Cecilia Ford, who has been a psychologist in private practice in New York City since 1987, has addressed emotional issues for us in many articles over the years. This week, she counsels a woman hit by a trifecta: chronic depression; the sense that her medication is no longer effective; and feeling detached from other people in a season of joy.

 

 Dear Dr. Ford:
 

Don't mean to keep listening to Bille Holiday, but...

Don’t mean to keep listening to Bille Holiday, but…

It is the holiday season again, and I am certainly not filled with cheer. I have depression and have taken medication for years that allows me to function reasonably well, but I have hit a new low this December.  I am in my late forties. I never married or had children (probably because I was too depressed to do anything but get up and go to work for most of my adult life). I don’t make friends easily, and find it hard to be around all these cheerful people at work and church events. My sister and her family include me every year for Christmas Day, and I go out of a sense of obligation, because during my darkest times she was always there for me, but I don’t know how I can manage it this year. I see my doctor only every six months, and never had the money or time to see a therapist. I have been on a drug that has worked since I first saw the psychiatrist 20 years ago. Is it common for medication for depression to stop working? Do you have any suggestions for people like me who have depression and then get hit with the holiday blues as well?

Donna

 

Dr. Ford Responds:

 

Dear Donna:

Holidays can be stressful, but they are particularly challenging when you are depressed.
Nothing makes people who are down or lonely feel their alienation as much as the display, larger and longer each year, of how happy and joyous “the rest of us” are feeling. Mental health professionals find that for vulnerable people, the week between Christmas and New Year’s is often the worst of the year. For my patients, family holidays usher in a host of stresses and woes that begin with Rosh Hashanah in September and don’t end until Easter or Passover  (whichever comes last).

Your letter, however, is especially distressing because you are facing these stressors with the extra burden of depression. It is hard to tell if you are suffering from chronic or undertreated depression, but you are definitely not getting the treatment and attention you need. Your care is not the right kind, not enough, and is probably not being delivered by the right kind of doctor. Finally, if you are like most depressed people, you probably don’t feel as if you have the energy to address the problems I have just enumerated—as you have already said, there are obstacles of time and money holding you back from taking further steps.

The signs that you need to change course, however, are overwhelming. To begin, most well controlled studies have shown that depression is best treated by a combination of therapy and psychopharmacology (drug treatment.) According to the Harvard Medical School (and others), all forms of psychotherapy, when paired with anti-depressants, provide the most powerful combination of treatment than either alone.

Second, the idea that you would have been started on one anti-depressant many years ago and kept on that one drug all these years is very dated. Not only do anti-depressants often lose their effectiveness over time (“Prozac poop-out,” as it is sometimes called), but in recent years new drugs have been developed that may be more suitable for you. Also, many psychiatrists now use a combination approach of a few drugs at once for optimal effect. It can take weeks or months of closely supervised pharmacotherapy to find the right drug(s) for each individual. Finally, over the course of time, the drugs may need to be “tweaked” in order to make sure the patient is getting a therapeutic, i.e. effective, dose.

As you can see, this is a fairly sophisticated business and should be handled only by a physician who is trained in the field of psychiatry (or better yet, a psychiatrist with a specialty in psychopharmacology). Too often, depressed people are handed a prescription for Prozac or Zoloft by the G.P. and sent on their way. The psychiatrist should follow you closely for the first weeks and then monthly, in close consultation with your psychotherapist.

Finally, optimal treatment includes, in its ideal form, exercise, whose benefits on physical and mental health are being validated in study after study. This is something that can begin immediately, and is free (and, some studies show, is best performed outdoors). However, like all the other steps I’ve mentioned, this is something that probably feels to you like a bridge too far. I realize that in your bleak state of mind you cannot imagine taking on all the steps I’ve listed, but any one of them might help break the stalemate you’ve been in all these years.

Since you say you feel particularly grim this year, I recommend you go for a consultation with a psychiatrist first to adjust your medication, and while you are there, explore the option of psychotherapy. Despite the time and expense worries, the issue is not just the quality of your life, but your life itself, which is slipping by, and which can be literally threatened by your illness if it gets worse. The doctor may be able to help you find low-cost treatment. Also, the Affordable Care Act is ushering in true parity, for the first time, between mental and physical illness in insurance reimbursement.

If this first step is taken, you may begin to have the energy and hope to take some of the others. I can’t emphasize enough how important it is for you to take this seriously, Donna. As I have written in previous columns, untreated depression literally causes brain damage, and the longer it goes untreated, the worse it is. Please make this Christmas the one you give yourself the care you deserve.

Dr. Cecilia Ford