Herbal Health

In depressed people the most frightening ideas do not generally come from fear of the outside world but result from turning the darkened lens of depression towards the interior and finding it to be full of self-doubt, self-criticism, guilt, recriminations about the past and grim predictions for the future. All of these thoughts are not only symptoms of depression but, according to the cognitive theory of depression, developed by Dr Aaron Beck and others, can actually propagate the depression and make it worse. Based on this theory, these researchers have developed a psychotherapeutic approach to depression called cognitive therapy, which has actually been shown to be as effective as anti-depressant medications in some studies of mild to moderate depression.

Cognitive therapists have developed a way of breaking down depressive thinking into its different components and showing how once you recognize these specific types of depressive thoughts, you can actively work to overcome them. For example, these therapists have accurately recognized the tendency of depressed people to engage in what they refer to as ‘all or none thinking’. So a depressed person may regard a project that was not a dazzling success as a total failure. Most ventures in life are not total successes or failures but some mix of the two. A positive attitude enables a person to enjoy those elements of the mix that are successful while learning from the failed elements, and then to move on to the next project. This is very hard for the depressed person, who is likely to expend valuable time and energy obsessing about, and magnifying, the failure. The depressed person has difficulty modulating responses to all sorts of stimuli.

Several other specific distortions of the depressed mind are also worth noting. One is overgeneralization. A depressed person who makes an error is quite likely to think, ‘You see, nothing I ever do succeeds.’ Cognitive therapy would seek to challenge this distortion by encouraging the depressed person to find areas in life where he or she has clearly succeeded. Overgeneralization is commonly seen following rejection. A depressed person is likely to take a single rejection as a sign that nobody will ever accept him or her. A healthier approach would be to accept that rejection is part of life and that a single rejection does not necessarily mean that others will follow. Excessive sensitivity to rejection can affect people at any age or stage of life, whether it be the child looking for a friend in the playground, the adolescent calling someone for a date, or the adult applying for a job or submitting a manuscript or proposal to a publisher or grant agency. Nobody enjoys being rejected, but we can develop ways of putting it into perspective and recognizing that further efforts might well be rewarded with acceptance. After being rejected a depressive person might avoid taking new initiatives for fear of further rejections, thereby greatly diminishing the likelihood of future success. Once again, the depressed person’s intellect can be recruited to help understand that this type of thinking is a costly distortion that can be corrected with proper guidance and systematic efforts.

One of the most painful aspects of overgeneralization is that it gets projected into the future. T will never succeed/ ‘No one will ever love me’ or T will never find happiness’ are common distortions of this type that greatly add to feelings of sadness and pessimism. Such distortions have been labelled ‘fortune-telling’ by cognitive therapists, a term that conveys the sense of assurance that a fortune-teller might offer about the future when plain sense indicates that there are too many imponderables to make such predictions with any degree of reliability. This can be pointed out by a skilful cognitive therapist repeatedly to good effect. Allied to this magical depressive tendency to fortune-telling is ‘mind-reading’, a process by which the depressed person thinks and talks as though he or she can read what is in another person’s mind. So a depressed person might say ‘She didn’t want to come on a date with me because she thinks I am too dull and nerdy/ or an unsuccessful applicant may say ‘He didn’t accept me for the job because I’m not qualified.’ The cognitive therapist will point out that other possible explanations for these outcomes abound. The girl who declined to go out on a date with you may already be committed to someone else; the prospective employer may have an inside candidate in mind for the job, and so on. Bearing in mind these alternative possible explanations empowers the rejected person, who is then more easily able to pursue other possibilities. In contrast, depressive thinking tends to paralyse the thinker, increasing his or her sense of powerlessness and reducing enthusiasm for making further efforts, which might be more successful.

In summary, it is important to recognize and address frightening thoughts, more technically known as depressive distortions.

Fortunately, treatment strategies have been developed to tackle such thoughts and these work if they are implemented diligently and systematically. For those interested in learning more about cognitive therapy, I provide references to further relevant reading in the Bibliography and Further Reading chapter.

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Scientific testing is essential for the development of new drugs, but it can sometimes seem heartless to the layman. For instance, many clinical trials for new drags only last six to eight weeks. Thereafter, no matter how much better a participant might feel, the drug can no longer be obtained until it is fully approved and available on the market. When a patient who has been otherwise unresponsive to all other marketed compounds does extremely well on an investigational new drag, it seems cruel to withdraw the medication. Fortunately, once the testing period is over, a humanitarian protocol is available for a limited number of outpatients taking antidepressant, antianxiety and other psychiatric and medical drugs from pharmaceutical companies testing these compounds. After the initial trial, a patient may report a great improvement of symptoms along with the information that no other drag on or off the market has worked so well as the investigational drug. The patient, through the principal clinical research investigator, may then apply to the drag company with this information, and upon evaluation by the company, the patient may be given the drug to be monitored through the clinical investigator, even though it has not been approved by the FDA for release to me general public.

