is the distress? How is the distress impacting your ability to function?

·         If the distress is arising in response to a life situation, how have you managed similar situations in the past? 

·         How well are you sleeping? How well are you eating? 

·         Are you using alcohol or other substances to cope?  If so, what, how much, and how often are you using them?  (Please be honest with yourself and your therapist!)

·         Will medication facilitate the deeper work of psychotherapy? 

It’s important to talk through these questions and share any concerns you have about medications and their possible side-effects with your doctor or therapist.  A good assessment is essential before any medication is considered.   How these questions and others are answered are all part of a good evaluation—an important first step toward making an informed decision.

That said, here are a few thoughts: 

Acute distress clouds thinking.  When you’re in distress, your attention narrows and focuses on those factors that either create or contribute to your distress.  When you’re acutely uncomfortable, it’s harder to see the bigger picture.  Decision-making can become impaired by acute distress: it’s harder to clearly see the issues and all the factors impacting those issues. It's harder to discern the consequences of the decisions you might have to make.  Everything is experienced through the fog of distress.  Depressed clients often report that their thinking slows down when their depression is acute, and one of the hallmarks of depression is the inability to make decisions.  Anxious clients report that they feel unsettled, distractible, hyper-vigilant, and afraid to act. 

Anti-depressant or anti-anxiety medications can take the edge off of acute emotional distress.  Anti-psychotic medications are essential for managing schizophrenias or other psychotic disorders.   The right medication(s), prescribed and monitored by a psychiatrist who has evaluated and understands your distress, can be very helpful.  But medication alone is rarely the sole answer to psychological problems.  However, medication used in conjunction with psychotherapy, especially Cognitive Therapies, has been shown to be very effective.  (Indeed, there is a great deal of research literature in support of combining medications with psychotherapies.)

As a therapist, I want you to have your feelings, but I don’t want to you become flooded, overwhelmed or disabled by them.   Emotional distress signals problems that need to be addressed.  Therapy is about working with your thoughts and feelings.  And meaningful psychotherapy asks that you be willing to experience enough of your distress (without being overwhelmed by it) so that you can work through it.  Finding a medication at an effective dosage that allows you to have your feelings and think clearly can certainly support our work together. 

The idea is not to avoid distress but to work through it.

The Landscape of Depression

All the signs were there: pervasive feelings of sadness, inability to eat, insomnia, the sense that he was in a rut and could not break out of it, chronic pessimism, perceptions that he could not solve his problems, the belief that he would always come up “short”. In a word, he was depressed—although initially he bristled at the word “depression.” As he put it, “I don’t think of myself as depressed. I’m just going through a hard time right now.” However, as the session progressed he revealed that he had been feeling this way for months. In fact, he told me that he could not recall a time when he felt otherwise. Although he admitted to feeling depressed for a long time, the event that brought him into therapy centered on receiving a critical performance evaluation. The evaluation triggered a cascade of feelings and thoughts; he wanted to “re-evaluate my whole life” and felt overwhelmed by alternating feelings of sadness, helplessness, and anger.

Depression is most typically associated with a mood—usually sadness, feelings of helplessness and hopelessness. However, other feelings can be present in depression—feelings that, to an onlooker, do not look at all like depression: early in my training I worked with a man who was constantly agitated, irritable, and angry. I recall being surprised when my supervisor remarked that the client had an agitated depression; he certainly did not look depressed to me. However, I began to understand how complex depression really is when I hospitalized him after he became violently suicidal. Indeed, depression is an insidious illness.

Depression often has a particular texture: heaviness, lethargy, lack of energy. Sometimes, the sensations of depression are acutely painful. (This was especially true of the client I hospitalized: after he was stabilized and released from the hospital, he insightfully told me that he had been fighting the feeling of lethargy for quite some time; his agitation and anger had kept him from falling into the "abyss".) The novelist William Styron wrote of “the slowed down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained… depression takes on the quality of physical pain” (from Darkness Visible, 1992). The pain of major depression can become so acute that thoughts of self-harm or even suicide arise. Although the client I described at the beginning of this essay did not report physical pain or suicidal thoughts, he reported a persistent feeling of fatigue, of “being weighted down.” (In Bi-polar disorder, the sensation of lethargy and heaviness alternates with the sensation of manic energy and a kind of pressure to discharge that energy.)

It’s been my experience, though, that a hallmark of depression centers on a particular pattern of thinking. The depressed person’s thoughts are distorted: life events are negatively personalized (e.g., “this would only happen to me” or “she didn’t answer my call; she must be mad at me”); perceived in stark, absolute terms (“only bad things ever happen to me” or “I can’t do anything right” or “I’m worthless”). The negative is accentuated while the positive is filtered out or minimized (“the glass is half empty”). As these distortions take hold, the depressed person loses a sense of communal context and tends to become isolated; the world narrows as the depressed person loses interest in people and activities that previously gave enjoyment or fulfillment.

At the core of these distorted thoughts (made worse, of course, by the physical sensations that can also manifest) are beliefs that are central to depression. Like the distorted thoughts, these belief are distorted and tend to center on self-efficacy, the sense of not having mastered or being able to meet and master life’s challenges, and one’s sense of relatedness: “I can’t do anything right. I am inadequate. I am incompetent. I am unlovable. I will always be this way, and I will always be alone.”

The landscape of depression is different for each person. Likewise, treatment will vary from person to person. Some people may require medication to address the imbalances of their brains’ chemistry and to ameliorate their physical symptoms. It’s important to be evaluated by a psychiatrist or psychopharmacologist for medication—especially when insomnia, changes in appetite, extreme lethargy, physical pain, suicidal thoughts or thoughts of self-harm occurs.

It's important to seek help to treat depression. It's often not a matter of "pulling yourself up by your own bootstraps." Indeed in major depression, it's not physically possible to move yourself out of depression. Moreover since the landscape of depression is typified by distortions in sensation and cognition, psychotherapy is even more critical to becoming well. It often takes a trained professional to spot depression because its signs can be so subtle and insidious. But once depression has been identified, a great deal can be done to treat it. Therapy is typically directed at assessing the patterns of thinking and beliefs that manifest, challenging and correcting the distortions in thinking, and eventually getting at the root causes of the depression.

The landscape of depression is full of shadows and can be dangerous. However, just as there are pathways that lead into the landscape of depression, so too there are pathways that lead out of it. To my mind, a healing relationship is critical to finding the pathway out of depression. Indeed, whatever the specific path one takes to enter the landscape of wellness, having someone who knows and understands the path and can serve as a guide seems key. A therapist can be just that guide.