Depression Treatment Nashville

Depression is not really a feeling; it is a condition of numbness, of nonfeeling.

“Depression is not really a feeling; it is a condition of numbness, of nonfeeling.  In my work with depressed men, I differentiate between states and feelings.  States are global, diffuse, impersonal.   One’s relationship to a state is passive, disembodied.  A state of depression just drops over someone, like bad weather…Feelings, in contrast to states, are specific, anchored in the body of one’s experience.  Depression is a state.  Sadness and anger are feelings.  Anxiety is a state.  Fear is a feeling.  Intoxication is a state.  Happiness is a feeling.  One feels about something.  Feelings are embedded in relationships; thus, when one feels something about a relationship, one can take relieving action.  Emotions are signals that emerge from the context of our interactions.  The cure for states is feelings…unlike states, which tend to congeal, feelings will run their course in due time…Feelings are not endless, but our numbing attempts to avoid them can last a lifetime.” (I Don’t Want to Talk About It:  Overcoming the Secret Legacy of Male Depression by Terrence Real, pp. 285-286)

Depression is among the conditions for which most patients seek out a psychologist.  Thus, most psychologists have a great deal of experience in how to treat this condition.  As a psychologist, I have been trained to diagnose depression and other mental disorders in Nashville, TN.  Often, I will use screening instruments in my office, such as the PHQ-9, to help me in making a diagnosis.

Prevalence of Depression   

Depression is the most common of all psychiatric illnesses.  The World Health Organization has found that depression is second only to heart disease as the world’s leading cause of death and disability.  In any given year, 10% of the population of the United States (as many as 30 million people) will become clinically depressed.  One in five people will experience a major depressive episode at least once in their life.  Worldwide, depression is the leading cause of disease burden for women.  Depression is also the number one cause of disability in the world.

 

Overview of Factors Contributing to Depression

Depression occurs when feelings of extreme sadness or despair last for at least two weeks or longer and when they interfere with activities of daily living—such as working, eating, or sleeping.  Depressed individuals tend to feel helpless and hopeless and tend to blame themselves for having these feelings.  Chronic and serious illnesses such as heart disease or cancer may be accompanied by depression.  Significant transitions and major life stressors, such as the death of a loved one or the loss of a job, can bring about depression.

A number of different factors could be responsible for an individual patient’s depression.  Some patients are genetically predisposed to depression.  For these individuals, it takes only one-half as much stress for them to become depressed.  As stated above, sometimes grief and loss “will run their course in due time.”  However, some patients, especially if there is profound guilt or self-criticism, will develop “complicated grief,” often leading to major depression.

 

Learned Helplessness 

Sometimes depression is triggered by what has been called “learned helplessness.”  This was discovered by researchers working with rats in a laboratory.  When the rats were put in a large glass beaker filled with water, initially, they kept swimming to try to find a way out.  When they realized there was no way out, they gave up and drowned.  Thus, it was suggested that when a human patient tries and tries to find a solution to his/her situation, and no solution is found, the patient may give up, and often depression sets in.

 

Depression as a Wake-up Call

Sometimes depression is our bodily system’s way of trying to get our attention.  Our system may be trying to communicate to us that there are some things about how we are living our lives that no longer work for us.  It could be that the relationship or marriage I am in is no longer a fit for me.  Or it could be that my job or career is not fulfilling and needs to be changed.  As a psychologist, my job with my depressed patient is to help him/her to explore what might need to be changed and how to go about this.

As N.F. Smith has written in a NIMH publication, “Depression may be nature’s way of letting us know that something’s gone awry in our lives and that it’s time for a change…depression can be viewed as a mechanism that keeps you from persisting too long in a behavior or activity that has grown increasingly unproductive or unhealthy—a bad marriage, perhaps, or an unfulfilling career, even poor nutrition or eating habits.  ‘You can’t really fix the depression until you learn new, healthier ways of dealing with the problems in your life,’ says Ralph Mumpower, a North Carolina psychologist.”

My Personal Experience with Depression

In his seminal book The Hero with a Thousand Faces, Joseph Campbell describes the steps in what he calls “The Hero’s Journey.”  He writes that these steps are evident in the myths of cultures all over the world, going back thousands of years.  A chapter in his book is entitled “The Belly of the Whale,” recalling the biblical story of Jonah’s being swallowed by a whale, with no idea if he will ever survive.  Campbell writes, “The hero…is swallowed into the unknown, and would appear to have died.”  (p. 74)

My own personal “belly of the whale” period began in my early 40s when I fell into a major depression.  In a New York Times (4/12/2020) article entitled “I’m Grieving Now.  You May Be, Too,” novelist R.O. Kwon describes her own plunge into deep despair: “The last time I suddenly found myself in a state of deep grief, utterly unable to go on as usual…the world I’d known shifted, cracked open and fell apart…for some time I felt as if I might be the loneliest person alive.”  

