In general, therapists are taught that depression has a good chance to respond to medication when it is feels like a physical illness. In other words, if a person is tired and exhausted, feeling physically sick with symptoms such as weight changes, loss of appetite, loss of libido and ongoing insomnia, there may be benefit. There is difficulty in concentration, no stamina, and everything feels flat. Other symptoms indicating potential appropriate use of antidepressant medication are feelings of intense sadness and/or loss of interest in what used to interest them.
According to the guidelines, the depression should last at least two weeks, not just a few days, before anti-depressants should be considered.
Unfortunately, antidepressants are often given as a first response to depression – without considering whether a patient’s circumstances might reasonably invite the emotion we also label depression. For example, I had a patient in her forties who came to be depressed for years. She was deeply conflicted between trying to be a “good daughter” and her unwillingness to face her abusive father.
This conflict was exacerbated each year as she was expected to attend every Christmas family dinner. She feared missing the change to see her ailing mother, but dreaded the next Christmas party. Understandably, she was unable to effectively communicate this to her father. Whenever she tried to confront her verbally and sexually abusive father, he just laughed it off, saying that she was too uptight and had no sense of humor.
Would antidepressant help to alleviate those circumstances? At best, it might allow her to see her mother at the dangerous cost of being abused by her father. That re-traumatization likelihood is not an acceptable trade-off and would not fundamentally change the dynamic that was causing the depression. Using an antidepressant in those circumstances is not mental health treatment. Rather, it is the expression of the mental health system dynamic of treating symptoms solely with chemicals. That expression would fundamentally be equivalent to participating with abusers in a known emotionally and potentially physically violent event.
The question is what do you do with a creep like that as your father?
This patient finally decided to sacrifice her chance of seeing her mother. She chose to escape to live in another part of the country.
I had another patient, a single mother of two, who made arrangements to drive over 900 kilometers to see me about her “depression.” Before I saw the patient, it was clear that this was not a patient for whom I would blindly prescribe high doses of antidepressant. Why? People who are diagnosed as having Major Depression per the DSM-V are not able to plan and organize such a long and complicated trip. She had to drive hundreds of kilometers to a far away city and to make arrangements to stay there for a few days with only limited financial resources – all while pressured by the uncertainty of meeting a new psychiatrist.
The first thing I needed to do was to listen to her. Why? Because the first thing she needed from me was to be listened to. Incredibly, for many years the only treatment she received was heavy doses of antidepressants. No treating therapist had made any note on her chart that her husband was physically abusive, that her own family was against divorce, and that her fellow church members and her pastor could offer her prayers but not support in divorcing her abuser. All she could do to express her emotions was to cut herself. By the time she came to see me, her children were already taken away for adoption – with the support of her family – because of her repeated hospitalization for “depression.”
Her depression was not Major Depression per the DSM-V. But by ignoring her circumstances, her relentless self mutilation was seen as an expression of “depression” and therefore was mistakenly treated with anti-depressants. To me, that self mutilation is more anger than depression. My thought was the depression was not inappropriate at all under the circumstances. Her primary goal was to resolve this difficult relationship and get back her children. She also was suffering from undiagnosed DID.
This was clarified even further by the fact that she did not talk with me about her depression. Instead, she spoke about her life-long history of being abused and traumatized. There was zero support from her family of origin, or from her close-knit Church, to acknowledge her abuse history of the past or for leaving her abusive husband in the present. (See Chapter 5, Ruth, in Volume 1 of Engaging Multiple Personalities.)
This example from my practice where, as I mentioned before, a patient’s level of depression does not always indicated by how many times they commit self-harm. The patient mentioned in the last paragraph was certainly thought to be severely depressed and was hospitalized with that diagnosis multiple times since early in her life. A few months prior to coming to see me she was kept in a general hospital for 5 solid months just so that she could not continue to cut herself.
Soon after she started therapy with me, I discontinued her antidepressants. She was so motivated to heal soon after therapy began. Why? Because, for the first time, someone was listening to her circumstances. Someone was able to see her suffering in context, and healing quickly progressed. I have been in touch with her over the past several decades, and she had never needed any antidepressants since then.
Remember, doctors get wined and dined by drug company representatives in the name of continuing education. Certainly, that is how things ran for decades before my retirement from practice in Canada. With enough alcohol and food, and the vast majority of peers taking the marketing push without even a single grain of salt, anyone can be bought.
