Key moments, in order
So much of what actually makes a patient better is the alliance, and most of that is a shared understanding of what the problem is, what the goals are and how to get there.
Depression is probably the biggest umbrella term in psychiatry. Depression is a symptom, not one diagnosis: perhaps the biggest mistake early clinicians make is hearing depressive symptoms and concluding major depression.
A core depressive syndrome is persistent (at least two weeks in a row, or at least half the time over a couple of years) and comes with problems in energy, motivation, sleep and appetite.
A diagnosis is for medical purposes, a small way to capture one specific problem. It does not explain everything about you as a person, or even the whole problem.
Every clinically significant depression comes from a biological, psychological or social source, or some combination, sometimes all three.
Treating the biological side can have a knock-on effect on the psychological and the social.
There is no imaging, lab or radiology test, so you can never really know what you are dealing with in one person until you try the treatments.
If a patient does not believe in a treatment at least halfway, their negative expectations will stop it from working.
Medication and therapy are probably equal in efficacy. Medication is a little faster: standard antidepressants take about four to six weeks to work, with some effect at about two weeks.
When everything feels negative, therapy can stall because the patient cannot keep an open, flexible mind. Medication can help them get more out of it.
The major mimics of depression are substance-related depression, PTSD, personality disorders (recently also called complex trauma) and bipolar disorders.
Even when depression seems to come from a medical illness, recovery is usually fullest and fastest when the depression and the medical condition are treated at the same time.
Whatever the cause of a depression, regulate the daytime and nighttime cycle, with good sleep hygiene and protected sleep time.
Treating depression while the substance use goes on is like trying to fill a boat with a gigantic hole in it.
Alcohol deserves a specific call-out because it often feels relieving. In test animals, a single dose disrupts sleep quality for a couple of weeks.
Cannabis may not directly worsen depression, but it does directly prevent recovery.
Trauma disorders respond better to trauma therapy, and developmental interpersonal problems respond better to changing how you conduct your relationships, and with whom.
Until you address upstream problems like trauma or personality, the depression continues. A medication may work for a month or two, and then it poops out.
Depression alone is unlikely to bring lots of nightmares, fear responses, startle, irritability, anger outbursts and fearful avoidance. Seeing those, suspect trauma.
For depression, ask whether the low mood is there no matter what is happening, or mostly in the context of bad feelings between the person and others and in how they relate to themselves.
Any effective therapy needs the patient to understand clearly what the problem is, for that understanding to be accurate, and for patient and therapist to agree on how to solve it.
When a patient says therapy didn't work, remember that therapist skill varies enormously. It is like saying a book didn't help: which book did you read?
The easiest way to tell if you are in a good therapy is how your therapist responds when you bring up issues about the therapy itself.
The minimum effective dose of therapy is once a week. Going every two weeks because there is nothing to talk about misses the point.
A low-hanging fruit: tell patients to get 15 minutes of sunlight within the first hour of waking up.
Social media can feel like socializing without the important feelings that real socializing brings.
There seems to be a set of people who never meet full bipolar I or II criteria and still do not respond well to typical first-line antidepressants.
Family history is the biggest pointer: a sprawling family history of bipolar disorder really raises the chances. A first-degree relative with a clear diagnosis counts most; vaguer stories are the realm of fuzziness.
Build stability so the days have patterns. Wake up at the same time every day, with a little morning routine to get things going.
The most important behavioral piece is enforcing a steady wake time every single morning, no matter what, with some kind of morning activity or ritual.
Depressed patients wait to get motivated and the motivation never comes. Behavioral activation flips the script: you do things in order to start feeling better, not the other way around.
The point is to set goals, however small, and accomplish them. If they are not being met, make the goals even smaller, so the plan does not add more stress.
Social supports, people you can rely on and talk to about your feelings, thoughts and wishes, are a very important part of long-term recovery. The need for attachment and relationships is a human need, not an add-on.
Reconnecting helps: with old friends from college, a church, a meditation center, a sports group.
When therapy is not possible, at least have them work through a workbook. Feeling Good or Feeling Great is a very nice one for the classic melancholic patient, and The Happiness Trap is the other we always recommend.
Depression does not make people more realistic. It is a huge negative bias, rose-colored glasses of negativity, and that bias is what CBT works on.
If you can see a problem as something that is not fundamentally part of who you are, you have more hope of changing it.
Patients who depend on staying ill (litigation, benefits) are less likely to get better. Often it is unconscious: getting better is scary and unknown, and means facing past failures and regrets.
Ask how they relate to the diagnosis: when you say I have depression, what do you mean by it?
On who to tell: the zippers are on the inside. You control who you tell, what you tell them, and how vulnerable you want to be.
Taking even one medication every day is a lot harder than people give it credit for, whatever it is for.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.