Personally, I can speak well to this study’s findings. I’m a practicing Catholic, but prior to the year 2000, I waxed and waned when it came to the “practicing” part. Mood disturbances, although not severe, were more common for me back then. Since recommitting myself to a pattern of more formalized religion – which includes daily prayer as well as regular attendance at Mass, I rarely have any dysphoric mood symptoms. And when I do, I attribute the symptoms to sleeplessness with its attendant fatigue.

I find the word spirituality somewhat perplexing. I’ve actually asked many people I’m close to what it means to them, if anything at all. The answers I received were divergent, but mostly centered on prayer themes.

Religion, on the other hand, is more easily definable for me. It is linked to a place of worship, often at specified times of the day or week. I like that it’s structured. I find it centering and grounding. And with a belief system firmly rooted in the concept that God is good, my Church serves as a safe haven where I can thank God, or ask for grace, strength and guidance to face the tribulations of daily life. There’s peace and contentment in this, something that only a Supreme Being can deliver. So I believe.

It has been most refreshing to learn that more and more mental health professionals are incorporating spirituality and religion into their recommended treatment plans. Seminars and workshops on this subject are popping up all over the place.

One of the hardest things to accept about life is that some circumstances will stay unresolved – and that, in and of itself – is a resolution. So we should all do ourselves a favor and stop trying to extract fairness from a world that never claimed to be – or had a history of being fair. There’s simply no way to attain justice without outside cooperation.

We can however seek relief independently, through faith, therapy, fitness, spirituality. Or generosity and giving of ourselves.

1. How the depression presents. There are some 12 subtypes of major depressive disorder, but none of them are reliable predictors of antidepressant response. Nevertheless, there needs to be a starting point for the selection process. For example, is the client’s depression accompanied by anxiety and insomnia or is it characterized by melancholia, hypersomnia and a vegetative state? In the first example, any of the SSRIs except Prozac would be acceptable choices; the latter example would be better served by Prozac, SNRIs (Effexor, Cymbalta, Pristiq) or Wellbutrin.
2. Family history. Does the client’s history include a family member who was prescribed an antidepressant drug and responded to it favorably? If so, use this DNA phenomenon to the client’s advantage by using the same medication.
3. Drug characteristics. Prozac and Wellbutrin are examples of “energizing” antidepressants; whereas Paxil and Celexa tend to be more sedating. Initial choices therefore, should be predicated on how the depression presents – as outlined in #1 above. The point here is that one size does not fit all and selection should not be based on what samples are in abundant supply or what pharmaceutical representative just visited.
4. Reasonable expectations. When anyone is started on an antidepressant, the individual should be informed as to what to expect from the drug. They should be made aware that antidepressants won’t do the heavy lifting when it comes to managing their depression nor will these agents change behavior. They should be counseled to take the medication as prescribed for a defined period of time – say six months – before a reassessment.
5. Integrated recovery. An estimated 10 percent of Americans over age six now take antidepressants. Much of this use is being driven by television, internet and print ads through which pharmaceutical companies target consumers directly. The television commercials speak language the consumer can accommodate, and the compassionate, caring voiceover frames the drug as the pathway to relief. They have enormous appeal to a population of depressed people intent on getting a quick fix and instant gratification. I’d respect the ads more if they made an effort or even hinted at incorporating other treatment modalities into the improvement process. But they don’t – leading vulnerable people to conclude that hitching their wagon to a pill fills the bill for what they have to do to get better. This is understandable. The technology revolution alone has us all buying into the “I can have it now” mentality. So drug companies merely capitalize on this mindset.

Getting better and minimizing the possibility of relapse requires strategic planning on multiple levels. This is what integrated recovery means! In more studies than I could possibly give credence to in this space, psychotherapy for depression has a stellar track record. But nowadays treatment by medical doctors, any by psychiatrists in particular, nearly always means psychoactive drugs. And increasingly, I’m finding that non-psychiatric MDs aren’t pushing back against patient requests for antidepressants. More and more, I’m being referred patients who are already on antidepressants for no more than mild reactive dysphoria. The shift to drugs as the first-line treatment modality coincides with the increasingly controversial “chemical imbalance” theory that emerged over the last couple of decades.

Competent, focused and well-designed cognitive-behavioral treatment that focuses on belief system and behavior modification is a must for a truly depressed individual. So are diet changes, some semblance of an exercise regimen and even spiritual development. Many days with many clients though, I feel as though I’m paddling upstream. The power of the pill creates substantial headwinds.

