Professional Treatment of Depression

   Up to this point, much of the material presented has been concerned with so-called self-help: what you can do to help yourself recover from depression. In this chapter, we turn our attention to the professional treatment required by the more serious depressions.

   Eighty percent of people with serious depressions can be treated successfully. The sooner the treatment is started, the greater is the likelihood of a successful outcome. Even the most severe forms of depression can respond rapidly to treatment. In fact, it is often the case that the more serious the depression, the more readily it responds to treatment.

   Most treatments for depression are conducted in combinations; medication complements counseling or therapy. Such combined methods are often more effective than any one method by itself, but that depends on the nature of the depression. If you suffer from recurring episodes or from mania, you may need to stay on medication all the time in order to prevent or alleviate further occurrences.

WHAT ARE THE MAJOR TYPES OF TREATMENT FOR DEPRESSION?

   They can be classified into three groups. The first and most important is psychotherapy or counseling. The difference between them is one of intensity and intent. Psychotherapy is focused on significant personality change, whereas counseling provides guidance and insight in dealing with normal problems. Both use another person with whom we can discuss our feelings and explore what's going on in our lives.

   Professionals who work with this treatment include clinical psychologists, psychiatrists, pastoral counselors, and marriage and family counselors. The psychotherapy skills of the clinical psychologist or psychiatrist are focused on the treatment of the more severe forms of depression. They often collaborate to combine psychotherapy with the use of medication.

   Psychotherapy is used by itself in the treatment of reactive depressions and combined with other types of treatment in helping the neurotically depressed sufferer.

   A second major category of treatment is medication, specifically, the use of antidepressant medication for the treatment of endogenous depressions — those that result from some medical, physiological, or biochemical disturbance. Such treatment is given primarily by a psychiatrist, often in consultation with a clinical psychologist. In recent years, many other medications have also come to be used in endogenous depressions, so this has become a complex field requiring a high degree of specialization.

   A third category of treatment, probably the most severe, is the use of electroconvulsive therapy (ECT). It is, unfortunately, grossly misunderstood. It involves giving the brain an electrical impulse that causes a mild seizure while the patient is anesthetized. The procedure is repeated a number of times. ECT is remarkably effective in treating certain severe depressions, especially in the elderly. It is most effective with the endogenous forms of depression.

WHAT IS THE ROLE OF PSYCHOTHERAPY IN TREATING DEPRESSION?

   Psychotherapy is a most important technique for treating depression. It's the primary, and often sole, treatment in the reactive or psychological depressions, and it may be used together with the other treatments (medication and ECT) in working on the endogenous depressions.

   Psychotherapy is an interaction between people that provides help through someone listening and providing understanding. The process of psychotherapy also helps us to interpret what's going on in our lives and develop insight into what our losses are and how to grieve them.

   I would not restrict this therapy to what goes on in the formal, professional

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sense between a psychologist and a client. Therapy goes on in all healthy relationships. Your spouse and friends can be very helpful in providing understanding. In Christian communities, the whole notion of fellowship the bearing of one another's burdens and of being there to help, listen, and understand is what psychotherapy is all about. It just so happens that professional psychotherapists are trained to provide such help more effectively and efficiently.

IS THERE A RELATIONSHIP BETWEEN THE DURATION AND THE INTENSITY OF A DEPRESSION?

   Sometimes. Quite often, the more serious endogenous depressions come on rapidly. In a matter of a few days, people can find themselves in a very deep depression. But the deeper the depression, the longer it's likely to last. Reactive depressions, likewise, will be deeper when the loss is greater. Again, the key to when professional help is needed is when things seem to be getting out of control and the depression is interfering with normal duties.

WOULD YOU RECOMMEND THAT A CHRISTIAN CHOOSE ONLY A CHRISTIAN PSYCHOTHERAPIST?

   Yes, where possible. That doesn't mean a psychotherapist has to be a Christian to be helpful any more than a surgeon has to be a Christian to operate successfully. Nor does it mean that a Christian psychotherapist is necessarily more competent. But psychotherapy does get into some intimate details that often require a client to change or modify values. A secular therapist could, therefore, be hazardous.

