Should you hire an Antidepressant?

Although the question of whether we are becoming a more depressed society or are simply getting better at identifying and acknowledging depression is open for debate, what’s clear is that the rate of prescription of antidepressant medications has dramatically increased since their introduction into the market place some 60 years ago. Today, there are over 30 types of antidepressant formulations available, and they have become the most commonly prescribed class of medications, outdistancing the second most commonly prescribed (blood pressure medications) by 5 million prescriptions per year (US figures for 2008).

In my counselling practice it’s not uncommon to hear clients say they were offered a prescription for an antidepressant by their family doctor or walk-in clinic physician, often after only a brief discussion of their symptoms and concerns. So if antidepressants are more available in general, and can or have been made available to you specifically, what do you need to know to determine if they are the right approach for you?

It’s a multi-faceted question, but to help start to answer it, I often ask clients to use the analogy of hiring an antidepressant, the way they would consider hiring an employee. That means working through several steps:

     1. Getting clear on the job you’d like the antidepressant to do. What are the symptoms of depression you’d like it to relieve? For example, “I’d like to sleep better, I’d like to get through the day without crying every 5 minutes, I’d like to have some energy and not feel like everything was a chore” are all good job descriptors for an antidepressant. “I’d like my partner/parents/children to be less annoying” is not.

     2. Giving the antidepressant a fair trial at the job. This means taking the medication at the dosage prescribed, and for the duration (typically 6 to 8 weeks) necessary to assess its effectiveness. It also means not mixing antidepressants with other medications or excessive amounts of alcohol, or with other mind or mood altering drugs.

     3. At the end of the trial period, evaluating the antidepressant’s performance. That is, assessing how well it did the job you hired it to do, and also determining its cost to you (both the financial cost, and any cost paid out in side effects).

You can – and I would suggest, should – research an antidepressant’s ‘qualifications’ by reading about its track record of effectiveness and its history of results and side effects, but that’s not sufficient information to know whether it works for you. Ultimately, you yourself are the best resource to determine whether something is helping or not, and that’s a power (and responsibility) you don’t want to outsource.

Do You Need Help?

Although you might enjoy therapy – who wouldn’t like having someone’s undivided attention and a space to talk about whatever they wanted without the need for filtering or reciprocation – do you need therapy? Deciding the answer to that question is an inside job, but if you were asking me if I thought you needed therapy, I would want to know a couple of things about you: the nature of the issues you have experienced or are experiencing, and the quality of support you currently have available in your life.

Ultimately, that’s one of the things a therapeutic relationship offers, high quality support to stand with you as you process the issues in your past or present, someone who can help you gain a different perspective, a new direction, or just some peace and resolution.

If you’re trying to determine whether therapy might be right for you, writer and psychotherapist Martha Beck has devised a list of questions to ask yourself. While the list is not exhaustive, I think it is a good starting point:

  1. Is there anyone who knows and cares about all or almost all the significant events of your life?
  2. Do you feel as though you’re living life behind an invisible screen, unable to truly connect with anyone or anything?
  3. Is there at least one person you talk to at least once a week who really understands all or almost all your feelings?
  4. Is there anything you feel you can’t or mustn’t tell anyone?
  5. Do you feel comfortable crying in front of the person or people you love most?
  6. Have you recently suffered any kind of serious emotional wound, such as the loss of a job or a loved one?
  7. Have you benefited from therapy in the past and recently felt wistful about it, missing that kind of reliable support?
  8. Do you have unexpected negative emotional reactions to others’ behavior toward you, such as feeling shame when you are praised or anxiety when you are loved?
  9. Are you able to freely express love to your family and friends?
  10. Does your fear of others’ disapproval dominate your choices?
  11. Are you lonely even if—or especially when—you’re with a group of people?
  12. Do you have to be under the influence of alcohol or drugs in order to be open about your thoughts and emotions?

Finer than Fine

A few years ago, when I was working in a Drug and Alcohol Counselling Agency, a client gave me a curious look when she asked how I was doing and I responded “Fine.” She told me in her recovery group she’d learned that fine stood for F***ed Inside, Nice Exterior. Since that day I’ve tried to take that word out of my feelings vocabulary, and hear it a little differently when someone tells me they’re doing “Fine.”

Alexithymia, which literally translates to “without words for feelings,” is a psychological term that’s garnered a fair bit of interest. While there are people – mostly male people according to the research – who may be diagnosable alexithymics, most of us are fewlexithymics. Don’t bother googling, I just made it up; it means using the same narrow range of words to describe our feeling states. So when someone asks us how we’re feeling, we don’t say “effervescent” or “melancholy,” we say “fine” (or “crappy,” as the case may be).