I’m finding it increasingly difficult to get clients to do the “work” of recovery from depression. Some tell me doing anything else than swallowing medication is just too hard. Others say little and have a look of quiet resignation on their faces. With an attitude of victimization and impediment, and a reliance on only medication as a pathway for getting better, they’re boxing themselves in.

Breaking free from the bondage of depression is hard yes, and what I’ve said may sound harsh, but the quantity and quality of improvement derived is proportional to one’s effort. That’s the way it is with anything in life.

The skilled mental health diagnostician is not seeking perfection as there is no such thing. Instead, this clinician is seeking diagnostic assuredness. It begins with a thorough assessment of the presenting client and not a memorization of the DSM. In fact, the mental health bible stays on the sidelines, serving only as confirmation and as a reference for coding purposes. Savvy practitioners rely on the “art of the question.” That’s not to say they don’t bring an excellent command of the signs and symptoms of the mental disorder spectrum to the process. They do. But the essence of their skill lies in the ability to frame a series of insightful, intuitive questions around the client’s presenting problem. Adroitly, assertively, yet tactfully, they approach assessment with tactical precision and are aware that success with any client means this: the language controls the discussion; the discussion controls the relationship; and the relationship controls the quality of the outcomes. As such, the highest premium is placed on rapport building.

Observation is also important. The nuances of client head movements, facial expressions and overall body language are every bit as important as the changes in their vocal delivery. What these clinicians see in a client is every bit as important to them as what they hear.

The inability to confirm a diagnosis by way of objective findings notwithstanding, mental health work has another strike against it – the intimacy of the practice setting. When a patient visits his or her primary care physician, there are often layers of staff – receptionists, lab technicians, nurses, and physician’s assistants – to sift through before seeing the doctor. Mental health settings tend to be more one-on-one, so it’s natural for someone to guard their information at first. The experienced mental health clinician tackles this head on by first putting the client at ease before getting down to work.

Systematically then, the clinician shapes the client’s responses and non-verbal behavior – gathered though their questioning and aided by insight and intuition – into a diagnosis. Then and only then does the hard work of helping the client reach their expectations for treatment begin.

A final point. Those professionals who are undeniably accomplished and highly sought after understand that while diagnoses have utility, there will probably never be clear, undeniable “markers” as found in general medicine and that the notion of chemical imbalances and neurotransmitter difficulties is highly speculative. So they don’t go there; they deal instead with what and how the patient presents.

For some time now, I’ve been taking improvisation classes and have become part of an improv group. I began taking the classes to help me with spontaneity and to think quickly when on the spot. In the very first class – all newcomers – we were welcomed and then immediately brought on stage. There was no theorizing about improv’s place in history as a viable art form. As ill-prepared as I was with the techniques at first, my journey had begun.

You can read all the books you want about improv, skydiving or poker playing, but it’s all theoretical until you step up on the first stage, jump out of the first plane or deal your first hand. I’d much rather work with someone who helps me to actually do something than someone who talks incessantly about the theory of doing it.

There’s an argument for and against these new guidelines. First, let’s look at the “for.” Treating children with medication at a young age can help get a jump on a disorder that may very well progress into adolescence and on into adulthood. And this guideline modification builds greater awareness about ADD, helps more kids and increases their chances of succeeding in school.

Now a look at the “against.” In busy practice settings, ADD is often diagnosed in a cavalier-like fashion and prematurely treated with medication – especially under the relentless pressure applied by drug companies and direct advertising to parents and teachers. Thus despite good intentions, this AAP guideline will most surely lead to a glut of medication being prescribed to children who have been inadequately assessed. Translation: no good deed goes unpunished.

Here’s my take. These guidelines piggyback on the folly associated with the senseless expansion of criteria we can expect to see with the DSM-5 – supposedly crafted by “experts.” A preponderance of these experts has worked only in academia, hopelessly removed from how these new guidelines will be misappropriated at the real world level.

Here’s a quick refresher if you’re not familiar with generic names. Zolpidem tartrate is Ambien®. And sublingual administration allows for rapid absorption into the blood stream when placed under the tongue. The recommended and maximum doses of Intermezzo® are 1.75mg for women and 3.5mg for men. The recommended dose is lower for women because women excrete zolpidem at a slower rate compared to men.

