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Unfortunately it’s fairly common to have thoughts of self-harm. Many people don’t act on them, which is a good thing, but some do. Generally, the underlying reason for self harm is when you feel so much emotional pain, you’re just going to explode and you’ll do anything to get rid of it – so you change the pain into physical instead. Physical pain is easier to feel than emotional pain. Typically that’s the idea behind cutting or scratching or burning or picking or something like that – the idea is you’re trying to turn your emotional pain physical. What you would want to do about it: when you have so much emotional pain and you feel like you’re crawling out of your skin, the best thing to do is try to get it out. You can get it out in multiple ways: you can talk to a friend about it. You can scream into your pillow. You can go to a boxing class – that really helps with anger. You can create something with art. Whether that means that you write a whole bunch of journal pages or you paint a picture that you’re trying to get intentionally, like how can I get this feeling that’s in me portrayed on paper? How do I get it out of me? If you’re not the type of person who wants to create anything, go looking at what other people have created. Look for music where the lyrics describe how you’re feeling. Look for music that matches your feeling – sometimes if you feel super amped up and you find amped up music, it makes you feel relaxed. Go looking for things that can help you get rid of the feeling inside your head. Another thing that you’d want to look at is if you do have a constant urge to cut – so you cut your wrists – not for suicide, but just across – you can put a hairband there and you can snap your hair band. That’s not my favorite go-to, but it can help if you do really have the urge of I need to do something that physically hurts.
When I was younger, I had a friend who was in a terrible relationship. He was really abusive to her and she knew that she should break up with him, but she didn’t want to. We had suggested – many of us had suggested to her – to go to therapy and her defense was: No, no, no, I can’t go. I know what they’re going to say. They’re just going to say break up with him. So I don’t want to go. I imagine this is a fairly common perspective or belief of what people think – if they went to therapy, the therapist would say hey, you need to do this, this, and this and all these things are bad for you. I want you to know that’s not true. A good therapist will not say do this. They will not judge you. Their main goal is to help you understand your own patterns and your own blind spots. They’re going to help you understand what it is in you that wants to be with the abusive boyfriend and why you’re drawn to him. They’re not going to say you need to break up with him – that’s not a therapist’s place. We do not give very concrete advice such as do this, we sit with you and help you think through the different aspects of yourself, the different sides of you (one side wants this, but one side wants this) and we try to help you resolve the conflicts. That’s sort of a general overview of therapy. If you get really specific: there are many different types of therapists and we all seem different sitting in the room. On one hand, you have what’s called Cognitive Behavioral Therapy. If you go see CBT therapists, they’re going to be much more active with you. They’re going to be coming up with ideas along with you and they’re probably going to give you homework. They’re going to say let’s figure out how to treat these symptoms in the most direct way possible. There’s tons of different types of therapists, but let’s go to the other end of the spectrum. Let’s go to, say, a psychodynamic therapist. Someone like that is going to sit down and they’re going to be much more laid back and their goal with you is to go over your life story – what happened in your life, things that happened before. Say your parents got divorced and your house was really upset for four years, but that happened when you were 14 and now you’re 18 – a psychodynamic therapist is really going to try to look at that and realize how that affected you. Let’s say right now your symptoms are: you tried drugs or you’re cutting or you’re depressed, you don’t know what you want to do with your life. They’re going to look at the whole big picture to say, Hey, you know what? I bet you that stuff back there really hurt and there’s a possibility that that has to do with your drugs right now. No therapist is going to look at your bad behavior and judge you for it. They’re going to see it as a defense and a band-aid for something that hurts underneath.
Thinking about suicide and death is actually much more common than you may think. Acting on it – luckily is not as common. What you want to do is if you have thoughts of suicide: you want to talk about them. You want to talk to a friend, a family member – anybody you can find to be honest, just get it out of you. Because when you have thoughts inside your head and you express them out loud (you can even write them down), they’re much less likely to be acted on. So the same is true with – it comes up a lot because of celebrities who have committed suicide lately or some of you may know people personally who have committed suicide, you maybe the parent of a child who has said that they’re suicidal – what’s very, very important to know is common instinct says: don’t ask those people because you don’t want to put the idea in their head. That’s false. One hundred percent false. You will not put the idea in their head. That’s not possible. You need to ask them so that if they are thinking about suicide, they’ll talk to you. The more you talk about something like that, the less likely you are to act on it. So I urge you: ask anybody you know who you’re worried if they’re potentially thinking about suicide.
If you’re having thoughts about death and dying, you should definitely go talk to your parents about them. They should be your first line of defense, especially if you have good parents that are available to you. Go talk to them because any thoughts you have inside yourself about suicide, you want to get them out, say them out loud, write them down. Anything you can do to get them out of you, will make you less likely to actually act on them. So it’s very, very important to go talk to your parents about those thoughts.
Social media is really difficult. I imagine we’re talking about Snapchat and Instagram – those are the two main ones that kids are using these days. If you’re using, say, Instagram: what I really recommend to kids is if you don’t want to delete your Instagram and you don’t want to delete your friends, make sure you are cognizant about who you’re following. Who you’re following creates sort of your Instagram life in your head. If you’re following a bunch of depressing quotes or deep dark black, black and white dark photos, that is going to get into you. If you’re watching and scrolling all day long about these dark things, you’re going to start to feel dark too. So all of the people you’re following that are not necessarily your best friends – make sure they’re positive. Make sure they are something else that you prefer – it can be art, it can be pretty pictures, it can be puppies – it doesn’t matter. But it’s very important that if you don’t feel well, delete everybody that’s giving off any kind of negativity because it really, really does change your world. Same thing with Snapchat. If you have, faraway, say third-tier friends who are posting videos of themselves being depressed or they’re doing this or that – remove them. If it’s your best friend – it’s a little bit different. You can go talk to them yourself. But if they are third tier, just delete them. You don’t want to see the negative stuff because it will bring you down.
There’s a feeling that people describe that’s not sadness – it’s something that they described as much worse than sadness: it’s empty. Like there’s no feeling there at all whatsoever. When clients describe that to me, I immediately start to think: okay, maybe this could be a depression. If you feel that feeling for say two weeks or more, you really do need to consider that you could possibly have depression. Let’s say you feel it right away and you want to know what to do. First thing you’ve got to look at is sleep. You have to try to sleep eight to nine hours a night. Next thing you’ve got to look at is exercise. Try your very best to exercise three times a week, three to four times a week for 30 minutes. You can go bike, you can go run, you can do a yoga video on YouTube – just something really basic is fine. Then if it still doesn’t work, I would recommend that you go see a therapist and if that doesn’t work, then I would look at some medicine from the psychiatrist.
If you’re feeling hopeless, like everything is going wrong and nothing’s going to get better – what I want you to do is get a piece of paper and start writing. Write out everything that’s going wrong. Make a list of it, get it all out of your head so you can see it. It’s all the same place. It’s all concrete right here. Then it doesn’t feel so overwhelming. And then what I want you to do is I want you to sit: today, I’m in ninth grade and I’m blah, blah, blah. This is what I have to do. What do you think comes next? What will high school be like? What do you want college to be like? What do you want your life after college to be like? Where do you want to live? What do you want to do? What kind of people do you want to be around? You know, what kind of job you want to have? Do you want to have grandkids someday? I want you to stretch it out into the future. When you take your vision more wide instead of right now, it’s easier to see: okay, right now life sucks, but clearly I won’t be in this exact same place forever. When you look into the future, then it becomes not quite so overwhelming or seeming like it’s going to last the rest of your life.
