Warm Horizon

Psychotherapy through a qualified therapist is one option. Often therapists can effectively assist depressed persons to examine their circumstances along with their inner thoughts and feelings, to establish and express new awareness, and then to resolve the issues involved in driving their biochemical alterations. It is an interactive process of great symbolic value.

One problem with this method is the time required for it either to succeed or clearly fail, although therapeutic benefits may be obtained immediately. Even beyond this problem, some persons are too depressed to engage effectively in psychotherapy, or some may have been unsuccessful with it previously.

Thus, in many cases it may make the most sense first to inquire about possible antidepressant medication, since psychotherapy may require greater effort and cognition than is possible if the illness is severe.

Again, I suggest that a psychiatrist be seen. Doing so would not mean that your relationship with a personal physician would have to end or change significantly. In fact, it is likely that your family doctor would participate in monitoring the effects of any antidepressant the psychiatrist would prescribe. And the only eventuality requiring revisiting the psychiatrist would be if problems with the medication (such as side effects or declining effectiveness) become evident, although a prescribing psychiatrist may ask to see you two or more times a year to evaluate the medication’s effectiveness and your continuing need.

Test data have shown it to take two or three weeks minimum, and in some cases six weeks, for most antidepressants to become fully effective. The reason for these delays is the time required for the medication to be in the bloodstream before the brain can make the necessary changes that allow for maximum effectiveness. And that is the primary reason why your doctor may wish to continue an antidepressant even if you report inadequate benefit from it after three or four weeks. Moreover, your doctor may know it is the best available option for your particular treatment needs. So it is important to give medication a strong and complete trial before concluding that it has not worked.

I assure you that the antidepressants available have been carefully formulated and tested to bring about very precise adjustments in brain chemistry. If your physician is a psychiatrist, he/she is well aware of these adjustments and is basing treatment decisions on highly technical and often complex sets of factors. So leave the decision about medication to your psychiatrist. Indeed, information about the various antidepressants will not be a part of this series.

Should an antidepressant be prescribed for you, that would certainly not preclude the option of engaging in psychotherapy. In fact, medication in combination with psychotherapy is probably still the most common means of treatment for depression.

Some research studies suggest that this combination treatment is the most effective. But one study (Wexler and Cicchetti, 1992) suggests that there is no significant difference between psychotherapy as the sole means of treatment and the combination of psychotherapy and pharmacotherapy. The results of the study did suggest, however, that the combined treatment is slightly more effective than pharmacotherapy alone. The resulting conclusion from this study is that psychotherapy alone should in most cases be the first means of treatment attempted. (That is, provided one has the financial means for it.)

Electroconvulsive therapy (ECT) has been portrayed repeatedly throughout its history as some horrid kind of experience—more often resembling a punishment than the carefully applied treatment it is. These portrayals usually present ECT as a “last-ditch” effort to control a severely deranged individual who is experiencing the ultimate degree of insanity.

Such representations are utterly false and stem largely from ignorance. Admittedly, these images in part stem from the employment of ECT (primarily before 1960) without the brief use of anesthesia combined with a muscle relaxant (prevents an actual convulsion of the body) and other forms of medication used today. But please be assured that this form of treatment is greatly refined when compared with earlier methods of application. Examples include levels of electrical stimulus, how treatments are administered, and how patients’ brief recovery periods are handled.

ECT continues in most cases to be the choice of treatment only after more than one trial of antidepressant medication or other treatment regimens have been deemed unsuccessful. It is generally quite safe, with relatively few noteworthy side effects: occasional temporary headache and, less commonly, temporary abdominal discomfort are reported by patients. Short-term memory deficits are often seen in patients at or nearing the end of their initial series of treatments, but these are usually temporary.

In my experience, the number of treatments in the initial series has averaged between five and ten (more for some patients), but the total number is determined by the treating physician. Decisions affecting the number and overall success of the treatments are based on standardized testing, collaboration with patients and their families, and other technical factors. (Treatment with ECT has been shown to have greater efficacy and to achieve its benefit much more quickly than medication and certainly than psychotherapy.)