Depression is Never Inevitable

Yes, it's challenging to grow older. Yes, the isolation brought on by COVID has been tough on older adults, many of whom were separated from their adult children and grandchildren for months, a year, or more. Yes, it is upsetting to watch one's body age and no longer be able to perform the same skills it did so easily during youth. And, yes, it can be devastating to suffer the loss of a loved one.

Credit: Dario Valenzuela

But depression is never inevitable — not after divorce, not after being diagnosed with cancer, and not after losing a loved one or a job. Yes, there is sadness, fear, worry, loss, and regret. But no situation necessitates becoming paralyzed with unrelenting despair.

The word "depressed" can be confusing, as it's used to describe different conditions. When some people feel blue, they say, "I feel depressed." But when I am referring to someone who is clinically depressed, I am describing the person who can't get out of bed in the morning, has continuous negative thoughts, and/or is moody, cantankerous, argumentative, and irritable from sunup to sundown, over minor things.

No matter how you justify this mindset and behavior, no matter how you rationalize it, if this is the state someone is in for two weeks or more, they are clinically depressed.

Sadness, mourning, anger, and other emotional states are the stuff of psychotherapy. Depression is due to psychobiology. In fact, often it is only after treating the biological component of depression that people can mourn.

The good news: depression is treatable. There is a vast array of psychotropic medications today that can be mixed and matched to offer relief for just about any person suffering from symptoms of depression, with almost zero long-lasting side effects.

In fact, when patients are referred to me and described as having "treatment resistant" depression, I often discover that they are not treatment resistant at all. Rather, their doctors had not yet found the best medication for them or failed to prepare them for what to expect during the course of treatment and so they became anxious and stopped treatment before it took effect.

Treating depression is not just a matter of better living through chemistry. No one needs to choose between antidepressants, psychotherapy, meditation, breathing exercises, or any other approach to relieving depression.

Medication is frequently the first essential step to relieve the most severe symptoms, at which point psychotherapy, mindfulness, meditation, exercise, good nutrition, sleep, spiritual well-being practices, and other positive lifestyle habits all work to create and boost a positive sense of self. It is not an either/or proposition when it comes to drug treatment. It's either/and. It's a holistic approach that can be transformative.

As a psychiatrist, psychopharmacologist, and psychoanalyst who has treated patients with depression for over 30 years, I strongly believe that providing a patient with psychoeducation is key to a successful outcome.

These are the seven key take-home messages I emphasize to patients who come see me for depression:

1. Depression is biologically rooted. (No, it's not your fault and you don't need to be ashamed.)
   
2. Medication can take 6-12 weeks to have a full effect and can be tweaked and dosed to ensure that all symptoms are addressed with few, if any, side effects.
   
3. There is every reason to be hopeful that you will be successfully treated.
   
4. Psychotherapy can thrive once the biological roots of depression are addressed.
   
5. Mind-body practices, like meditation, mindfulness, yoga, and Tai Chi, can play an important role in regulating emotions and mood.
   
6. New exciting advances, like ketamine, transcranial magnetic stimulation (TMS), and psychedelic therapy (described by The New York Times as "the hottest new therapeutics since Prozac") provide alternative avenues for relief if, for any reason, someone is resistant to medication.
   
7. Many people who are successfully treated for depression become the happiest, most fully actualized people they have ever been. Often individuals treated for depression come to realize that they have had a persistent low level of depression for years. Once the increased severity of their symptoms led them to take antidepressants, they discover they feel better than ever before.

Ignoring signs of depression is no less dangerous than overlooking signs of heart disease or cancer.

It is especially important to be alert to depression in people who are 60+, as depressive symptoms — which include moodiness, fatigue, sleep problems, appetite issues, impatience, low frustration tolerance, decrease in sexual desire, and lack of interest in activities — are often ignored or misdiagnosed because they are erroneously attributed to aging, changes in life circumstances, illness, or a reaction to medication.

At a time when most physicians work in medical centers or clinics where they are under time pressure to see a high volume of patients, it's more essential than ever before to advocate for yourself and your loved ones about mental health concerns.

For most people that means making sure your primary care physician takes your concerns seriously. It's rather astonishing, but the majority of people who are depressed see a primary care physician rather than a psychiatric specialist.

But no matter whom you seek help from, there's one thing to remember: If you are not satisfied with the explanations, treatment recommendations, or guidance offered by the health provider you consult, seek out another one. Everyone deserves to — must — get the practical, educational, and emotional support and follow-up they need to recover from depression.

Depression is the mental health scourge of our time. With our advanced treatments and a comprehensive, holistic approach, there is enormous potential for treatment success.

There is no reason to be depressed about being depressed! All depression is treatable. But you must find the right health care provider to collaborate with and guide you on your road to recovery.

Samuel L. Pauker, M.D. 



Samuel L. Pauker, M.D. is a psychiatrist, psychopharmacologist, and psychoanalyst practicing in New York City and the author of a forthcoming book on treating depression. He is Assistant Clinical Professor of Psychiatry at Weill-Cornell University Medical College, Assistant Attending at New York Presbyterian Hospital, and Adjunct Faculty at Columbia University Center for Psychoanalytic Training and Research. Read More