If you’re feeling angry and irritable most of the time, it can be a contributing symptom of depression. Depression in children looks like anger most of the time, so just keep that in the back of your mind. But let’s say you feel super angry because somebody did something mean and you just feel like you’re going to blow up or something else happened and you just feel really angry and you don’t know what to do with it. My best advice for that would be to workout. Do something that absolutely exhausts you. Whatever it is, whatever you have access to: go run, go to the gym, go to a boxing class, join martial arts. Do something that makes you feel like you can use all of the strength in your body and use it up until you’re exhausted. Burn up the anger. Another thing is to write it out. Write out everything you’re angry about and then edit it. Do it in the notes in your phone and you can edit it so that it gets to the most concise you can get it so you actually know how you feel. When you’re angry about something, you don’t want to tell the other person and drone on and on and off. They won’t hear you and your point will get lost. What you want to do is you want to be able to say it in the least words possible. So that involves a lot of editing and a lot of writing out how you feel, edit down less, less, less and less. And then you can know to yourself how you feel and be able to express to the other person how you feel and hopefully have a much higher chance of them hearing you.
I wish there was an easy answer or easy advice for feeling lonely. If there is, I don’t know of it. When I see clients in my office that feel lonely, we could say you should make more friends, you should go out more but to be honest with you: they’re already out with all their friends. They just are lonely while surrounded by a bunch of people. I think part of the reason this comes up (especially during adolescence) is because you’re recognizing who you are as a certain person and that may not be similar to the people you’ve been friends with growing up. You might feel disconnected, you might feel like you’ve outgrown your friends and that can lead to loneliness. Another aspect of feeling lonely could just be that you’re old enough now to recognize the existential crisis that we are actually all completely separate from other people and we are living our own life and not other people’s. So as far as feeling lonely, that’s a difficult thing that I usually work with in therapy over a course of many weeks and months to alleviate. It’s not something that I think I have a quick tip or advice for.
There’s a symptom of depression called Anhedonia, and what that means is when you lose interest in other activities that you used to enjoy. When you’re in adolescence, it can happen in a few different ways: maybe you’ve lost interest in those activities because you’ve outgrown them and you want to try on something new and that’s obviously not a problem. But if you feel like you wish you wanted to go dancing again, dancing still like you used to, but you just don’t – that’s more along the lines of Anhedonia. What you want to do is if you’ve lost interest in things like that, make sure you get enough sleep. Make sure you try exercising even if you don’t want to – it might spike your endorphins so that you can start getting back into the habit again. And if that doesn’t work, then talk to your parents and perhaps see a therapist or a psychiatrist because that does lead to more along the lines of depression.
Sorrow and despair can come from many different things. Some of the most common might be someone in your family passing away, your parents getting divorced, breaking up with your very first true love. I think at some point every adult knows the feeling of I cannot do this. I feel like I’m dying. My chest is so heavy, I feel so awful – so miserable. I do not know how I’m going to get past today. I’m just going to worry about today, one day at a time. What we do with those feelings is: you have to use up the sadness. You have to use up the grieving and you give yourself time. Depending on what it is, if it’s a breakup or if it’s a death, a death – it’s going to take a long, long time and it’s going to go up and down. Some days you’ll be fine. The next you’ll be super sad again and you just sort of have to sit back and watch your emotions process themselves. Don’t try to stop them. That’s the important part. Do not try to stop how sad you are. You have to keep functioning, but when you’re home or when you’re in the car, then it’s fine to cry and it’s fine to still talk about it with somebody else. If you are going through a breakup, then something similar is going to happen and what I recommend to do is set aside a couple hours every night – maybe not a couple, set aside one and a half – and say: okay, from 7:30-9:00, I’m going to sit and I’m going to talk about ex-boyfriend and I’m going to cry. This is the time I have to do it. Outside of that time I cannot talk about him. And then day after day you only have your hour and a half in the evening to talk about him, but you have to use the whole thing. You can’t stop early – that’s the trick. And after a couple of weeks, you will start to notice yourself being like, ah, screw it. I don’t want to sit here and cry anymore. I don’t want to sit here and be sad and talk about it anymore. And then you can stop. Otherwise, the sadness can sometimes take over your whole day. You’re in the bathroom crying at school when you should be sitting in class. That’s what I would recommend if you’re going through a breakup. If it’s something more severe, like I said, with somebody dying – you want to ask for help and just watch the emotions. Don’t try to stop them. Just keep going. After about six months, a year, a year and a half – it will start to get better.
Unfortunately a very common theme in our society is the idea that you could just snap out of depression. Sometimes this works, I guess, but then it wasn’t really depression in the first place. Real depression has a really strong grip on you and it gets a hold of the chemicals in your brain. When you don’t have enough serotonin or enough of the neurotransmitters created by your brain that you need to feel what we would call typical then that’s when you have depression. To snap out of it doesn’t make any sense because your brain would literally have to create more chemicals and we can get those chemicals sometimes by exercising or sleeping more or using healthy things for our body, but most likely you can’t just snap out of it. You probably need to process through why you’re depressed in the first place and go through all of the things making you sad and angry and go through that with somebody. Another thing is that many times with depression, you just have to have antidepressants. Nothing else has seemed to work and you could stay in that space for a really, really long time without the antidepressants to help you.
If you know someone or you’re seeing someone post disturbing images or suicidal notes on Instagram or Snapchat, etc. – if you don’t know them, probably don’t follow them. If you do know them, what you need to do right away is you need to call their mom, call their teacher, call her dad, call anybody you know, call your own parents who can try to figure it out – but you do need to contact an adult as soon as you can. It’s very important. Do not ever feel bad that you’re telling on your friend or your consulting parents when you don’t need to. If your friend is willing to post that stuff out in public, they should know that somebody’s going to get help for them and somebody’s going to call their parents. That is definitely my advice is to get ahold of somebody in control who can do a lot more than a kid can.
There’s many reasons your grades could be dropping and you don’t care. We’re looking at grades dropping, so we’re taking the assumption that your grades used to be good. Many different factors: the first thing that comes to mind is – what’s going on in your life? Have you started using drugs or smoking weed? That can really take down your motivation to focus on your grades. Have you joined a new social crowd? Have you been going out with your friends and trying to make new friends and social climb and grades have fallen by the wayside? Is something happening in your family? Are your parents fighting more? Are they yelling at you more? Or are there things going on that are distracting you from doing your homework? There’s a lot of different things that could be going on and I do really recommend that you try your best to figure it out. First line of defense should be to go talk to your teachers. They can help you if you are struggling with depression or things going on in your family and they may be more likely to give you an extension or grade you a little bit more lenient. If you have really good grades and you’ve had them every year up until now, you deserve to go advocate for yourself because I really, really hate to see GPA’s completely slashed because of something that happened in one semester in your life and it got wrecked. So please go advocate for yourself and try to figure out what you can do to keep your grades up.