Like Kwon, I felt in my depression as if the world I’d known had “cracked open and fallen apart.”  While I’d struggled to fully utilize personal psychotherapy in the past, I was now much more able to benefit from it.  I also contacted a psychiatrist, who prescribed an antidepressant for me.  I changed therapists, to someone who helped me greatly to recover from my depression.  I worked diligently with my new therapist to figure out what I needed to change about my life in order to fully recover.

 

Men and Depression

Terrence Real is a Boston psychotherapist who has written extensively about male depression, particularly in his seminal book I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression.  While the DSM-5 cites a higher prevalence of depression in women, Real believes that as many men as women suffer from depression.  Real writes, “Identifying depression with its more dramatic features—anguish, despair, paralysis—we expect that ‘a truly depressed man would lie in bed in the morning, staring up at the ceiling, too apathetic to drag himself off to another meaningless day.’”

Real continues, “But the vast majority don’t act that way.  They work—indeed, many are workaholics.  They bully, even abuse their families—or withdraw from them.  They medicate their pain with drugs and alcohol.  These are the manifestations of ‘covert depression,’ hidden from public view and the sufferer’s own consciousness, a condition that bears little resemblance to any ‘depression’ you’ll find in the DSM-IV.”  Real also states that depression in most men tends to be “mild, elusive, and chronic.”

Where does covert depression come from?  Real finds its origins, both biological and psychological, in the chronic, low-level traumas that typically accompany growing up male—the enforced denial of feelings and rough treatment or neglect by parents or peers.  At its core, Real explains, “covert depression is a disorder of self-esteem.”  He shows how “the inability to cherish oneself in the face of one’s own imperfections leads depressed men to a narcissistic obsession with money, sex, power—just about anything other than their own deepest selves.”

Marital Discord and Depression

According to Steven Beach and Page Anderson, in an APA publication, “People in unhappy marriages are at a 25-times greater risk for developing major depression than those in happy marriages (Weissman, 1987)…negative marital events (such as marital arguments) often precede depressive episodes, especially during the month immediately prior to depressive onset (Paukel, 1979)…Marital therapy can be as effective in the treatment of depression as individual therapy, with the added benefit of increasing the likelihood of enhanced marital adjustment.”

Depression can be ‘Contagious”

According to an article entitled “Health” by Myron Pitts, Psychologist Laura Rosen, director of family therapy at Columbia University’s hospital, noticed that “Family members often seemed to end up suffering from the same symptoms…depression can be contagious,” Rosen says.  “People living with someone who is depressed are four times likelier to be depressed themselves; spouses of the depressed are more vulnerable to emotional problems.”

The Depressive Mind

According to Michael Weinberg in a publication of The Meadows Treatment Center (Fall, 2000), “People who are depressed tend to see themselves in a negative manner…they also tend to have a negative view of the world.  That is, depressed individuals visualize their world during their waking and sleeping hours as filled with loss and hopelessness…A depressed individual will almost always conceptualize the future with negative expectations.  Not only do they believe that they are bad now, but that they will remain so in the future (or get worse). They feel pessimistic about what is to come and helpless to change it.”

The Depression-Rumination Cycle

According to Bridget Law in the Monitor on Psychology (November, 2005),” ruminating about the darker side of life can fuel depression…Ruminators develop major depression four times as often as non-ruminators…Many ruminators stay in their depressive rut because their negative outlook hurts their problem-solving ability…ruminators express low confidence in their solutions and often fail to enact them…ruminators often believe they’re gaining insight through rumination, often have a history of trauma, perceive that they face chronic, uncontrollable stressors, and exhibit personality characteristics such as perfectionism, neuroticism and excessive relational focus—overvaluing relationships with others to the degree that one will sacrifice oneself to maintain them, no matter what the cost.” (pp. 38-39)

Psychiatry and Medication in the Treatment of Depression

Antidepressant medications can be very helpful in reducing the symptoms of depression in some patients, particularly for cases of moderate to severe depression.  Often the combination of psychotherapy and medication is the best approach.  However, some depressed patients may prefer psychotherapy to the use of medications, especially if their depression is not severe.

As Dr. Volney Gay stated to me in a personal correspondence, “Surely, all mental health providers need to grasp the full range of mental illnesses.  Psychiatry is an essential, foundational discipline for all of us.” (June 8, 2019).  Ever since beginning my private practice in Nashville in 1991, I have sought out psychiatrists to whom I could refer patients whom I think will benefit from medication.  I have developed mutually beneficial relationships with a number of psychotherapy-friendly psychiatrists.  In recent years they have included Ben Frock, M.D., Eric Rueth, M.D., Thomas Campbell, M.D., and Scott Ruder, M.D.