   As a Christian psychotherapist, I recognize that one of the most important aspects of Christian psychotherapy is the application of God's resources that are available to us. It's important, then, that we see someone who understands the nature of our beliefs and our commitment to the power of God in our lives. Any Christian seeing a non-Christian therapist who frequently challenges or threatens his faith should end the relationship immediately. Christian psychotherapy is now an accepted and available form of treatment.

ARE THERE DANGERS IN A FRIEND OR SPOUSE'S ACTING AS A PSYCHOTHERAPIST?

   There are limitations to the help a nonprofessional person can provide. Untrained people should never try to be psychotherapists. For one thing, they don't always understand the finer points of what is going on in the relationship.

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They're not trained to understand how certain psychological functions interact or how defenses of various sorts operate. People who have a little knowledge of psychology are perhaps the most dangerous. It's like knowing a little about surgery and so trying to cut and stitch. Once you open up a problem, you may find it far more difficult to contain than you expected.

   Another limitation of friends and spouses is the intimacy of the day-to-day relationship with them. Often they can't be as honest or transparent as is needed. Alternatively, they may be too hurtful. Depressed people need help from someone who is not involved in their daily lives, someone who can be impartial. For these reasons, unless the problem is relatively minor, it's often better to go to a professional.

WHAT CAN A PROFESSIONAL COUNSELOR DO FOR US THAT WE CAN'T DO FOR OURSELVES?

   A professional counselor provides understanding gained from experience in dealing with depressed persons and from the study of the technical aspects of depression. Also, the professional counselor is trained to provide and communicate a unique type of understanding to the individual. We might call this a "detached involvement" in the client's problem. Such detachment is necessary to avoid too much sympathy.

   As I've said, people who are close to us are biased and can't always put things in proper perspective. They're probably part of the problem. So the professional provides expertise and a unique type of understanding.

WHOM SHOULD WE SEEK COUNSEL FROM, A PASTOR, PSYCHIATRIST, OR PSYCHOLOGIST?

   That depends on the nature of our depression, the availability of professional counselors, and the skills of those people. Pastors who are well trained as counselors can provide effective help for minor depressions and referrals to other professionals. Many pastors are not trained to counsel, however. They will know when they've reached the limits of their capabilities in specific situations and will then refer people to more-specialized help. Either a psychologist or a psychiatrist can provide the necessary help for the more severe depressions.

   Where medication is necessary, it may be preferable to go directly to a psychiatrist. But clinical psychologists are trained to collaborate with psychiatrists

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and will call for a consultation if medication is needed. Again, the choice is often determined by the availability of a particular specialist in one's community.

SHOULD WE GO TO A MEDICAL DOCTOR IF WE'RE FEELING DEPRESSED?

   If we have a good relationship with a medical doctor, that may be a good place to begin. With knowledge of our background and understanding of our physical condition, he or she would be a good judge of whom we should see next. It should be noted that if a psychologist or psychiatrist feels there is some physical problem in our depression, our doctors should be informed.

DO SOME COUNSELORS SPECIALIZE IN DEPRESSION?

   Not really, although some counselors are better at working with depressed people than others. It takes a particular type of understanding and a lot of experience with depression to be good at it. It's possible to be in practice and not see many depressed people or be effective in treating depression. Without that experience, it's difficult to develop the special type of understanding needed.

HOW DOES A DEPRESSED PERSON DETERMINE IF A COUNSELOR IS PROVIDING EFFECTIVE TREATMENT?

   It's quite possible that because of the depressed person's bleak outlook, he or she will not be able to judge the counselor's effectiveness. What's important is that the person feel comfortable and trust the therapist. That's critical in the therapeutic relationship. If the person feels uncomfortable, that should be addressed directly to the counselor.

WHERE CAN A PERSON RECEIVE FINANCIAL ASSISTANCE FOR PROFESSIONAL COUNSELING?

   The first place is through your health insurance policy. Most medical aid plans now provide assistance for psychological problems, if only for a limited number of sessions. Ask your agent about specific coverage of psychotherapy for depression. In most communities, counseling services are available that charge on a sliding scale related to income. The fees in such cases may be nominal, although few will provide free service.