If you’ve already hurt yourself many times – the best thing to do is to come up with a plan of what you’re gonna do instead next time when you’re calm. So right now maybe you’re calm, you need to come up with a plan of what you’re going to do next time when you get really, really upset and you feel like there’s way too much pain going on and you don’t really know what to do. You could plan to go exercise, you could plan to call a friend, you could plan to draw, you can plan to lay there and listen to music and sit on your hands. You can plan anything. But you need to come up with a plan when you’re calm. What I would recommend is that you play this sort of game with yourself – this is cognitive behavioral therapy: for every week that you don’t hurt yourself, you get a little gift or a prize or whatever encourages you. For every month that you go without hurting yourself, you get something else. The longer you go, the more rewards you get. Also, you have to think of it in your mind as I’ve been clean for a month, clean for two months, clean for three months from hurting myself so that you don’t think to yourself, I’ll just do it once and it doesn’t really matter. I don’t care. Also, if you’re already hurting yourself, you do need to go talk to your parents. You need to go talk to an adult. Especially depending on the severity – sometimes it’s very easy to cut too deep and need stitches. Also, we’re just talking about superficial hurting yourself. If you’re suicidal or you’re cutting your wrist to die, then you absolutely need to call 9-1-1 or go talk to your parents or go get help from anybody you can find.
If you’re experiencing physical pain or stomach aches or other things going on and you’ve been to the doctor and they don’t find any diagnosis, they don’t find any reason for it – probably they told you to see a therapist and they’re considering anxiety. A lot of times anxiety disorders can manifest in your physical body and we call that somatic disorders. And the best way to treat that is to go sort of far back and understand your whole life and your whole psyche and what could be making you anxious that you’re not consciously aware of. You usually can’t say I’m anxious because of this, so my stomach hurts. Sometimes you can, but not usually. So what you’d want to do is you’d want to go see a therapist and try to understand what anxieties are going on, what depression symptoms you’re having that are going on. And if we make them conscious and you talk about them, it generally starts to alleviate the actual physical symptom.
Another form of medical treatment for severe depression is what’s known as TMS or Transcranial Magnetic Stimulation. This is a newer form of treatment that is still being studied but is used quite frequently in the appropriate patient population. It works by generating magnetic pulses that are targeted at specific parts of the brain that are thought to help depressive symptoms. Unlike ECT, there is no seizure being induced and there is no need for general anesthesia, meaning that a person is not put to sleep during the procedure. It is usually performed more frequently than ECT. It could be even five days a week in an average course. The benefits relative to ECT are not fully established yet. Currently it is thought that it is not as beneficial as ECT is for severe depression, but it continues to be studied and developed. And this is something to ask your doctor about when you’re considering various options.
Ketamine is a molecule that has been used for years for surgical anesthesia, also been abused as a street recreational drug that some researchers are looking into for a rapid treatment of severe depressive symptoms. It is still largely investigational, largely being administered in research studies and protocols, but there is some preliminary evidence that it may prove beneficial for people in a severe depression. It’s thought not to produce a lasting effect, meaning that someone takes the medication and they remain depression-free for the rest of their life, but it is thought to perhaps jumpstart, if you will, that if someone is severely depressed, perhaps suicidal and they’re administered this medication, that those feelings and thoughts could lift very rapidly, pull them out of that rut if you will, and then other sorts of treatments could then be administered and kick in to try to help maintain them to stay well. There are some potential risks associated with ketamine, which are also still being explored, including the significant concern for addiction as well as effects on blood pressure. Hopefully we’ll know more about this as it continues to be studied.
Magnetic Seizure Therapy is an investigational medical non-pharmacological intervention for depression. On some level, it’s a little bit of a blend between electroconvulsive therapy (ECT) and Transcranial Magnetic Stimulation (TMS) in that it uses magnets to induce a seizure that is thought to help depression. It is not widely available and it is still being researched, but it is hoped that this may also provide some relief in the future for the appropriate patients. Nitrous oxide is an anesthetic that’s been around for years that is currently being explored at low doses to potentially help with the rapid treatment of depression. Repastinel is a medication that is being explored in research trials, hoping to work similar to ketamine
Insurance coverage and the treatment of depression is somewhat variable. Some psychiatrists take insurance, some do not. Some therapists take insurance, some do not. If you’re having a hard time finding a doctor who takes your insurance and it’s important for you to use your insurance, a good first step is to call the insurance and ask for a list of the providers who are in network for them (meaning the ones who are covered to the greatest extent) and you can then either ask other people you know if they recognize any of the names or try calling some of the doctors and see if they seem like a good fit. Hospital services will usually be covered by most insurances. Partial hospital programs will usually be covered by most insurances, residential programs – it may vary more. So obviously for each of these issues, it’s important to talk with your insurance ahead of time in order to ensure that it is indeed covered.
There are two things that we like to work with, which are the internal and external resources. Those are the positive things that a person has going on for them. For example, an external resource will be their support network – who is there for them? To support them, to help them thrive throughout life? Another one is the internal resources which are accessed through insight, and this is what therapy is so good. An example of an internal resource will be their communication skills or their perseverance or something else that they have going on for them that will help them thrive as well.
One way that I like to explain to clients about depression is with the emotional jar analogy. Imagine you have this glass jar with a top on and every time something happens and events such as you lose your job or you had a fight with your boyfriend or things are not going well at work, you put all those emotions about those events in this jar. Your anger, happiness, sadness – everything goes in that jar. There comes a point when the jar does not fit anything else in there, so what’s going to happen? It’s going to blow up and it’s not going to look nice and what it’s gonna look like with some symptoms of depression, anxiety, or anything else that comes up. Sometimes it might even be showing up in some physical things. So what happens when you come to therapy? Well, when you come to therapy, you can work through those emotions, process each of those events to find some emotional relief.
The difference between CBT (or cognitive behavioral therapy) and psychodynamic is also in the role of the therapist. In CBT, the therapist takes a role of more of like a teacher and in psychodynamic, it’s a person that is there to guide you to help you process events. So what happens with CBT or cognitive behavioral therapy? You’re going to explore your negative thoughts, those patterns that you keep on repeating. In psychodynamic you’re going to go more into the past and look into what has brought you here. A good analogy that I like to use for this is a band-aid analogy. So imagine that you got hurt and you have this horrible wound now. It’s an open wound, it’s bleeding. So the first thing to do is to go ahead and grab band-aid to stop the bleeding. Well, the band-aid does not do much. It stops the bleeding and it might take a little bit of the pain away, but the reality is the wound is still there and it will keep on hurting and it will show up maybe in other areas it might get infected and show up in other areas. CBT and psychodynamic work sort of in those ways. CBT is sort of like that band-aid – it will give you the tools to help you manage your symptoms that you’re struggling with right now. That doesn’t mean it heals. It will not heal your emotional wound. It just helps you cope with it. Psychodynamic goes more into the wound, deep into the wound to see how it took place and how we can start healing. So I know that I’m a little bit biased on this because I am a psychodynamic therapist, but the reality is that there are two different kinds and you can still (as a psychodynamic therapist) I can provide you with some tools, which I usually do such as breathing techniques to help you cope right away with your, your most intense symptoms.
Some of the great tools that I encourage my clients to use are breathing techniques (which helps those who struggle with anxiety), journaling (which is a great source to relieve some emotional tension), meditation (you don’t have to do 20 minutes on the first time, you can start with one minute a day and there are some good apps out there that help you with that), exercise (it’s great for your health and it’s also great to release some tension), and last but not least, the support network (the use of a support network is very important and it will help you thrive and live a healthier life.
Journaling is a great tool that I encourage my clients to use. Journaling works sort of like a diary except that you want to in there include all the feelings that you struggled with throughout the day. So for example, if you had a hard day at work, what did it feel like for you? What kind of feelings did it bring up for you? The other thing about journaling is that it’s important to develop some sort of routine with it – so maybe it will be something that you do before bedtime. You prepare a nice cup of tea and this will be a bedtime thing that you do. It’s part of self-care. The great thing about journaling is that it allows you to process all of the emotions. So for those who struggle with traumatic events, it really allows them to process those traumatic events. So there are a lot of great things about journaling. I hope this encourages you to start one.