This is a great humanitarian boon to a limited number of patients who have been chronically (to pressed for years or suffered other illnesses dot can be relieved only by a drug still in a premarketing stage of development In these instances, the hoped-for improvement the patient found through agreeing to participate in a scientific protocol did not turn out to be temporary. The slight risk the patient took was worth it.

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Every psychiatrist needs to be aware that a not-so-small percentage of people who seem to be unipolar eventually blossom into bipolarity. This is less rare than one might expect. After following a group of patients at the University of Tennessee Mood Clinic for a period of several years. Dr. Hagop S. Alaska and his colleagues found that 14% of the patients originally considered ”neurotic depressives”—the old term for those afflicted with dysthymia— developed hypomania, and an additional 4% became manic; a total of 18% of the seemingly unipolar patients became bipolar. No wonder so many patients are misdiagnosed. The disease spectrum itself changes shape, and psychiatrists often fail to be good historians or medical detectives. They miss the mild highs, and as a result the patient is misdiagnosed as unipolar depressive, either major or dysthymic, or as having a personality disorder with subclinical depressive symptoms.

How do these bipolar depressed patients react to the older standard antidepressants? Often quite well. Over the past three decades, there are many dramatic responses, both with lithium alone and with lithium combined with the standard antidepressants. But even though people may feel more even-tempered and energetic with older antidepressants, symptoms such as constipation, blurred vision, and weight gain can be very bothersome; and they are all the more unbearable for people whose depression wasn’t that bad. The MAOIs present the additional difficulty of prohibiting tyramine-containtng substances such as cheese, Chianti wine, chocolates, and other foods and some over-the-counter medications.

In the vast majority of people, the side effects of Prozac are extremely mild or nonexistent.

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Many physicians and psychopharmacologists feel comfortable with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) because for over thirty-five years they have prescribed them with great success for millions of patients. It is true that these drugs have more side effects than Prozac and the other new SSRIs, but patients can often tolerate the side effects without undue complaints if educated in what to expect: dry mourn, constipation, sometimes a little dizziness, mild sexual difficulties. These side effects are annoying but not terrible, and by and large, these older antidepressants have worked well. Thus, many physicians are reluctant to prescribe a new drug, despite the miraculous claims that may accompany it. Faced with a depressed patient, cautious, conservative physicians and psychopharmacologists often turn to the old medications first, If the patient cannot tolerate the side effects or if the dosage, when escalated to the top, does not bring the patient out of the depression, then they may try one of the new SSRI antidepressants, Wellbutrin, or Effexor.

Finally, many psychiatrists prefer to prescribe the older drugs whose long-term effects are predictable rather than a new drug whose long-term safety is still unknown.

Despite the hesitation of so many conservative physicians, the number of psychiatrists using the old battery of ten to fifteen antidepressants has eroded every year since Prozac was launched.

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Claims like these lead inevitably to disappointment for most patients, although transformation does occur in a chosen few. Even on Prozac, shy depressive with personalities like that of the poet Emily Dickinson—unless they have a history of extreme highs and lows or family history of mood disorders – would not turn into extroverted rock and roll singers.

For most people, the changes created by Prozac are more subtle; the depression clears, the symptoms disappear, and positive life changes occur, A few of my patients who report feeling like themselves again say that they can’t imagine living without Prozac. Indeed, it can offer a certain brightening, a new equanimity, or a boost in self-confidence. However, in patients who have major depression, this is a phenomenon that also occurs with most other antidepressant drugs.

Prozac is not a magic wand: seldom does it turn a wallflower into the belle of the hall. Nonetheless, like other psychiatrists, I have witnessed a few transformations and my interpretation of why they happen and how they can be predicted may surprise both patients and physicians.

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A general medical principle is that even nonalcoholics should drink only moderately or not at all while taking any medications, including Prozac. After being stabilized on Prozac or other antidepressants, patients who do not have an alcohol problem are permitted to have a glass of wine at dinner, provided that no adverse effects on judgment or mood take place. Obviously, patients who are taking Prozac or any other psychotropic drugs should not use alcohol prior to driving. Most medical authorities argue that no alcohol should be used by anyone who plans to drive.

If the patient is alcoholic, as is often the case with those suffering from major depression, dysthymia, and bipolar manic depression (due to a genetic alcoholic predisposition), it is imperative to abstain from alcohol completely. Interestingly, a least one study suggests that a dosage of 60 mg of Prozac may cause heavy drinkers to drink less alcohol but not to smoke fewer cigarettes.

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