How does a psychiatrist treat depression?
The diagnosis of depression is made when the doctor sees a patient is either feeling sad or, empty or irritable, and it is a significant change from their usual state of mind. There are thousands of kinds of depression, and each kind is different because it comes from a person. Each person is a unique individual with a distinctive history, and unique hopes, dreams, and values. They have a sense of their own freedom and a direction in their life. It is in this context that a person feels sad. You can’t ignore the person if you want to treat the depression.
Depression is biological, psychological, and social. That’s how a psychiatrist sees things in three dimensions. For biological issues, there are biological treatments. For psychological issues, there are psychological approaches that can help. And for social things, there are responses that involve an improvement in social skills and social perception that can make a world of difference.
The job of the psychiatrist is to understand all three issues that bear on a person’s depression–and then act on all three issues roughly at the same time.
Let’s say a person started getting depressed in grade school. Their parents got divorced. They had to move to a smaller house because of financial reasons. Let’s say one parent battled addictions and another battled depression, and that resulted in the child getting less attention and feeling less valued by the parents.
Let’s say the child internalizes that experience and develops low self-esteem and social anxiety. They were afraid of going to school. Because of that, they got lower grades, reinforcing their belief that their self-worth came from the approval of others.
Under the weight of this anxiety, the child became depressed, first in middle school, then worsening in high school. This is a common history, unfortunately.
While the parents were well-meaning, they were preoccupied with work and their own mental health issues. Hence, the child felt even less valued and turned to abusing marijuana and alcohol to lessen the pain of their emotions. Alcohol lowers serotonin activity, which worsens the depression, although temporarily it lessens anxiety only for it to become worse later on. That is because alcohol works by increasing gabba activity in the brain, causing a calming effect, but hours later, the brain reacts to that by increasing glutamate activity, which heightens the baseline or free-floating sense of anxiety for hours or days later. That’s why alcoholics drink alot to get to sleep at night, only to find they wake up at 3 am because their body has digested the alcohol, lowering the blood level of that, but glutamate activity remains high and since it is the wake up and anxiety chemical in the brain, people wake up feeling anxious. Bad living through bad chemistry! Marijuana can similarly diminish anxiety for a short period of time, but long-term effects include lowering motivation, and impairing recall of information represented in words. Bad chemistry!
Struggling in this way, the young person gets lower grades but doesn’t know what to do. Threatened with failing classes, she sees a psychiatrist.
Gathering the above history, the psychiatrist sees the first thing is to create trust. The person hasn’t had a rewarding, trusting relationship with an adult authority figure for years. A psychiatrist built that over several visits.
Then the patient is willing to accept guidance from the psychiatrist and ask for help with the anxiety. The psychiatrist noting the addiction history recommends gabapentin, a non-addictive, anti-anxiety medicine also used for seizures. The medicine reduces social anxiety 50%, much to the patient’s relief. And further, trust is gained. This allows the brain to respond to learning social communication skills, eventually allowing the patient to phase off gabapentin.
The patient allows the psychiatrist to ask even deeper questions. There is a long history of a lack of any good friendships or of a patient understanding how friendship happens. During in-person visits, the psychiatrist notices there’s a lack of facial expression response and that is typical of autistic traits or extreme anxiety.
Upon further questioning, the patient admits she has refused to let anybody get to know her because she was traumatized in preschool. Her parents ignored her complaints, thinking she was being hysterical. She felt discounted, and decided to keep her drama a secret, and not let anyone get to know her. So she repressed her feelings of wanting to be appreciated and understood, and so her post-traumatic stress disorder persisted through the years.
The depression was a crushing weight on her mind and was leading to potentially failing grades in two classes, which would not allow her to graduate from high school. She accepted an anti-depresent, which didn’t work because of her persisting, marijuana and alcohol use at night to get to sleep. This was replaced with trazodone, an anti-depressant that doesn’t cause weight gain and has no addictive potential. She felt much better rested, and without the alcohol and marijuana, the anti-depressant could work. Her mood improved by 50%.
As she approached midterms, her low grades in two classes were a constant source of worry. The doctor wrote a letter asking for accommodations, namely more time to finish homework homework, and a quiet test-taking room. Her distractibility from her anxiety was causing lower grades. The school responded by providing these accommodations as well as a tutor for those two classes. They also allowed her to take those classes online at home, where she wouldn’t be distracted by her social anxiety. Her grades improved considerably over the next month. She could retake previous tests and get a better grade for those two classes.
