For someone who has experienced the full weight of a clinical depression, they have truly known what isolation means. The loss of all executive functions and the obliteration of “self” is so overwhelming, that one is left feeling hopeless and helpless and convinced that the depressed mental state will last forever. Loved ones and friends may offer sympathy, but they have no idea how devastating the condition is.
I see depression in many different forms, ranging from Major Unipolar or Bipolar Depression to Depression from Adjustment reactions. Some of the more severe forms of depression have crippled and immobilised patients on treatment for up to a year without remission, where the patients can’t even leave their homes; whilst the majority of depressions accompany one in daily living, like a heavy spirit, pulling one forever down into darkness, but go into remission within a few months.
It has always been clear to me that the above depressions have a biological component to them and modern antidepressants together with other medications play a major role in treatment. The majority of patients with depression do however require psychotherapy, when they feel able to interact.
Cognitive Behavioural Psychotherapy (CBT), is more accepted in the biological, symptom focused, medical model approach, where cognitive distortions and learnt helplessness are re-programmed. The benefits from CBT are confirmed by scientific research. However supportive and depth-psychotherapy is very much neglected in psychiatry and no training is available in the psychiatric departments at the medical schools. Surely it is obvious that at the very least, at a supportive level, patients need to talk in the privacy of a containing and confidential setting, about their feelings of isolation and despair; their fears of not recovering; their suicidal ideation and the burden they feel they are to others. They especially all need reassurance that they will get better. Taking therapy a bit deeper, patients want to explore their personality vulnerability; the reason or the susceptibility they have had to develop the illness and many other personal matters and intra-psychic vulnerability factors.
In my thirty years of experience, I regard depressions as being curable, with the majority of patients going into remission within few months. A slower recovery almost always implies either serious social complications, the presence of a physical illness, or personality disorders.
Patients should be reassured and comforted by the fact that the psyche has indigenous healing factors, and that psychotherapy and medication are facilitating this inner healing potential. My role as a psychiatrist and therapist is to not only choose the correct dose and combination of medications, but also to tackle the psycho-social factors in the patient’s life, and especially to focus on personality problems.
Self-esteem and confidence is at an all-time low for the patient, and genuine care, reliable support and authentic involvement, accompanying the patient on their Nekyia, or journey into the underworld, will bring about healing and transformation.
It is crucial to educate ‘significant others’ in the patient’s life about depression. Once a threshold is reached in all of us, a physiological shift in the brain takes place. The “threshold” notion implies that we may all be susceptible to falling into a depressive condition, but that we have different thresholds. This threshold is determined by genetic factors, but also by emotional and psychological factors, as well as external factors. Major or accumulated life events have different ways of effecting individuals, and these need to be explored in great depth, especially with regard to previous losses in life and all the circumstances around the management of these losses. The prevailing social conditions of the patient needs to be carefully evaluated, e.g. whether they live within an empathic and containing marriage, family life or social milieu or in a critical and judgmental social situation and emotionally barren environment.
The depression makes one feel like a failure in life, and it is easy to feel that one is a burden to others. An empathic, emotional “holding” of the patient by loved ones, who understand the illness, provides the conditions necessary for recovery. However, a hostile, begrudging social situation, where the depressed patient is exposed to irritated or frightened family members, who feel inconvenienced or threatened by the patient’s depression, is toxic for recovery. Such family and friends may insist on applying pressure to the patient to “snap out of it” or they may give well meant “advice” e.g. to exercise or to change their diet or other aspects of their life, which serves to further undermine the depressed patient and increase their sense of isolation and failure . Family need to be educated into the fact that the symptoms of depression are “bigger” than the patient’s capacity to simply reverse, as a result of the fact that changes have taken place at the cellular level in the brain. Alterations have occured with the subtle interplay of neural pathways and their intricate network of connections. The ‘ecologically’ balanced neurotransmitter interactions are disturbed, and no simple change in attitude can reverse this cascade of neuro-chemical events, and turn the tide.