As I’ve often noted about treating depression, getting depressed people moving is essential. It’s even more essential for those spending inordinate amounts of time in bed and cutting themselves off from physical and other forms of social contact with others.
An initial key component pursuant to evaluating how to proceed treatment-wise is to thoroughly assess the individual’s motivation to get better. Phenomenology is important: How does the individual perceive and interpret their depression? What’s their relationship with it like, best friend? safe haven? How is the depression serving them – primary or secondary gain? Such questions are important because the more intimate the relationship with the depression and the greater the gains, the more difficult it will be to give up. Unlike reactive depressions which are influenced by external factors, melancholic, vegetative depressions have become a part of the affected person. It’s a marriage of sorts and endogenous in nature.
If motivation for improvement is low, the treatment course can be a long slow slog. Psychotherapy wouldn’t bear much fruit because of symptom severity, an inability to comprehend the path which the therapy is going and a lack of follow-up on directives and homework assignments. Diet changes accompanied by an exercise regimen wouldn’t be viable because of disinterest and low energy. Suicide risk however, is generally low, due again to the absence of motivation to develop, plan and act on any possible intent. Support systems that check in on the individual to best ensure that basic needs are being provided are a must.
Medication then, is the best bet for physical depressions characterized by listlessness, inactivity and profound social isolation. The goal of medication here is to achieve some reversal of the characteristic symptoms just mentioned. Thus, measurable mood improvement should be viewed at first as secondary to changing the behavior(s) that keep the individual immobilized and ensconced in the enveloping bubble that protects them from the social environment. In other words, the goal of medication is to disrupt the unhealthy equilibrium to which the individual has fallen prey. This all assumes compliance with medication though – all too often an obstacle.
Any of the contemporary antidepressants can be employed. Antidepressants are thought to stimulate the norepinephrine, serotonin and dopamine systems, all of which are activating to some extent. It’s important though to be attentive to drug characteristics within an antidepressant class. The SSRIs stimulate the serotonin system, but some typically do so more than others. Prozac is generally considered more activating than Paxil or Celexa, for example. The SNRIs (Effexor, Cymbalta) activate both norepinephrine and serotonin – a dual action effect. And Wellbutrin is all but exclusive to the dopamine system and can be very stimulating.
Stimulation will manifest as side effects within the first 7-10 days of use at a minimum. Users may report feeling hyperexcited and anxious, accompanied by difficulty getting to sleep. It’s important not to view these effects as negative to the individual’s well-being, but instead to perceive them as a vehicle for getting the vegetatively depressed person into a better position. Drug side effects are often utilized for their therapeutic benefits, taking us back to the original premise for employing antidepressants in the first place – to change inertia into energy and get the individual moving! An important note though: If suicide risk factors exist, this same 7-10 day period is when the person would be most inclined to act due to the excitability factor. As such, close monitoring of the individual is prudent.
Disrupting the behavioral status quo produces “dis” ease and discomfort that can influence the emergence of positive behavioral effects such as getting out of bed, getting to the breakfast table, attention to personal hygiene and even venturing out into the social environment for a walk or a visit to a local coffee shop – initial steps that are critical to longer-term, more sustained improvement.
Reprint Permission
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.