Being present means listening with purpose. Imagine showing up – not just physically but also emotionally and with all of your senses for your partner and most importantly – for yourself. Imagine those simple tasks, how much better they will look when you, for example, wash the dishes and you feel the warmth of the water in your hands or smell soap. Or even better, each morning when you prepare your coffee and you grind those beans and you can smell the coffee about to start getting ready and then you pour yourself a cup of coffee and you feel the warmth in your hands. Imagine each thing being able to enjoy it with all of your senses. Well, that is the magic of being present and how it brings happiness into your life. This is something that you can do with every activity you have each day. Nowadays, we focus so much in technology and we’ve missed this – enjoying the here and now of each day. Why don’t you try it?
A great breathing exercise that I encourage clients to do is the 4-7-8. Four: you’re going to inhale: 1, 2, 3, 4. You’re going to hold it for seven: 1, 2, 3, 4, 5, 6, 7. And then you’re going to let it out from eight: 1, 2, 3, 4, 5, 6, 7, 8. This is a great technique for those struggling with anxiety, panic attacks, and depression and it is a great relaxation technique. If you have children and they struggle with anxiety and they need some breathing techniques as well, there’s a great exercise called the starfish: you tell the child to open their hands wide like a starfish and then they’re going to trace with their other finger – each finger. As they go up, they inhale. As they go down, they exhale. Inhale, exhale, inhale, exhale, inhale, exhale, inhale, exhale. And they can do it about four times, three times – as many times as you think that it will help them – usually three times and they’re tired. This is a great exercise to teach them to also start regulating their emotions as well. I hope you give it a try.
When the symptoms of depression get severe, sometimes the person might struggle to get out of bed or struggle with some suicidal thoughts. The therapist might advise to seek some evaluation from a psychiatrist to see if at this time, medication is needed.
During teen years, teenagers struggle with a lot of pressure – either from school, from their parents, family, or from their friends. It is important that they have the support they need during those years. Some of them might develop some symptoms of depression and anxiety, and this is where group therapy’s a great place for teens to develop some sense of self, develop their identity and boost their self-esteem. It is important that they keep open communication with their parents and the school counselor to be able to ask for the help they need.
Hope is something that you can find within yourself and around those who love you, so hope is built from that network of support that you have – that’s where you can find hope. Also, it’s great to build hope around your volunteer work. It is said that volunteer work brings more to yourself than actually what you give to others and it’s actually true. So one great way to build hope is to go out into the community and see how you can be of use out of help for others.
Another great technique that I like to use with my clients is the safe calm space – it is a visualization exercise. So for this one, you’re going to close your eyes and imagine a place where you feel safe, relaxed, comfortable. For a lot of people, that place is a beach. You’re going to be there and you’re going to use all your senses. So you close your eyes and the first thing that you feel, what is it? Is it warm sand on your feet? What kinds of things are you seeing? Are there other people there? Are you alone? What kind of sounds do you hear? Is it crashing waves on the shore? What kinds of tastes do you feel? Do you feel the taste of the beach, of the ocean, is it saltiness? What kinds of smells come up for you while you are there? Is it the smells of the ocean? This is a great place for you to go every time you are stressed, anxious, or struggling with situations – it’s a calm place for you to be.
Sleep is the most important thing for physical and mental health. A lot of times parents will bring in their kids and we’ll sit down and talk. They’re suffering from many different symptoms of depression and the first thing I ask is: how many hours do you typically sleep at night? Kids need to sleep eight to nine and when you break that down, that means they have to go to bed at like 9 or 10 so they can get up for school in the morning. That’s not happening very often. Sometimes they’ll look at their fitbits and they say, oh, I guess I slept four hours last night because I was doing homework. Five hours the night before because I had a soccer game and five and a half the day before that because while I was on Facetime with my best friend. What we want to look at is what symptoms that could be causing that looks like depression but might not be. It can cause irritability and fighting with parents. It can cause social withdrawal and being too tired. It can cause poor concentration and doing poorly in school and it can also cause considerable increase in appetite. So we really want to focus on the sleep. It’s worth spending a lot of energy, a lot of time on Google trying to sleep more hours, trying to sleep better. Vice versa, we also need to look at if you do have clinical depression, a symptom of that is an inability to sleep. If that’s the case and you just can’t sleep, you lay there at night, you go to bed at appropriate time and you just lay there – that’s the time to seek out a doctor or a therapist to try and get some medication or get some help sleeping because that might really hinder your depression from getting better.
A bully’s main goal is to isolate you. Either they say something mean to you on the internet or they intimidate you in real life – what they’re trying to do is get you alone. When you’re alone, you feel bad. You crouch down, you withdraw into yourself and they can be even more mean to you. The first thing you want to do is if you have even the tiniest bit of bullying coming towards you: tell your friend. Do it before your self-confidence gets so low that you’re ashamed of yourself. Do it right away. You have got to tell your friend. You have got to tell your parents. You have got to tell your teachers. The goal for you is to get a community around you so you’re not alone. Therefore, you can still think clearly. You can remember: okay, I’m not actually so terrible and bad like they’re saying. I’m not so awful. Because you’ve got people around you who agree with you. If you wait too long to get help, you start to internalize everything they’re saying and doing. You start to crouch down and then they come at you even more.
This is a really common question for adolescents. Throughout adolescence, that’s the developmental phase where you start to question: Who am I? What do I want to be? What have I been? And you start to look at what kind of person you want to be and you can try on 15 different ways. Where I like to start as a project is I ask clients: who are your grandparents? Tell me about your grandparents. Tell me about your grandparents’ relationship with your parents. How were they? Tell me about your parents. Tell me about your parents’ relationship to you. And through doing that we start to see: you didn’t move out of a vacuum. You do have a history. This is who you are today. It certainly doesn’t need to be who you become as you come into your own adult life, but it’s something to know so that you’re making conscious decisions. You can really sit down and pick apart your parents’ values and choose which ones you want to internalize and keep for yourself versus which ones you’d prefer to throw away and that’s not really you. One of the things that I really encourage kids is to dream. Be very creative. Think about yourself a lot. Think about your life and what you want. What might you like to do? Where might you like to go to college? Do you want a small school or big school? Do you want to get married? Do you want to have kids? Do you want to go on a lot of vacations or do you like to stay at home and have a simple life? All of these things are really important and you don’t get to any of the answers unless you just sit there and dream. You come up with all these crazy ideas and you’d be willing to edit them at any point, but it’s important to just sit down and dream.
