Assessing the Need for Medication

A reader recently wrote to ask about medications: when is medication indicated for a depression or anxiety? Do you need psychotherapy and medication? What differentiates depression and anxiety from “stress”? Depression is a widely used term to identify a particular set of mood states—the feeling of being “down” or “low”. Most of use experience depression at some point in our lives. Many of us may feel depressed in response to a particular situation: loss of a job, family stress, conflict in a marriage. Situational depressions are common and often get better when the situation changes or improves. However, depression becomes more serious when it starts to significantly impact a person’s ability to function in the world and persists over a period of time.

Many symptoms characterize depression, and they persist over a period of time:

• Persistent feelings of sadness or emptiness • Diminished interest or pleasure in most activities • Low self-esteem • Significant weight loss when not dieting, or • Significant weight gain • Insomnia, or hypersomnia (too much sleep) • Agitation and irritability • Daily fatigue or loss of energy • Feelings of worthlessness or inappropriate guilt • Diminished ability to think or concentrate • Indecisiveness • Feelings of hopelessness • Recurrent thoughts of death (suicidality) • Impairment in social functioning: withdrawal and/or isolation • Impairment in vocational functioning: inability to work --from the Diagnostic and Statistical Manual (4th edition, revised)

We know that depression has a chemistry and neurology. In depression, the brain’s chemistry is altered, resulting in changes in mood and thinking. Medications work because they restore “balance” among the neurotransmitters in the brain.

There are a number of different types of depression, and therapists and other clinicians are careful to assess symptoms, the length of time symptoms are present, circumstances surrounding the onset of symptoms, stressors and life situations that impact mood, family history of mood disorders, and medical conditions that might impact mood. In addition, there are several standardized assessment protocols (e.g., the Beck Depression Inventory; the Hamilton Rating Scale for Depression) that help clinicians evaluate the severity of the depression—which might also indicate that medication is needed.

As a therapist, evaluation of mood is something I routinely do every time I see a client. Further, I always explore changes in mood and note when they persist. I am alert to depressive patterns of thinking; these patterns and the thoughts themselves are focal points for discussion. Several factors typically indicate the need for a medication: persistent changes in appetite, sleep, and libido; persistent feelings of worthlessness and guilt; significant cognitive changes that bother the client –i.e., difficulty with concentration; and, most significantly, thoughts of suicide or death. (When these last symptoms occur, I immediately evaluate for safety and am not hesitant to recommend or arrange for a hospitalization.)

I’ve found that medication is a helpful adjunct to psychotherapy. Since I am not licensed to prescribe medication, I typically refer clients to a psychiatrist or psychopharmacologist for a medication evaluation. (I rarely recommend that clients ask for psychotropic medications from internists or general practitioners; physicians who do not specialize in psychiatry often do not conduct full evaluations and often are not well-informed about psychotropics; consequently, they do not properly medicate clients. However, it is important that you tell your doctor you are taking an anti-depressant or anti-anxiety medication!)

I also believe that psychotherapy is critical to the treatment of depression. There is no magic pill. A prescription may alleviate some of the symptoms but will not address the psychological factors—i.e., low self-esteem, distorted thoughts and beliefs—that are part and parcel of depression. Psychotherapy will address those issues. In addition, certain psychotherapies help build coping skills or strengthen the coping mechanisms that are already in place but may have become eroded by depression. Together, medication (when it is indicated) and psychotherapy have been shown to be effective means of helping people with depression.

I will address anxiety in another posting…

Finding Power in Powerlessness

“I feel powerless.” I hear statements like this often. Any experience of trauma or loss—loss of job, intimacy, relationship, health—can evoke feelings of powerlessness. Similarly, the sense of being trapped in an unsatisfying career or unsatisfying relationship, being the parent to a “rebellious” child, an unwanted medical diagnosis can stir up powerlessness. Powerlessness is often a symptom of depression; powerlessness also induces anxiety.

Indeed, the experience of helplessness and powerlessness is one that most of us avoid at all costs. It is a deeply disorienting and disturbing experience. Depressive symptoms arise: tunnel vision, narrowing of interests and activities, lowered self-esteem, lowered energy. The experience of powerlessness also evokes strong feelings of shame, and shame can engender identification with the powerlessness and reinforces negative beliefs about self-efficacy: “I AM powerless; I AM incompetent; I AM inadequate.” The experience of powerlessness can become paralyzing and traumatic.

Powerlessness is often a response to factors that appear to be—and sometimes are—outside our control. And too often, the experience of powerlessness produces a regression where power is completely given over to external forces.

Emotional reasoning is one of the hallmarks of that regression. We typically tell ourselves stories about powerlessness, and the stories often reflect our misperceptions and dysfunctional beliefs about ourselves and where our power lies. And often the stories we tell about our present circumstances resonate with older stories of powerlessness that originate in early family experiences. Often, that early childhood story is repeated throughout adulthood, with variations that reflect the current situation.

Herein lays one of the keys to moving out of powerlessness: focusing on the facts of the here-and-now situation. This means detaching from the feelings and looking at the facts of the situation—including an acknowledgment of the real, fact-based limitations of self-efficacy. It means changing one’s relationship to the situation. It often means widening one’s focus to see the larger picture and one’s place in it—which may also mean asking for help in order to see the situation a bit more objectively. It means letting go of, and even changing, the story. It sometimes means taking risks and making decisions that take us out of our comfort zone. It means living with uncertainty. Paradoxically, there is power in ambiguity: the power to make new, different decisions.

Moving out of powerlessness takes time because meaningful change toward empowerment is a complex, multi-layered process. Therapy is about empowering people make decisions that alleviate anxiety and depression, and create freedom; therapy is about helping people create and own power. Engaging in a fact-based examination of the circumstances, engaging in some short-term problem-solving, exploring patterns of thinking and feelings, exploring the beliefs that fuel the feelings and thoughts of powerlessness, exploring the meaning of power and powerlessness, and experimenting with new thoughts and activities can help. Of course, looking at the roots of shame and powerlessness is also critical to long-lasting, meaningful change.

The work continues…