If You’ve Withdrawn From The World, Time to Come Back In

His first intravenous infusion left him bewildered and invigorated. The night of his first “trip” he amazed his parents by cleaning his room and heading outside for a walk for the first time in quite a while.

This is a description of a young man who had his first experience with ketamine – which for better or worse, is being highly touted as working rapidly for depression.

I’ve commented on the pros and cons of ketamine in previous posts, so no need to expand on it here. What intrigued me about this Time magazine article, which discussed the limitations of antidepressants and new treatments in clinical trials, is the length to which some people like this young man will go – after a series of antidepressant and ancillary medications – in pursuit of the next drug… and the next one, to treat their woes. Their sole focus is a drug solution. So here we have a young guy who doesn’t clean his room at all and avoids going outside for even a brief walk ostensibly due to anergia, but somehow motivates himself to get to a psychiatrist’s office to discover whether a several hundred dollar infusion will work for his depression.

Just as the lure of the Sirens captivated sailors with their enchanting music and voices, often causing then to wreck their ships, so too is the seduction of big Pharma sounding off on the next new remedy to keep hope alive for depression sufferers. The thing is, successfully managing depression is a lot like marketing – someone has to try a number of different strategies and approaches in pursuit of improvement. And while depression saps energy, motivation and enthusiasm, anyone who has taken antidepressants for a period of time benefits at least somewhat. The inherent clinical properties of these drugs strengthen and restore some sort of resilience to the brain, providing neuroprotective benefits that help people cope. As such, I no longer encounter the debilitating type of depression in my office with patients who have tried these drugs – in spite of little, if any success in some instances.

My point is this: There’s no reason the young man discussed above shouldn’t at least be capable of making his bed or taking a walk around the block. He has to change his motivations. People with depression often withdraw from the world and they’ll need to be brought back in if they’re ever going to feel better.

Behavioral Activation Therapy is today’s 50-cent term to get moving. It derives from CBT, but is much simpler to learn and is easily integrated into typical treatment sessions. Behavioral activation therapy (BAT) encourages depressed people to push themselves into engaging in more general activity, physical movement and social interaction, thus countering the tendency for them to withdraw, disconnect and disengage from previously enjoyed activities and other social outlets. BAT asks those with depression to describe a typical day for them and assesses whether they are avoiding activity. And if they are avoiding, this therapy concentrates on having them learn or re-learn activities that add meaning to their life – like reading, socializing over coffee, volunteering, exercise, regularly visiting family and friends, and moviegoing, to name a few. And it specifies they are to get into these actions without waiting for their mood to improve first. The emphasis here is that through action and activity, energy and enthusiasm will fuel mood improvement. Thus a vicious cycle of withdrawal and worsening mood is replaced with a complimentary cycle of positive engagement, experiences and improved mood.

I have long held that treating depression should be behavioral-cognitive, not cognitive behavioral, particularly in the beginning stages of the treatment process. Depressed people tend to think too much, which subsequently gives rise to excessively negative, repetitive ruminations which turn molehills into mountains. Such folks are better served by action. Examining and reframing irrational thinking comes later.

For treating depression, my motto has long been “first, get them moving.”

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.