When trying to treat your own depression, I usually present to clients sort of a hierarchy approach – we need to knock off the most important first that could be most impacting your depression. Number one is sleep. You have got to go to sleep. You got to try your very, very best to get eight to nine hours of sleep per night. A way that I recommend clients to do this is either to get a FitBit that tracks your sleep or you can just use an app on your phone – it’s really not that difficult. The second thing (once you’ve taken care of sleep) the second thing you need to do is you need to exercise. Research shows that exercise about 30 minutes, four to five times a week – it doesn’t have to be super strenuous. It could be a bike ride, could be a run, it could be following a yoga video on YouTube. If you do that, research has shown that it’s equally as effective for depression as antidepressants are. Sometimes you need both, but that’s a really good place to start. The third thing I would go to is looking at your sadness and looking at your anger. Depending on why you feel depressed right now – you might be super sad about a breakup, sad about your parents divorce, sad about your friends abandoning you at school – if you feel particularly sad about that, what I want you to do is write about it. Paint it. Find some creative outlet to use it up. What we want to do is not avoid the sadness and run away from it and try to distract ourselves, but rather: okay, I’m really, really sad today. Let me schedule in my calendar an hour to lay in bed and cry to Grey’s Anatomy or cry to sad music. We need to use it up – not all 24 hours, but just one hour a day. You’ve got to use up your sadness. And the same thing goes for anger. Depression can many times come from anger turned inwards. We’re angry at our parents, we’re angry at people at school, we’re angry at our teachers, we’re angry about a lot of things we can’t control. And so – screw all of it. We get angry at ourselves. I’m awful, I’m bad, I can’t do it well enough. My family’s a mess because of me. We need to try and turn that anger back outwards. That doesn’t mean screaming at your parents and other people, but writing – writing is my favorite way to do it. Write down a list of everything you’re angry about. Journal it. Try and get as much of that anger out of you as you can. Anger is much easier to process than depression itself. And the third tip – if you’ve done all of those things and they don’t seem to be working, next, I would look for a therapist. Talk to your parents, talk to your counselors at school, see if they’re willing to get a therapist and bring you to therapy. If that still doesn’t work, then what we do is we go to a psychiatrist. Psychiatrists can prescribe antidepressants or medicines that can help you feel better. If you’re way up at the top and haven’t tried any of these things yet and you feel really helpless, there’s a lot of things you can still do that we can really try to tackle these feelings and get you feeling better.
Additionally, there are medications that seem to have caused depression in some people – or at least symptoms that look like depression: certain asthma medications, certain blood pressure medications, certain hepatitis medications, smoking cessation medications all seem to cause these types of symptoms in some vulnerable populations and therefore whenever you’re starting a new medication, if you are struggling from depression, it’s a good idea to run the new medication by your doctor to make sure that there’s nothing that would require additional monitoring. Other biological contributors to depression that we think about are substance abuse and really addictions of any sort: alcohol, recreational drugs, gambling addiction, sex addiction – all of these can contribute to symptoms of depression in many individuals and have to be very thoroughly considered in the diagnosis. Psychological factors also have to be considered as potential contributors to depression, so people who tend to think in all or nothing terms (for example: everything is all good or everything is all bad) will often be more subject to depression. People with low self-esteem are at a significantly higher risk of depression. People who don’t deal with adversity or don’t have as much of a coping system may be at higher risk for depression than many others.
When talking about the causes of depression, it is important to note that while we lump everyone together as having major depressive disorder, in reality, these may be very different conditions. A person who has depression related to lack of sleep may be very different than a person who has depression related to low thyroid hormone, may be very different from someone who has depression due to poor coping skills. We generally group them together with the same term as a sort of final common pathway that they’re all showing the same symptoms, but in reality they may be very different conditions that in the future we may better understand and be able to individualize the treatment in a more specific way.
There are a number of red flag symptoms that should encourage someone to seek help for depression right away. These would include things like: thoughts of harming oneself or others, or if the depression is tangibly affecting them in a very direct way. So for example, if someone is in danger of losing their job, losing a relationship due to their depression, they should certainly seek treatment right away. The other general recommendation we give when it comes to seeking treatment is if the depression is not going away. What’s considered not going away? Obviously there are different opinions on how to define that. A general rule of thumb we give people is about two weeks. If a person is having consistent symptoms for one week, that could be a fluke. Once it’s getting to two weeks, that’s already getting closer to the point where it’s probably a good idea to speak to someone just to try to turn the current before it becomes more entrenched.
There are many different mental health professionals who can adequately treat depression in different ways: a psychiatrist is a medical doctor who can prescribe medications and other forms of treatment for depression and can also provide psychotherapy (which is a fancy term for talk therapy) that uses dialogue to improve the symptoms of depression. Other professionals included psychologists, social workers, marriage and family therapists, who are all specialists in providing psychotherapy and can be extremely helpful in treating the depression. So if you’re looking specifically for medication, a psychiatrist would be the way to go. If you’re looking for therapy, any one of those professionals would be a fine way to go.
Depression can be treated in a variety of different settings, depending on how severe the symptoms are. At the highest, most acute level is what we call inpatient hospitalization – meaning that a person goes to the hospital (it may be in voluntarily in some instances) to receive treatment. Sometimes people will voluntarily elect to go to the hospital as well, where they’ll receive more intensive attention, medication therapy, hopefully psychotherapy as well that can help boost them and pull them out of the depression more rapidly. Inpatient hospitalization will be particularly appropriate in situations where there are concerns for safety. So for example, if a person is having thoughts of harming him or herself, it is very important to strongly consider inpatient hospitalization and sometimes this even needs to be pursued involuntarily to save a person’s life. Below inpatient hospitalization is residential treatment. Residential treatment is where a patient will go and live in a particular place – a particular facility. It is not a locked facility, it is not a hospital, but it will often have a doctor or a mental health professional on staff to help with the treatment to convalesce. This may be appropriate for someone where there is not a significant concern for suicidality or other risks to health, but where the symptoms are still too severe to be managed while they’re living at home.
Other times, people will treat their depression in what we refer to as a regular outpatient setting, where they will see their doctor or their mental health professional every week, every couple of weeks, depending on the severity of their symptoms as recommended by their doctor or a mental health professional. They’ll continue going to work, they’ll continue their regular routine, but will have check-in appointments at the specified frequency. Another level of treatment is what is referred to as a partial hospital program, commonly known as PHP or an intensive outpatient program, commonly known as IOP. These are very similar entities and therefore we’ll group them together, which are basically day programs where a patient will be living at home, sleeping at home, but go a certain number of times a week for a good chunk (if not the entire day) to an intensive setting where they’ll receive therapy, group therapy, medication management and other services. Again – meant to provide a more comprehensive package in the treatment of their depression.
When we think of treatments for depression, we often divide them into medical and non-medical categories. Medical categories being ones that generally a medical doctor would be prescribing or administering, and non-medical ones being ones that either a medical doctor or a psychologist, a licensed therapist or a social worker might be prescribing as well. Let’s start with the non-medical treatments first. First treatment would be no treatment, funnily enough. Sometimes a watchful waiting approach, monitoring someone, giving them time to recover, renewing their focus on the bread and butter activities of a healthy lifestyle. For example, focusing on their sleep, deepening their connections, exercising, renewing their commitment to meaningful pursuits in their life. That may be all that’s needed in some instances to lift the depression. The decision to opt for that track should ideally be made by a mental health professional.
Behavioral activation can be very helpful in treating depression as well. Behavioral activation means that a person, even though he or she does not have the energy, even though he or she does not have the desire to go ahead and engage in certain tasks, they will be encouraged by a therapist or by a family member to go through the motions to continue doing their routine, to continue doing things that they enjoy, even though they’re hating every second of it. And there is data that supports that as being an effective weapon in the treatment of depression.
Exercise can be a helpful non-medical intervention in many individuals struggling with depression. Although the data is mixed regarding the efficacy of exercise in helping depression, anecdotally it certainly does seem to help people who are undergoing other treatments for depression at the same time. I usually recommend a minimum of 30 minutes of intense cardiovascular exercise three days a week to start, obviously assuming that a person is capable from a medical standpoint of engaging in that level of exercise. Before you start any program of exercise, always important to clear it with your primary doctor as well.