And what’s wrong with that? Well some may argue that putting words to a feeling is an integral part of fully experiencing that feeling (hence the interest in studying alexithymia). And even if there’s nothing lost in not being able to colourfully describe our feeling states, surely there’s something to be gained in finding the word or phrase that aptly captures both the quality and the intensity of what it is we’re experiencing. After all, expressing our feelings is an exercise in connection, first connecting with ourselves (so that we even know what the answer to ‘how am I feeling?’ is) and secondly connecting to another by giving them a glimpse of our internal landscape in that moment. “Fine” gives a broad and unfocused view while “anguished” or “thankful and inspired” or “uncertain and confused” offer a richer and more precise picture.

Should you be Committed?

I was recently talking with a friend, laughing hysterically at her description of a post-surgery re-introduction to using the bathroom (I’m sure it was funnier in the telling than the experience). Besides voicing a heightened appreciation for things we typically take for granted, my friend ended the story with “I wonder if my husband knew when he was saying ‘in sickness and in health, for better or for worse’ that this is what it would someday come to.”

Some commitments – like pledging to join our lives to a partner’s in marriage – we make with a lot of forethought (ideally), and an air of ceremony that lends weight to the fact that a commitment has been made.

Others – like pledging never to drink again after waking up with a head that makes us long for the release that death would bring – have a shorter shelf life. That’s because it isn’t forethought and a careful weighing of the pros and cons that inspires these latter commitments, they are instead driven by whatever motivation is available in the present moment.

The key difference between motivation and commitment is that one is dynamic and subject to change when conditions change, while the other is a statement of – well, commitment, regardless of conditions. Motivation says: “I want to, I need to, I’ll try, I really should…” Commitment says: “I will.”

This is a discussion that comes up a lot as I work with people who are struggling to let go of addictive attachments in their lives. Before getting to the place where there’s no desire to use food or sex or alcohol (or whatever else) to buffer feelings, there are inevitably times when we feel like acting out (or merely numbing out), and are faced with making the choice to stick to our commitment not to.

So what and whom are you committed to? In good times and in bad, when it’s easy and when it’s hard, when you’re motivated and when you’re not.

What I learned from Reality TV (this week)

I’m a little obsessed with watching the Discovery’s Channel’s Naked and Afraid. Truth be told, I find the purported ‘reality’ in a lot of reality TV pretty fascinating (from a purely psychological perspective of course, I’m not wasting precious hours of my life, I’m doing research!)

For the uninitiated, the premise of Naked and Afraid is to take a man and a woman who are self-described “survivalists” in their normal lives and drop them (naked) in some remote and awe-inspiringly dangerous part of the world, where they do their best to survive the elements and each other for 21 days.

For me at least, the show supplies unending grist for the psychological mill, but here are three of the things that have stood out most:

  1. Shoes are truly the unsung heroes of attire, and much more of a necessity (versus a nice-to-have) than I ever appreciated.
  2. The line we draw between food/not-food is arbitrary and highly context-specific. In my day-to-day life, a severed and partially decomposed bird’s head found of the beach would be solidly in the not-food camp. This show makes the case that 18 days without a solid meal would have one reconsidering that.
  3. It takes a lot of work to make and maintain a fire.

For the Naked and Afraid contestants, fire is fundamental to survival, and they accordingly approach it with a high degree of reverence and care. Today fire (and everything that comes with it) is something most of us take for granted, but the many references to fire that show up in our language speak to its primacy in our ancestral legacy. We ‘light a fire under’ things (or people) to get them going, we question whether or not there’s a ‘spark’ when we meet a potential partner, we say ‘the flame’s gone out’ when passion has taken its leave, we hope for an idea to ‘catch fire’ or watch it go ‘up in smoke.’

Many of the clients I work with come to therapy in part because they’re trying to light or re-ignite a fire. Some have found that depression has dampened all their tinder so that even generating a spark seems unlikely, some are trying to keep the winds of self-doubt from extinguishing intention before it has a chance to catch, and others are poking at the dying embers of a love relationship, wondering if they can be coaxed back to life.

What I’ve learned from the Naked and Afraid contestants is that lighting a fire takes focus and patience, and that timing is everything; the same gust of wind that would encourage a going fire snuffs out the kindling’s flame. I’ve also learned that lighting the fire is only half the battle. Once you have your fire lit (or your project started, or your lover back), you need to keep tending and adding fuel to the fire, all the while keeping an eye out for any rainstorms brewing in the distance.