   Interestingly, free service is often not very beneficial, because there's an absence of commitment to the therapeutic process. If a fee is charged, even

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though it's small, it involves the client to a much greater degree, and the benefit is therefore much greater.

   Some churches provide free counseling services to members, so that's an option to explore with your pastor.

IS THERE A DANGER THAT ONE MIGHT SEEK COUNSEL FROM A PASTOR JUST TO AVOID THE COST?

   Yes, pastors often get called just because they don't charge for their services. And because their counseling is free, it's tempting to continue going to them longer than we should. Also, some pastors either don't realize or won't admit the limitations of their training in dealing with severe depressions. That could also prolong a depression. Be aware, too, of the tremendous demands on a pastor's time, and be sensitive to his or her need to help many other people as well. If you can pay for the help, employ a professional counselor.

HOW DO I FIND A CHRISTIAN COUNSELOR IN SMALLER OR RURAL COMMUNITIES?

   That may be a problem, since counselors don't usually list themselves in the Yellow Pages as being "Christian" (although some do). The obvious first step is to consult your pastor. If he or she doesn't have information, contact a referral agency. Here at the Fuller Graduate School of Psychology, we keep a referral listing, as do the Rosemead Graduate School of Psychology at Biola University and Focus on the Family.

HOW SUCCESSFUL IS MEDICATION IN THE TREATMENT OF DEPRESSION?

   Medication is not very helpful in treating the ordinary reactive depressions most of us experience. Its primary use is with the endogenous depressions. The exception would be the occasional use of medication to restore the body's chemical balance after it has been disrupted by a lengthy depression, such as may occur in bereavement. As I have pointed out before, although reactive depression

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has a psychological cause, it affects the physical system as well. After a long depression, that balance needs to be restored before relief is realized.

   Medication is used mostly in the more severe forms of depression, particularly those that have some sort of physical basis. Medicines have revolutionized the treatment of those types of depression.

   In treating the very severe, life-threatening forms of depression, medication is essential. It has reduced the need for ECT (electro-convulsive therapy) to the point where the latter is now used infrequently, and it has provided relief from depressive moods for many people.

   I spoke recently to a minister friend who has been taking antidepressant medication for more than 12 years for an endogenous depression. He contrasted the first part of his ministry with the second, saying the difference was like that between night and day. For many years after he first became a minister, his mood was constantly depressed. Life was a great burden. After he started taking an antidepressant, his whole attitude changed. He now enjoys the ministry and is much more effective in his work. His body no longer sabotages his mood, and he feels relatively free from the depressions that used to plague him.

   Medication may sometimes be used in reactive or psychological depressions that are of long standing, where the body's chemical balance may have been disturbed. The medication helps to give the body a "jump start." However, in long-standing neurotic depressions, antidepressant medication is of little value. The reason is simple: such depressions are not true depressions but problems in living.

WHAT SORTS OF MEDICATION ARE PRESCRIBED?

   There are basically two types of medication, tricyclic antidepressants and mono-amine-oxidase inhibitors (known as MAOI's). The tricyclics are given under a variety of trade names and are the most common form of antidepressant. They are frequently used in combination with with a tranquilizer to control both anxiety and depression, particularly in agitated depressions.

   The second major type of medication, the MAOI's is used less frequently and normally only after a tricyclic has proved to be ineffective. Because of significant side effects, MAOI's are usually given in a hospital setting, where the individual can be watched carefully. Strict dietary restrictions must be in force. More and more, however, MAOI's are now being used on an outpatient basis with great effectiveness.

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WHAT TYPES OF SIDE EFFECTS OCCUR WITH THESE MEDICATIONS?

   Some of the general side effects are dry mouth, dizziness, insomnia, and constipation. Only the dry mouth is of real significance, and that often goes away in a week. A number of side effects are unique to different individuals, and even those will occur with varying intensity. If a person can't tolerate the side effects, all that's usually needed is to cut back to a lower dose of the medication, and the body rapidly adjusts to that level. When the side effects disappear, the person can return to the prescribed level.

   The side effects are most intense during the first few weeks. The antidepressant drugs, unlike many others, take time before they take effect (up to three weeks). This is good in that it prevents a person from becoming dependent on them. Addictions are not a problem. The most important point to remember is that the benefit lies beyond the side effects. Those needing these drugs should not be put off by the side effects and give up too soon.