Meditation/relaxation exercises can be helpful for some individuals who are struggling with depression. Mindfulness (whereby a person non-judgmentally notices the thoughts and feelings that they’re experiencing), focusing on a person’s breathing, stretching – all may have some role (certainly adjunctively – meaning in addition to – regular treatments) for the treatment of depressive disorders. Light therapy, whereby a person uses a light box to provide illumination at certain times during the day for certain intervals, has also been shown to be helpful for some people with depression. While this used to be used more for seasonal affective disorder (meaning people who have depression that manifests more during the winter months or specific times a year) it has been shown that in some people this can be beneficial. The decision to use a light box, though, should always be done with the guidance of a professional as there are some specific details that have to be worked out and it is not necessarily without any risks.
There’s good data supporting the use of psychotherapy in the treatment of depression. The vast majority of people who go through therapy shows some improvement in their symptoms of depression. The effects can sometimes be more enduring than the effects of medication and the treatment of depression, meaning that after a person stops therapy or after a person stops medication, it could be that the benefits of the therapy last longer than the benefits of the medication in many individuals. When considering psychotherapy, it is important to keep in mind that the benefits may take some time to reap. A connection has to be established between the patient and the therapist, which takes time. Therapy can be very therapist-dependent, meaning that the therapist has to be a good fit for you as someone who you feel comfortable with and that you feel can help you. A person has to be at the level of being able to engage in therapy. In some instances of depression, the depression may be so severe that the person is not able to talk or to engage in meaningful dialogue, in which case it may be necessary to pursue other avenues of treatment.
A common question that’s asked is: should a person start with therapy or with medication? As with so many things, there’s no one-size-fits-all right answer, but there are some things to consider: therapy works well. Medications work well. The combination of the two seems to work better than either one by itself, and so oftentimes they will be combined. I often recommend it to patients if the clinical situation is appropriate to start with therapy. Therapy being a little bit more of a conservative option without the side effects that you necessarily could see from medication. If a course of therapy really doesn’t seem to be helping, then consider adding on medication. That being said, every situation is unique and it has to be assessed individually, so there are no hard and fast rules, but that is one potential way to consider.
Cognitive behavioral therapy is a type of therapy where the therapist and the patient focus on the patient’s thoughts and behaviors that may be contributing to the symptoms of depression. Interpersonal psychotherapy is very similar to cognitive behavioral therapy, but places an emphasis on the relationships in a person’s life and how they’re contributing to depression. Psychodynamic therapy, psychoanalysis are both related types of therapies which focus on the subconscious of a person and attempt to improve symptoms of depression by addressing some of the underlying issues such as resistance or defenses that may be contributing to their symptoms. Supportive psychotherapy is a type of therapy where the patient and the therapist work together and the therapist uses the medium of empathy (of listening closely, listening attentively, providing support to the patient) to help his or her symptoms. Group therapy is a type of therapy where many individuals who are struggling with depression will sit together in a group and a group leader will facilitate and the medium of the group will help people in ameliorating symptoms of depression.
Medical treatments for depression include medications as well as other procedures that may sometimes be helpful for people who are struggling with depression. Let’s talk about medications: there are many different types of what we call antidepressants – medicines that seemed to help certain individuals who are struggling with depression that can provide a significant amount of relief. The most common type of antidepressant medicine that we encounter and that we prescribe is what’s called an SSRI and that is short for Selective Serotonin Reuptake Inhibitor. These are medicines you may have heard of like Prozac (also known as fluoxetine) or Zoloft (also known as Sertraline.) They’re prescribed for depression as well as for anxiety, and they seem to help a lot of people. Basically, they are thought to work by increasing the amount of Serotonin – one of the neurotransmitters or chemicals in the brain in the spaces between brain cells. That being said, the actual mechanism is probably a lot more complicated than that.
People who take these medicines will start by taking them usually daily – your doctor will tell you if you should take it at night or in the morning. They’ll take it for a while, so patients will often take it for a few days and say it’s not doing anything. It’s not helping at all. To which the doctor will usually encourage them: keep taking it, stick with it every day, and usually what will happen is that after a number of weeks of taking the medication (and that can vary from person to person), they’ll come back to the doctor and say: You know, hey, come to think of it – I do feel a little bit more myself. I don’t know when it happened. There was no light switch that went on, a sudden moment of feeling better. But kind of just gradually in the background, something has been kicking in and I feel a little bit more back to myself. I’m sleeping a little bit better. I’m eating a little bit better. I’m not as numb as I used to be. We usually recommend taking the medication between four and six weeks to gauge an appropriate response to the medicine. Some people may show a response earlier than that. Other people may take longer than that to show a response, but it is important to give it a significant amount of time to kick in before dismissing it as being ineffective.
Another category of medication that is very similar to the SSRI is what’s called the SNRI, which is Serotonin Norepinephrine Reuptake Inhibitors. These include medicines like Ephexor (also known as Venlafaxine) or Cymbalta (also known as Duloxetine.) These work in a manner very similar to the SSRI’s, but there may be some subtle differences as well, both in terms of the effect that they have as well as some of the side effects that they have. Another antidepressant medicine of a different class (a different mechanism) that is sometimes prescribed for depression is called Welbutrin (otherwise known as Bupropion.) This is a medicine that doesn’t really work as much with Serotonin as much as some of the other neurotransmitters in the brain. It usually works by giving people a boost of energy that people, for example, who were telling me that they can’t get out of bed in the morning, that they have no energy to get through the day, that their depression is really sucking the life out of them – taking Welbutrin may sometimes endorse a little bit more pep during the day. Remeron (also known as Mirtazapine) may be helpful for depression as well. It works through a different mechanism relative to the other antidepressants and seems to help people not only with their depression, but also with sleeping and with appetite, in that it boosts appetite (makes people eat more). If that’s a symptom of their depression, they benefit from that effect of the Mirtazepine.
One of the questions I get asked a lot about antidepressant medication is how long should someone stay on the antidepressant medication? Is it okay to discontinue it right after the symptoms get better? Should they stay on it for life? Or is there some in-between area that is really the ideal length of time? And the honest answer is that there is no clear consensus on this and it does depend on a variety of factors that you should discuss with your doctor. Some of the things that your doctor may consider are the number of depressive episodes that you’ve had in your life. For example, is this the first time that this is happening or is this the seventh time that this is happening? That might impact on that decision. The severity of the depressive episode might impact on the decision of how long to stay on the medicine. The side effects on the medicine might impact on whether you’d want to stay on it long-term or not. Whether you’re involved in psychotherapy might affect that decision. And the level of support that a person has in his or her life. Family members, friends versus living a more isolated life without those sources of support and people who could encourage to come in if symptoms redeveloped, might also be a factor in considering the decision. It is really important to talk with your doctor about that.
Every medication in the field of medicine can potentially carry with it side effects. Some of the side effects are relatively minor nuisances, if you will, but things that people are fine tolerating and will continue taking the medicine despite that and others may be more significant and a reason to consider avoiding or switching a particular medicine in any given situation for any given patient. While it’s impossible to get into every single potential side effect from every medication in this form, it’s really important to talk with your doctor after he or she recommends a particular medicine about some of the side effects to anticipate. Broadly speaking, some of the common side effects to many of the antidepressant medications that we see are mostly mild ones at the beginning. So for example: nausea, upset stomach, some people may report a mild headache. These sorts of things usually get better with time. Most doctors will encourage patients to continue taking the medicine for a couple more days in the hope that some of those side effects will go away. Some of the antidepressants can affect a person’s sleep, making it harder for them to sleep or affecting the quality of their sleep. If you notice that, it’s very important to talk about it with your doctor. Some antidepressants can affect sexual function. If you notice that, it’s also important to talk to your doctor as there may be ways to address that issue. Many of the antidepressants also carry a warning for individuals up to the age of 24 that some data seems to suggest that there may be an increase in suicidal thoughts in these individuals. This is something that is important to talk with your doctor about and to weigh the risks and benefits of the medication in that particular population.
