I was feeling pretty religious
standing on the bridge in my winter coat
looking down at the gray water:
the sharp little waves dusted with snow,
fish in their tin armor.
That’s what I like about disappointment:
the way it slows you down,
when the querulous insistent chatter of desire
goes dead calm
and the minor roadside flowers
pronounce their quiet colors,
and the red dirt of the hillside glows.
She played the flute, he played the fiddle
and the moon came up over the barn.
Then he didn’t get the job,----
or her father died before she told him
that one most important thing-----
and everything goes still.“Disappointment”
Tony Hoagland
Good Poems for Hard Times
Garrison Keiler
Viking, 2005
What is depression? What do we know of it? There are clinical descriptions that can be gleaned from the Diagnostic Statistical Manual, 4th Edition which we therapist types wrote and the insurance companies require. There are statistics that cite how widespread this condition is.
There is evidence of the devastation and human toll the condition can have when left unaddressed or minimized. There is anecdotal information that gives a human face to the condition.
Charles Darwin whose intensity of sad feelings left him embarrassed and in his own words “not able to do anything one day out of three.” He wrote, “The race is for the strong.” And “I shall probably do little more but be content to admire the strides others made in science.”
Political leaders such as Abraham Lincoln also suffered from significant episodes of depression of profound intensity and with debilitating consequences. Artists, perhaps most famously Van Gough, have “suffered for their art”. Examples such as these have caused some to wonder if there is some “good side of depression” something in the suffering that creates a necessary environment for great insight, creativity, and discovery.
We think not. Depression is a crusher and must be confronted, challenged, and defeated. It should not be taken lightly or minimized.
For the therapist… “depression becomes an intimate. It is poor company. Depression destroys families. It ruins careers. It ages patients prematurely. It attacks their memories and their general health. For us--- for me---the truth that depression is a disease is unqualified.
Depression is debilitating, progressive and relentless in its downhill course, as tough and as worthy an opponent as any doctor might choose to combat.”
-“Against Depression, Peter D. Kramer, Penguin Books 2005
Like most human aspirations, the treatment of depression begins with an idea. Most commonly, those who are willing to reach out for help from a therapist, the idea is something to the effect of “I don’t want to live like this anymore and I am willing to allow myself to HOPE for an alternative ----- I am willing to give it a try.”
As therapists, it is our job to work with this idea, with this hope, to nurture it, to respect it, and to help bring it from the theoretical to the actual. We strive to remember that it is an honor and a sacred trust to work with an individual who is struggling and sincerely working towards positive change with no assurances that it will happen.
Every year, approximately 80 percent of those diagnosed with depression have it severe enough to affect their functioning at work or home, while close to 30 percent of those diagnosed are experiencing a form of major depression which, left untreated can lead to significant and lasting suffering.
Unfortunately, fewer than 50% of those diagnosed with major depression actually seek help, according to the Centers for Disease Control (CDC).
Estimates for those diagnosed with the disease in the United States range from 17 to 21 million people a year or roughly 10 percent of the country, though World Health Organization (WHO) reports that rates can vary dramatically by region and demographics.
It must be noted that there are many different types of depression, and all depression types are not the same. The three of most common are:
For most patients, episodes of major depression last a limited amount of time. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) specifies that symptoms last at least two weeks, and treatment studies report a median duration of about 20 weeks. But for some patients, the condition becomes chronic, with symptoms lasting at least two years.
The differences between episodic and chronic depression encompass more than just duration. Studies have shown that, compared with episodic major depression, chronic depression causes more functional impairment, increases the risk of suicide, and is more likely to occur in conjunction with other psychiatric disorders. Patients with chronic depression are also more likely than patients with episodic depression to report childhood trauma and a family history of mood disorders.
Because chronic depression lasts longer and tends to be more severe than episodic depression, treatment is more intensive, and relapse is also a challenge. About half of patients with chronic depression who respond to treatment (whether with antidepressants, psychotherapy, or a combination of the two) will suffer a relapse within one to two years if they stop treatment. For that reason, some type of maintenance therapy may be necessary.
But there are also other types of depression with unique signs, symptoms, and treatment strategies.
Medications and psychotherapy, either alone or in combination, are the most common forms of depression treatment. Electroconvulsive Therapy (ECT) and Vagus Nerve Stimulation (VNS) are generally only used when other treatments have failed or when medication could seriously affect the patient's health. Your doctor can help you choose the best depression treatment for you.
Depression treatments are largely determined by the cause of the disease. Depression can be caused by many reasons. Stress or problems with family relationships, at work, grief or loss issues, and exposure to trauma can lead to the disease. Individuals can also be predisposed to depression through heredity. Depression can also develop with no apparent cause.
By definition, in an episode of major depression, symptoms occur for at least two weeks. In chronic depression, they must last at least two years. Because chronic depression tends to be more pronounced than episodic depression, treatment is more intensive.
Some studies showed promising evidence of a type of therapy designed specifically for chronic depression, known as the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), a variation of CBT developed by Dr. James P. McCullough at Virginia Commonwealth University.
The premise of CBASP is that patients with chronic depression think, behave, and communicate in ways that make traditional therapy difficult. They may be uncooperative, they tend to focus on themselves and often have difficulty controlling their emotions. In addition, they tend to view current situations either as a replay of a negative event in the past or a precursor to a similar situation in the future.
Therapy with CBASP entails exposing and challenging these perceptions and behaviors. For example, using a technique known as situational analysis, the therapist helps a patient break down a distressing event into a sequence of events, and then find junctures where the outcome might have been different had the patient changed his or her behavior or reactions.
Cognitive Behavioral Therapy (CBT) involves learning new skills to manage your symptoms. It teaches you new ways of thinking and behaving by reframing situations in more positive ways. Because patients with chronic depression may have entrenched feelings of hopelessness, however, CBT techniques tend to be more intensive than usual.
It is often suggested that therapy take place twice a week instead of once a week, and often must target behaviors or thought processes most amenable to change, increasing the chance that patients will see progress. Patients often are assigned homework to practice new skills learned in the therapy session and then learn how to apply them to their life every day.
There are a variety of additional therapy approaches that can be effective as well. How does effective therapy choose the best approach? What is the common theme? What is the prerequisite for successful amelioration or elimination of depression? The therapist must encourage the growth of rapport, trust, empathy, and curiosity, and he must develop a deep understanding and sacred appreciation for the unique and nuanced aspects of the brave person sitting in the room with him.
References:
National Institute of Mental Health -- Depression Facts
http://www.nimh.nih.gov/health/topics/depression/index.shtml
CDC Data & Statisticshttp://www.cdc.gov/Features/dsBRFSSDepressionAnxiety/
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.
McCullough JP, Jr. "Treatment for Chronic Depression Using Cognitive Behavioral Analysis System of Psychotherapy (CBASP)," Journal of Clinical Psychology (Aug. 2003): Vol. 59, No. 8, pp. 833–46.
Boston Evening Therapy Associates, Brookline, MA, Depression therapist in Brookline, Massachusetts