Symptoms of Depression and the Range of Depressive Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the “Bible” which catalogs all mental disorders, and is the book that psychologists turn to in order to accurately diagnose mental conditions.  According to the DSM-5, “Depressive disorders include disruptive mood dysregulation, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, and unspecified depressive disorder.” (p. 155)

According to the DSM-5, “The common feature of all these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.  What differs among them are issues of duration, timing, or presumed etiology.”  (p. 155)

Again, according to the DSM-5, “Major depressive disorder represents the classic condition in this group of disorders…Careful consideration is given to the delineation of normal sadness and grief from a major depressive episode.  Bereavement may induce great suffering, but it does not typically induce an episode of major depressive disorder.  When they do occur together, the depressive symptoms and functional impairment tend to be more severe, and the prognosis is worse compared with bereavement that is not accompanied by major depressive disorder.  Bereavement-related depression tends to occur in persons with other vulnerabilities to depressive disorders, and recovery may be facilitated by antidepressant treatment.”  (p. 155)

Let us review the diagnostic criteria for major depressive disorder.  According to the DSM-5, “Five or more of the following symptoms need to be present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.” (p. 160)   I may diagnose persistent depressive disorder (dysthymia) in patients who have fewer than five of the symptoms of depression outlined below.

  1. “Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation by others (e.g., appears tearful). (Note:  in children and adolescents, can be irritable mood.) 
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 
  4. Insomnia or hypersomnia (excessive sleeping) nearly every day. 
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 
  6. Fatigue or loss of energy nearly every day. 
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.”  (pp. 160-161)

 

The Treatment of Depression

According to the article by N.F. Smith quoted above, “Current research indicates that more than 80 percent of depressed patients will respond to treatment, yet the National Institute of Mental Health says that nearly two-thirds won’t get help.  Why?  The lethargy that is a symptom of depression can keep people from seeking help; so can the social stigma or even a lack of understanding of the disease.  And since severe depression is an episodic illness, the sufferer often just waits it out.” (p. 188)

The article continues: “Psychotherapy works well for mild to moderate depression, but with moderately severe to severe depression, talk alone is not as effective as drug therapy coupled with psychotherapy.”  According to Dr. Frederick Goodwin, “Depressives tend to be especially sensitive to disruption in the circadian clock.  So I tell them they need to respect their sleep-wakefulness cycle.  And exercise is important in two respects: one, for its metabolic effect on the brain, and, two, because it regulates the body clock.”  In this same article, Dr. Nada Stotland states, “There’s a synergistic effect between psychotherapy and medications.  The debate about pills versus talk therapy is irrelevant.  I would do it all…Maybe you’ll never know which helped you, but if you end up feeling better, who cares?”  (p. 188)

How Does Psychotherapy Help in the Recovery from Depression?

An article from the Practice Directorate of the American Psychological Association (July, 1996) describes in detail how psychotherapy helps depressed patients recover: “Therapy offers people the opportunity to identify the factors that contribute to their depression and to deal effectively with the psychological, behavioral, interpersonal and situational causes.  Skilled therapists can work with depressed individuals to:

1) pinpoint the life problems that contribute to their depression, and help them understand which aspects of those problems they may be able to solve or improve.   A trained psychotherapist can help depressed patients identify options for the future and set realistic goals that enable these individuals to enhance their mental and emotional well-being. 

2) identify negative or distorted thinking patterns that contribute to feelings of hopelessness and helplessness that accompany depression. 

3) explore other learned thoughts and behaviors that create problems and contribute to depression. 

4) help people regain a sense of control and pleasure in life.  Therapy helps people see choices as well as gradually incorporate enjoyable, fulfilling activities back into their lives.” 

This article states: “Having one episode of depression greatly increases the risk of having another episode.  There is some evidence that ongoing therapy may lessen the chance of future episodes or reduce their intensity.  Through therapy, people can learn skills to avoid unnecessary suffering from later bouts of depression.”

Conclusion

I conclude with a quote from an article in The Nashville Scene (August 16, 2018) entitled “On Mental Illness” by Libby Callaway.  She writes, “One of the lone upsides to dealing with mental illness for such a long time is that I have learned what to do when the fog sets in.  I make an appointment with my shrink.  I speak to my psycho-pharmacologist about tweaking my meds.  Most importantly, I talk about it…I believe that in order to fight the prejudice (against mental illness) and save afflicted people from living what feels like a solitary existence, those of us who have been through the wringer need to talk about it openly and frequently.”  

Callaway adds, “I have to be vigilant.  I have to take my meds.  I have to exercise.  I have to engage with friends.  I have to tell other people what’s going on and be honest with them when they ask me if I’m okay.  I have to be honest with myself.”  (p. 31)