In addition to medications that are prescribed, there are various other natural herbal supplements that may or may not be beneficial for depression. Some of the more popular ones include something called SAMe (which is short for S-Adenosyl Methionine), Omega-3 Fatty Acids, St John’s Wort, Vitamin B6, Vitamin D, Saffron Extract – to name a few. Regarding the potential benefits, lack of benefit or harm, it’s really important to talk with your doctor individually about specific supplements. While they sound healthy, they sound natural, they sound like a good thing (and they may be in some instances) sometimes they’re not always benign and some of them can carry some significant side effects as well as significant interactions with other medicines you may be taking that could then become dangerous. It’s therefore really important to look into these but to also ask about them and to make sure that they’re an appropriate fit for you in your specific situation. The other thing to keep in mind with many of these substances is that they’re not FDA-approved for the treatment of depression and therefore they’re not regulated in the same way that a medication might be. And therefore, when it comes to a medication, the companies go under a very rigorous scrutiny to ensure that purity, that what you’re receiving, is what is advertised. With many of the supplements, there is significantly less regulation and there is the possibility that you may not be getting exactly what you expect to be getting. So that’s another level of caution that a person should maintain when exploring these options.
Let’s talk about some other medical but non-pharmacological forms of treatment – meaning things that your medical doctor or the psychiatrist might recommend, but that are not in the form of an actual pill that a person would take. One of the treatments that’s medically offered for depression is called electroconvulsive therapy or for short known as ECT. ECT works by applying a small amount of electric current to the brain while a person is obviously under anesthesia in a controlled setting to induce a seizure, which is sort of an electrical overactivity of the brain. This is a treatment that has been around for a while and has been refined over the years in terms of its safety profile. From a data perspective, ECT does seem to help a lot of people who are struggling with severe depression, but from a practical perspective it is often reserved for the more severe cases of depression. People who have tried lots of other interventions (for example: therapy, a number of medications) and nothing seems to be helping them and they are in a very severe state (for example: suicidal or not eating and losing dangerous amounts of weight, having psychotic symptoms like they’re hearing sounds or voices, losing touch with reality.) In those cases, it might be considered. Its use is restricted because A. it’s not a practical form of treatment – it requires going under anesthesia several times a week for usually about four weeks or so. And B. there are some significant side effects that have to be considered. This is something to talk with your doctor about in terms of the full list.
My name is Dr. Zev Wiener. I received my medical degree from Harvard Medical School and completed residency at UCLA where I served as the Chief Resident of the Resnick Neuropsychiatric Hospital at UCLA. I presently work as an attending psychiatrist at UCLA where I see patients and help train resident physicians and I also run a private practice on the side, as well.
Colloquially, we often use the terms sadness and depression interchangeably. People will say, for example, that they feel so depressed that summer vacation is ending or they feel so depressed that their car broke down. In medicine, when we use the term depression, we’re referring to Major Depressive Disorder – a specific condition that is very different than regular sadness. Sadness is part of the human spectrum of normal emotion. People feel sad at certain times and it’s appropriate to feel sad and certain times. Depression, on the other hand, is a mental illness that warrants treatment in many situations.
Sadness, oddly enough, can sometimes even have a richness to it. When people are crying, for example, they feel a cathartic element, as if they’re connecting to something very deep within them. There’s even something that may (oddly enough) feel good about a good cry, about feeling sad in certain situations. There’s nothing rich about depression. Sadness can be a motivating factor for a lot of people. If they’re sad, they’re unhappy about a particular situation, it may inspire them to want to get up and do something about it. Depression is usually the exact opposite and that it saps a person’s will. It saps a person’s motivation to feel that there is nothing that can be done about a particular situation. People who feel sad (if you ask them) will usually admit that there is a chance that a year from now, regardless of what’s going on, they may feel a little bit better. But in depression, hopelessness is one of the core symptoms where people will feel that there is no chance of things ever improving and the way they feel right now is how they’re going to feel forever.
Sadness is an emotion. Depression, on the other hand, is a complete emotional shutdown. Rather than people saying that they feel sad, they’ll usually say they feel numb, detached, cold. Sadness may be a component of it, but it’s certainly not the dominant theme that comes across. People who are sad may hurt a great deal internally, but will usually continue to eat, will usually continue to shower, to take care of their basic needs. People who are depressed may stop doing all of these basic functions and in severe instances may even consider taking their own life and may begin to experience symptoms such as auditory hallucinations where they’re hearing things that other people don’t seem to hear. A patient of mine once remarked that in their mind, the opposite of depression is not happiness but alive. That depression saps them entirely of their vitality, of any sense of feeling alive.
Depression is a very common illness. Some numbers estimate that as many as 6-7% of American adults may experience a depressive episode in any given year. In my experience, it’s very rare to meet someone who has not come in contact with depression either personally, through a family member or through a friend. Depression can affect people regardless of gender, age, race, socioeconomic level – it cuts across all boundaries. There are some trends, though, that have been observed: women seem to be diagnosed with depression significantly more frequently than men. It’s not clear whether this represents an actual difference or if the diagnosis and reporting are different between men and women. Depression seems to become a little bit less frequent as people age, and there may be some regional variations between different countries and different civilizations regarding the prevalence of depression, though this is somewhat debatable.
Depression can come in many different flavors. The standard of depression – when we say major depressive disorder – is referring to a condition which is severe but remitting, meaning that people will feel depressed for a number of weeks, perhaps months, sometimes even longer at a time, but then it goes away and they may feel better for quite a while and then there’s a risk that it could dip down again for a while. But it’s a block of depressed, not depressed, depressed, not depressed, for sustained periods of time. There are other though, models of depression that are seen as well. Persistence Depressive Disorder (formerly known as Dysthymia) is more of a low grade but chronic form of depression where rather than having these blocks of yes, no, yes, no all the time – just feeling really not good but not necessarily at the same level of severity as someone who is having a major depressive disorder.
It is very important when we’re talking about depression to distinguish between what’s called unipolar depression and bipolar depression. Unipolar depression is really just a fancy word for depression – for major depressive disorder – people who either feel their normal self and then dip down for a month for a week for however long it is, and then emerge and they feel at their normal level. In bipolar depression, people will have depression (just like in unipolar, it’s pretty much indistinguishable) so they’ll dip down, feel very depressed for awhile and come out of it. But then at other times in their life, rather than just being at their regular baseline, they may have what’s called a manic or hypomanic episode where their mood actually lifts to a level that is very much out of character with their usual state of being. They may not be sleeping. They may be saying very bizarre things. They may be having bizarre ideas, acting very recklessly, and that is an entirely different condition, then, called bipolar disorder, which has the depressions and the manias co-occurring.
Depression with mixed features is another flavor of depression where rather than just feeling down and numb and hedonic without any interest, there may be a mixture of other emotions as well. For example: severe anxiety, severe irritability, or an elevated mood at times as well.
Another type of depression is one which varies from season to season. Formerly, we would refer to this as Seasonal Affective Disorder, where people, for example, in the winter months when the days get shorter would experience intense symptoms of depression. But then as the days become longer, the sun comes out again in the spring and the summer, the symptoms might remit and the treatment for that might also be a little bit different in some instances than other types of depression.