WHAT VARIABLES CONTRIBUTE TO THE SEVERITY OF THE SIDE EFFECTS?

   The key variable is the individual's sensitivity to drugs. People differ in their sensitivity. Some can stand large amounts of a particular medication in their bodies and not notice it at all. Others can hardly bear to take an aspirin.

   Another general variable is the degree to which one is involved with life. Someone who is hospitalized for two to three weeks while starting on a medication, for example, tends not to notice the side effects as much as one who is under stress and continuing a normal life's routine.

HOW SOON CAN RESULTS BE EXPECTED?

   There is a slow buildup with the antidepressants. Significant improvement should not be expected sooner than three weeks after the medication is started. For some, it may be a bit longer than that. By the same token, people should never just stop taking antidepressants suddenly. They should be phased out slowly over a period of three weeks or so.

   It's often necessary to try several antidepressants before the right one is found; the biochemical disturbance can take many forms, and a different medication is used to treat each one.

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IS THERE A TEMPTATION TO OPT FOR MEDICATION OVER PSYCHOTHERAPY AS A QUICK CURE FOR DEPRESSION?

   Sometimes there is, but in the case of reactive or psychological depressions, the idea of a quick cure is ill-founded. Medication is of little value in treating them. Sometimes medicine is prescribed to help a person sleep, but since there is no actual physical defect in those depressions, medication can't change anything.

HOW SUCCESSFUL IS ELECTRO-CONVULSIVE THERAPY?

   A large percentage of endogenous depressions, including the severe psychotic depressions, respond well to ECT. It brings rapid improvement and is therefore justified when the person is a high suicide risk. Unfortunately, many people avoid this type of treatment because of misconceptions about its use.

WHY IS ECT SUCH A CONTROVERSIAL PROCEDURE?

   Fear and misunderstanding are the basis of the controversy. The thought of someone taking control over us, of having a convulsion, is very fear-provoking for many people.

   Much of the fear is based on misunderstanding. People don't know exactly what goes on, so they expect the worst, even though ECT is less destructive to the body than having a tooth removed.

   In times past, ECT was used on a wide variety of people in mental institutions, sometimes without proper permission and inappropriately. That has left some people with a lingering suspicion based on horror stories they've heard. The media have not been particularly helpful in this regard, tending to perpetuate misconceptions about ECT.

WHAT VARIABLES CONTROL THE EFFECTIVENESS OF ECT?

   Several factors help determine the effectiveness of ECT. The severity of the depression is an important variable. The more severe the depression, the more effective is ECT. Also, longstanding depressions tend not to respond to ECT. Age is another important factor. The younger the person, the more effective is the ECT; the older the person, the greater the risk. Often ECT cannot be used on an older person because of hardening of the arteries and the risk of stroke.

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ARE THERE INDIVIDUAL DIFFERENCES IN RESPONSES TO ECT?

   We're not sure whether differences in response to ECT are due to individual factors or to differences in the type of depression. It's probably a combination of both, but at this point we can't distinguish between them.

DOES ECT DAMAGE THE BRAIN IN ANY WAY?

   There is no evidence that ECT causes any brain damage in healthy people beyond that which occurs normally. Brain cells are dying in all of us every day, and that decay accelerates after about age 30. I must also point out that many people experience unrecognized seizures regularly daily or even several times a day. Those seizures are much greater than could be induced by any ECT damage. The risk of damage by ECT is negligible when the patient is properly screened and the ECT is administered competently. Fear prevents many people from seeking a very effective treatment for depression.

ARE THERE ANY SIDE EFFECTS TO ECT?

   The side effects are minimal, because the treatment is given under an anesthetic and with a muscle relaxant. There's usually a bit of confusion and vagueness immediately after the treatment, but that passes quickly. There is sometimes some memory loss for recent events, but that also lasts only a short time, perhaps the rest of the day. Most people can have ECT on an outpatient basis and go home within a few hours. I should mention, too, that today there are variations in the way ECT is done. It may be necessary to convulse the whole brain, but in many cases only half the brain is convulsed. That reduces memory loss. The ideal is to do as little convulsing as is appropriate for the depression.

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