In this process, she started working with another person for psychotherapy, with a female psychotherapist. She gradually developed a positive self-image that didn’t depend on other people’s opinions. She was learning to let go of the negative psychology caused by post-traumatic stress disorder. Because of the PTSD, she imposed her interpretations on why other people did what they do. “Oh, they don’t care about me.” “They just care about themselves.” “They will just make fun of you, you can’t trust them.” She noticed it felt so good to let go of this trash talk in her mind. Little of this would have happened if she was severely depressed and sleep-deprived, but the medication was helping for that. See how the combination of medication and counseling does so much good for a person trying to regain their old life?
The doctor reinforced this progress by asking, “What have you been learning in your counseling lately?“ She reported, “I’m learning to let go of the past, not be so hard on myself, and accept that everybody has good days and bad days. It’s OK if people don’t all get along. People can have different points of view and that’s ok. That means not everyone is going to like me, and I’m not necessarily going to like everyone else, too, and that is fine, that’s cool. It’s ok. That’s how life works. People can think for themselves.”
The doctor said he appreciated her hard work in counseling and visits with him, and he anticipated she would continue to learn more and more in counseling. He also said he appreciated she had given up alcohol and marijuana so that the counseling and medicine could work.
Eventually, her grades improved, and she graduated from high school. With her improved self-confidence, she entered a community college to get a certificate to be a certified nursing assistant. This required accommodations which were provided after the doctor wrote another letter for accommodations.
She learned how to meditate to help with sleep and keep a healthy daily routine, such as exercise and eating three meals per day and limiting fast food or junk food to no more than once per week. A year later she phased off her sleep medicine and a year after that, she phased off her anti-depressant. There was nothing “wrong” with medication, but her goal was only to take it if she needed it and now she didn’t need it. She didn’t change the medication on her own, but under the supervision of the doctor. Her continued good work and counseling paid off, with her getting her certification to work as a certified nursing assistant and she soon started that job.
The biological issues here were several.
Insomnia was treated with trazodone, without which the antidepressant likely wouldn’t work. The anxiety was treated with gabapentin, without which likely counseling and the antidepressant wouldn’t work. The antidepressant worked so she could wake up in the morning with a favorable sense of well-being. She didn’t have to constantly fight off negative self-talk or waves of anxiety that would come out of the blue.
The psychological issues were considerable.
In counseling with a female therapist, she developed insight that she was talking to herself like she thought her parents had talked to her when she was young. She had no idea the struggles they had. With further conversation, she began to see her parents or humans just like her. They had problems. They had struggles. They had to work to put food on the table. No fault of their own that housing costs became much higher and so they had to move to a much smaller home. Well, the patient saw this as a big loss. She lost contact with her friends. Yet, later, she saw from a mature perspective that her parents were being responsible, in reducing their overhead to keep their financial security. This allowed them to have money for her college one day, and for her to have a future in education. That was a considerable gift. From a more mature perspective, she appreciated how her parents were devoted to her. They weren’t perfect. They wanted to spend more time with her, but couldn’t. They were often tired at the end of the day because they worked all day and had to cook and clean in the evening. With a more mature perspective, she was grateful for their devotion to her and her future and her mental health.
Gradually, she began to turn around her negative self-talk into self-talk that was encouraging, supportive, like she would talk to her friends. She learned to be a friend to herself. She learned to let go of the past because it doesn’t exist. She learned to filter out negative thinking, such as catastrophizing problems or minimizing her accomplishments. This considerable progress in her psychology allowed her mood to improve and her confidence in herself to be lifted up. That’s why she did so well in her community college classes.
Still, her social anxiety was paralyzing at the start. With help from her psychotherapist, she learned communication skills. Instead of being preoccupied with what people might be thinking of her, she took a focus in what other people were doing. How had their day been? What were they thinking about doing tomorrow? She focused on being a good friend first, in order to have the chance of having a friend or having a closer friend. She learned to follow threads of a conversation. What did this person say first and second and third? If you were in their shoes, what would you be experiencing? With these and other skills, she learned to start and continue social conversations, and have rewarding experiences, focused on discovering things about the other person they had revealed previously. People found her a fun person who really took an interest in other people and was a great friend. As a result, her social life improved, and she looked forward to social times with her friends. If one friend lost interest in her, there were many others to take her place. She learned to accept that friends come and go and that’s OK. Life goes on and you can always make more friends. This became very reassuring for her. In the past, she would abuse alcohol and marijuana to numb the pain of her loneliness. And then she would get lonely but her therapist helped her to learn how to feel OK, being by herself, knowing she would hang out with her friends sometime later in the week.
And so it was with the coordinated approach, understanding the biological, psychological and social needs. She had her providers who were able to guide her to a place of much better mental health.