Treatmexnt-resistant depression is basically a depression that does not seem to be getting better. There is no official consensus on what constitutes treatment-resistant depression and why does this person have it and this one does not, but a general rule of thumb that a lot of professionals will use is if they’ve tried two different antidepressant trials – so if they’ve taken one medication, adequate dose, adequate time, and it didn’t help them, they tried another medication at an adequate dose and an adequate time and neither of them seemed to help the symptoms – many professionals will then consider them to be treatment-resistant. It’s significant when we label someone as treatment-resistance rather than regular depression because some of the medication and treatment options that we consider may be different between the two categories. Additionally, if someone is having depression that just doesn’t seem to be getting better based on the conventional treatments, it should prompt the professional to continue to explore and consider other potential diagnoses that may be masquerading as depression and that’s the reason why it’s not getting better with depression treatments.
Premenstrual Dysphoric Disorder is another form of depression occurring exclusively in women that can occur in about the week or so prior to the menstrual period in which a woman may experience symptoms of depression transiently. So more sadness, irritability, numbness, and that usually goes away a week or two later. The treatment model for that would be different. Sometimes depression can occur specifically around the time of childbirth, Peripartum Depression, either before childbirth or in the weeks following childbirth. And this again is a unique form of depression that has many similarities to the other types but is treated distinctly as well.
Depression can be associated with many different medical conditions: heart disease, diabetes, cancer, Parkinson’s disease, stroke – to name a few – do travel quite frequently with depression. The big question that emerges in every situation is whether or not depression increases the risk of these conditions. So for example, if someone is depressed, they may not eat as well and they may be more prone to develop heart disease or diabetes. On the other hand, we might say that maybe heart disease and diabetes in some way contribute to depression both in terms of the stress that it can put on a person and the fear for their wellbeing, the need for many medical appointments, etc., as well as perhaps on a biological level that’s not really well understood at this point. Finally, you have to consider the possibility that maybe both the associated condition and the depression are the result of some common underlying cause that manifests in both of these different ways. So there’s definitely a lot of research that remains to be done, but for the time being, we definitely see that these conditions do seem to go together with depression.
The gold standard for diagnosing depression is a clinical interview with a mental health professional – a face to face discussion where they will review with you all the symptoms that you’ve been having. They’ll review your prior history and try to put all the pieces together to come up with a diagnosis. Sometimes they may provide screening questionnaires where you check off boxes to calculate a total score, but that really should never be the substitute for an actual face to face discussion to really elucidate what their diagnosis is. There is no lab test that can definitively diagnose depression. Nor is there any imaging study that can definitively diagnose depression. That being said, doctors will often order a full lab panel of blood tests at a first visit to rule out any contributory causes. So for example, if your depression is being caused by too little thyroid hormone, it would be important to know and to check that to rule that out. Therefore at the first visit, your doctor will probably want to see what’s called a TSH – a check of the basic thyroid functioning in the blood.
Imaging studies are not used to diagnose depression, but your doctor may choose to order some imaging depending on the clinical situation. Again, to rule out other contributory causes that might be a part of the symptoms that you were experiencing.
Some patients who take medications may find that no medication is working for them or that they are extremely sensitive to side effects even at very, very low doses of the medicine. If that is the case, you might want to discuss with your doctor the possibility of genetic testing. This is a new area that is still being explored, but what we call pharmacogenetics: The way that a person’s genetic profile might affect the way they metabolize or process and medication can be significant in some individuals. While this is not usually pursued as a first line or a first step in treatment, it may be something to ask your doctor about if you are in that situation.
There are a number of very important symptoms to look out for when we’re concerned that someone may have depression. Sleep disturbances are a big one, so people will often report that they’re not sleeping well at night, specifically that they’re waking up early in the morning – what we call early morning waking. That can be a very common sign of depression. Sometimes people will sleep too much – they’ll say they can’t get out of bed even after sleeping for 14, 15 hours. When you probe a little further, you may find that they’re not even sleeping that entire time, but spending a very large amount of time in bed. Interest is another thing we look at with depression. People who used to have a variety of interests who used to love going out doing this and doing that. When they become depressed, they become what we call Anhedonic – meaning they’re not interested in anything. Nothing brings them joy. They have no desire to get out. They have no energy to get out. Guilt is another very common symptom of depression. People will often assume that it’s their fault that things beyond their control are their fault and take the blame in an unhealthy way for many, many things that are going on in and out of their lives.
Energy is another hallmark symptom. People with depression generally have a very low energy and simply getting through the day can be a big challenge for them. Concentration: people with depression will say that they read a page and it doesn’t register. They’re watching a movie and it’s going in through one ear, out the other ear. The ability to focus becomes severely impaired, and this is an important point because there are other psychiatric conditions that affect attention, which depression can masquerade as and sometimes will be misdiagnosed as an attention deficit disorder when the real root cause may be a depression. Appetite is another thing that we look at with depression, so people who are severely depressed, will usually eat a lot less than they normally do. They may lose unhealthy amounts of weight. In some instances, people may eat more than they usually do as a coping strategy, but certainly more common to find a decrease in appetite.
Psychomotor Retardation, which is a general slowing of movements of the body is sometimes seen in depression and severe cases can be what’s called Catatonia – in which a person becomes so stiff, so rigid, literally like he or she can’t move. Suicidality is perhaps one of the most dreaded symptoms of depression, in which a person may even begin to have thoughts of wanting to end the his or her own life. Other things that we’ve often find in depression include isolation, so people will cut off contact with those who they are closest with and have no desire to connect to other people. Sometimes people will experience somatic symptoms, meaning they’ll have stomach aches, they’ll have backaches, they’ll have unexplained pain. Interestingly, this is one of the ways that depression sometimes comes to medical attention – is people having these other symptoms that are perhaps a result of their depression.
Suicide is one of the most feared complications of depression and it unfortunately is more common in people who struggle with depression than in the general population. Some estimates say it may be up to 27 times more common in people with depression as opposed to the general population. While there is no way for any mental health professional to know whether any given individual will commit suicide, there are certain risk factors that can increase or decrease the likelihood and that a mental health professional will look at in trying to help stratify the risk of an individual towards suicide. Some of the risk factors that we think about are prior attempts of suicide being a high risk factor, male gender, hopelessness, and access to firearms can all increase (among other things) the risk of a person’s likelihood of committing suicide. Ways to decrease the risk would include obviously treating the depression, removing access to dangerous items like firearms or pills in the appropriate situation. Frequent mental health follow up with a professional and trying to mobilize as much support as possible in the person’s life.
In all honesty, modern science doesn’t really know what causes depression. Some people will tell you that it is due to a deficiency in the neurotransmitter (a fancy word for a chemical in the brain called Serotonin.) While Serotonin does seem to play an important role in the regulation of mood, to say that depression is just the result of too little Serotonin is probably a gross simplification. While we don’t really know what causes depression, we do know a number of things that seem to contribute to the risk of developing depression and probably all together are impacting the development of depression in a person. Here we have to think of a few different common causes. One is biological causes. Genetics, for example, can increase the risk of depression in some individuals, so if a person’s family member who has depression, they may be at risk for depression themselves. Certainly not a guarantee that they’re going to develop it and not even necessarily likely that they’re going to develop it, but their risk may be a little bit higher than the rest of the population. Certain medical conditions seem to affect depression. Things like heart disease, diabetes, Parkinson’s, stroke – all seem to travel together with depression and some of them may be involved in causing depression.
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