Therapy in L.A.

  article of the month
September 1999
By Alan Solomon, Ph.D.

Bob has been productive most of his adult life. Now in his late-thirties, he is struggling to keep his life together. In the last several months, he has missed more days at work due to colds, "24 hour bugs", aches/pains and fatigue than in the previous five years total. His concentration on the job seems off. He forgets some tasks, misunderstands some assignments, tends to be a bit careless with details, and has been late to meetings - all of which are not characteristic of his performance. At home, he spends much of time lounging around, watching sports on TV, napping on weekends. His wife has begun to complain that he seems less willing to spend time with her, the kids, or family and friends, usually begging off with complaints of being tired and simply not being interested in the kinds of activities which he usually engaged in with pleasure in the past. He's more irritable, being grouchy an d reactive to small things that he used to shrug off or deal with easily (e.g. minor crises at work, noise from the kids, small repairs needed at home, extra duties with extended family members). Bob complains about not sleeping well most nights, often having difficulty getting to sleep, or waking up early in the morning and not being able to get back to sleep. He has little interest in being sexual with his wife.

As he talks this over with his wife, they note that pressures at work have been heavier the last few months, due to some re-structuring and greater workloads as the company grows with success. An aunt has been seriously ill, which has created some worry and extra energy outlay to be of support to family members. The kids are older and more is needed in terms of activities, schedules, providing transportation.

But somehow, all of this seems like it's not enough to be causing the extent of Bob's difficulties. He has handled these kinds of pressures or worse, in the past, with little difficulty. There are many days when he feels like he is just barely dragging himself through the day. The worst moments are often in the middle of the night when he's up and unable to sleep. He has passing thoughts of wishing he were dead, if only to gain some relief from the grinding treadmill his life seems to be like these days. He is functioning, but certainly not up to his usual levels of success. He has begun to wonder, "What is going on?"

Bob is experiencing depression, something which affects a large number of people. Some estimates go as high as 10 percent of all adult Americans will likely go through significant depression at least once during their adult years. How do we distinguish depression from the occasional sad mood, "blues", or discouragement that we all feel at least once in awhile?

The American Psychiatric Association Diagnostic Manual (DSM IV) describes nine characteristics of major depression:

  1. Depressed mood most of the day, nearly every day, as reported by the individual or reported by others;
  2. Markedly diminished interest or pleasure in many activities most of the day, nearly every day.
  3. Significant weight loss or weight gain, or a decrease in appetite nearly every day;
  4. Insomnia nearly every day, or sleeping excessively nearly every day;
  5. Restlessness or lower activity levels nearly every day, as observed by others.
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive guilt nearly every day.
  8. Diminished ability to think/concentrate, or indecisiveness nearly every day;
  9. Recurrent thoughts of death or suicide, or a suicide plan or attempt.
Depression can be diagnosed if five or more of the above symptoms occur during a two-week period, with at least one of them being depressed mood or a loss of interest/pleasure. The person must experience significant distress or impairment in their functioning in social, occupational or other important roles. Other possible causes must be ruled out bereavement/grief, substance abuse, or another medical condition.

If untreated, this kind of major depression can result in severe family disruption, deterioration on the job to the point of disciplinary action or job loss, and sometimes suicide. The individual's pain and discomfort is palpable and unrelenting.

Diagnosis is often fairly straightforward when care is provided by an experienced clinician. A three pronged approach is most successful:

1. Medication - relatively new medications in use over the last decade or so often provide significant relief for many of the symptoms, often with only minor side effects, sometimes with no side effects at all. Each individual responds in his/her own way to these medications, which means that some trial-and-error efforts, careful monitoring and ongoing adjustments to dosages are needed. An experienced psychiatrist is the best choice of a caregiver; to be sure that quality care if provided.

2. Psychotherapy - support to develop a better understanding about the depression, build strategies to resolve difficulties, and to relieve symptoms further. Close coordination with the prescribing physician is essential to provide more data to adjust medications and monitor any side effects. As the depression eases, often within a time limited counseling approach, other issues may need attention involving important roles and functioning.

3. Family support - some counseling contact with spouses, children, and other family members may be essential to improve marital/intimate, parental, and familiar interactions. If the depression has been more severe and/or remained untreated for a significant period of time relationships in the individual's life often suffer. There is hurt, alienation, mistrust, or at the very least, distance that needs remediation so that the family as a whole can be returned to better functioning, richer relationships, and more rewarding interactions.

Research and clinical experience have shown that the best results require all three approaches. Medication alone, or psychotherapy alone, can provide some benefit, but to maximize the benefits, reduce the likelihood of recurrence, assist everyone affected, and respond much more effectively if depression does recur, a more comprehensive program is strongly recommended. Quality care involving medication, psychotherapy, and family support, of a more intensive and sustained nature if needed will produce the best outcome for most individuals.

Check the Book Review page under "Depression" for books recommended by Dr. Solomon and others.

Dr. Solomon is a psychotherapist in practice in Torrance. He is a member of the Independent Psychotherapy Network.

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