When it comes to sleep difficulties, if there’s a way to mismanage or misuse a medication, some people will find it. My concerns regarding Intermezzo® use are as follows:

• Some users will ignore the indications and use this drug to help them get to sleep. Why not do so? If the drug helps reinitiate sleep after awakening, why wouldn’t it help someone get to sleep in the first place? The problem with taking it to get to sleep is that upon awakening in the middle of the night people will repeat the dose. This is a no-no.
• Folks who awaken more than once during the night, say every two hours or so, would not be helped by this drug given the maximum dosage recommendations above.
• Those who use regular 5mg or 10mg Ambien® at bedtime and also experience middle-of-the-night awakenings could easily become confused with what dose they’re taking and when if they also use Intermezzo®. And this will happen, because some prescribers will issue prescriptions for both to the same person.
• The warning regarding use at least four hours before arising as planned will be violated. Optimally, if one is scheduled to rise at 7am, Intermezzo® shouldn’t be used after 3am. Those who count on a pill to promote or maintain sleep will ignore time frames. They’re married to the medication, so guidelines be damned.

There are too many variables associated with the sleep-wake cycle to micromanage   insomnia. Intermezzo® is a bad idea because the drug is ripe for manipulation. Also, for some people, broken sleep may actually be natural sleep.

For people with Generalized Anxiety Disorder however, nearly every aspect of life invokes a thought of “what if,” leading to a state of chronic worry often accompanied by sensations of doom and gloom. Literally, these are folks who: (1) worry all of the time, (2) worry about what they worry about and (3) worry when they’re not worrying. This makes GAD a chronic condition, and it is often linked to numerous physical complaints – with headaches, gastrointestinal distress and muscle tension heading the list.

It is important to understand that there are positive intentions associated with why people worry. I’ve had clients tell me that worrying about something will mean that the worst won’t happen, and that this is their way of doing justice to a situation fraught with possible negative outcomes.

Psychotherapy targeted toward challenging the belief systems that fuel worry is the core of competent care. Faulty premises and assumptions should be confronted; and the overarching goal should be to help those with GAD to view their distress more objectively. Medications such as benzodiazepines and serotonin antidepressants may temporarily ameliorate worry but won’t do anything to change core illogical beliefs. As such, they don’t add value to a treatment plan.

Appreciating the difference between concern and worry is important. Having concern for something is rational and potentially solution-focused; worry on the other hand, is irrational, circular and problem-focused.

Fish oils are made up of EPA (eicosapentaenoic acid), critical in heart function, and DHA (docosahexaenoic acid), critical in brain function. These oils are found in fatty fish that include salmon, mackerel, tuna and sardines, as well as in supplements in gelcap form. Both DHA and EPA affect calcium, sodium, and potassium ion channels that regulate cellular electrical activity in the heart and the brain.

Omega-3 fatty acids have been well established in improving nerve conduction. They are well on their way to being recognized as effective in the management of depression by regulating neurotransmitters like serotonin and dopamine. Studies have shown a correlation between low levels of omega-3s and depression. Trials using omega-3s are showing promising results in the use of this supplement as a treatment for depression.

For example, in 2002 a study was conducted in England with 60 men and women suffering from treatment-resistant depression (depression that did not respond to conventional medications). Those taking 1 gram of EPA a day showed significantly greater improvement on depression-measuring scales than did the placebo group.

Another study, this one led by a researcher at Harvard Medical School, examined 30 patients with bipolar disorder. The group that took 9.6 grams of omega-3 acids daily (EPA and DHA) showed significant symptom reduction and a better outcome when compared to placebo [olive oil] alone. The study’s conclusion: The omega-3 fatty acids were well tolerated, and they improved the short-term course of illness.

The typical American diet is high in omega-6 compared to omega-3, prompting experts to recommend at least three servings of fish a week to maintain a balance between omega-3 and omega-6 fatty acids. While omega-6 oils (corn, soybean, etc.) can generate an inflammatory reaction, omega-3 oils found in cold-water fish work by subduing inflammation. This is why the omega-3 oils are often used to alleviate the symptoms of rheumatoid arthritis, cancer, and Crohn’s disease. The human body can also manufacture omega-3s from walnuts and flaxseed.

When purchasing an over-the-counter omega-3 product, pay most attention to the fish oil content per capsule from a dosing perspective. Taking 2000mg of fish oil per day is recommended. For example, if a product contains 600mg of fish oil per capsule, two or three capsules per day should be taken.
There is some anecdotal evidence surfacing which suggests that omega-3s may be effective in the treatment of distractibility and inattentiveness associated with ADHD. Although efficacy is far from established in this regard, dosing recommendations for ADHD-diagnosed youth are between 500mg-1000mg of fish oil content per day.