Sunday, July 31, 2016

"I'm depressed. Should I pop a pill, go for therapy, or both?"

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Depressed and torn about whether to pop a pill or go for psychotherapy, also called talk therapy?  Here’s what to consider when picking a strategy for managing you depression.

In this piece, I look at medication, talk therapy, and studies that examine both. But it’s a long read and you’re busy, so I kick off with a quick summary. Then, if you have time, you can dive in.

Science Summary

Good news is that depression is very treatable. The American Psychiatrist Association report that 70% to 90% percent of people with depression eventually respond well to treatment. 

But it’s not a one-size-fits-all instant fix.

Medication works better than doing nothing. Roughly 50% of people with depression can see their doctor, pop a pill, and after 8 weeks find they’re happy with the results.  

Talk therapy works better than doing nothing. Roughly 46% of people with depression can talk to a therapist once a week and are happy with results after 8 weeks.

BUT thinking to fix depression in 8 weeks is a bit unrealistic.  Pills can work a bit quicker at first but if you look at results after a few months, people find talk therapy slightly better than medication for improving quality of life.

Today, big studieshave found that combining talk therapy and medication works better than using either one alone.

My View

I think of depression as spots: you may have spots because you have chickenpox, an allergy to soap, you lost your job or more. Depression can be a condition but it can also be a symptom. 

Figuring out what's causing it will lead you to the appropriate action. There's no point in changing your soap if you have chickenpox.

Depression is the same. There are lots of different causes and that's why there are various approaches for managing it. There's not one-size-fits-all.

Most studies don’t really look into the cause of depression, they just treat it all as one thing. So the science is not always very scientific.

My view is that before you do anything, you should try and figure out what’s going on.

If you are depressed because of your life circumstances, a pill may help with mood but it won’t change your life circumstances. 

For all depression, talk therapy will help you learn tools that you can use all your life.

However, if you are so down that you can’t function, medication can help give you the mental space to start working for effective change. 

Also, if you have regular cycles of depression, then meds can be helpful to balance your mood.

Finally, if you are suicidal, talking to your doctor is a must. 

Bottom line: if you are not suicidal, try talk therapy first and then you can always look at meds later. 

And now, the big discussion!

Depression: Talking About Medication

In theory, you’re depressed which involves your body, specifically your brain. If you have an infection, you take a pill to fix that, so if you’re depressed, taking medication will help fix it. Easy, right?

In practice, it’s a bit trickier.

There are about 20 commonly available anti-depressants on the market.  Exactly how they work is something doctors fight about.

If you’re a neuroscientist or pharmacologist well versed in neural pathways and neurotransmitter systems, go read up but for us ordinary mortals, the science is unintelligible.

What us non-doctors can examine is how many people find these drugs useful. 

How successful is medication?

Important fact: antidepressants take between 2 and 8 weeks to start working. People don’t always know this, so many of them pop a pill, think it doesn’t work and quit after a day or so.

Medication takes time to work.

Typically, if you prescribe antidepressants to 100 people and ask them how it’s going after 8 weeks:

  • 50 people will be happy with the results. The other 50 will not.
  • Of the ones who are not happy, a lot will say they feel no difference at all.
  • Some will say they feel a bit of difference but it’s not a game changer.
  • And some will say they feel a difference but they’re also experiencing side effects such as insomnia, fatigue, and loss of appetite.

As there are 20 types of meds on the market and different doses, a doctor may either adjust the dosage or give you a different brand.

Then you have to wait 8 more weeks and ask again, how is it going for you?  Typically, half will then be happy with the results and the other half not.

Although people with severe depression will keep going, trying different brands and doses, most people get so fed up with the process that they give up.

Also, research suggests that 30% of people have treatment resistant depression, meaning we don’t have the meds yet to help them.

In 2018 researchers at Oxford University conducting a meta-analysis of 432 randomized controlled trials involving 116477 people reported that any kind of antidepressant is more effective than placebos (taking sugar pills).

Medication is useful, better than doing nothing, so if you want to read up, there is the UK National Health Service overview of antidepressants and USA National Library of Medicine Depression: Learn More.

Depression: Talking About Talk Therapy

Aside from depression being like spots, the experience is not the same for everyone. And if that’s not complicated enough, you may find that your depression changes according to your age and circumstances.

What is a constant is that depression lies to us: it tells us life sucks, it promotes sadness and anger, makes us blind to daily happiness, stops us doing fun things, messes with our sleep, raises our anxiety, twists appetite, and causes general havoc.

During psychotherapy a therapist (me!) will help you identify how your depression works, and then we work together to figure out a system that will help you push back.

How successful is talk therapy?

That’s a really hard question to answer because there are dozens of different talk therapy systems. Each one has a different philosophy, a different approach, and as therapists are human and not robots, how it’s delivered is different too.

Plus, there politics involved. One particular approach, Cognitive Behavioural Therapy (CBT) has a philosophy that lends itself to automation. As hospitals and apps use that to create bots and apps (much cheaper than employing people!) it is the one that’s pushed most.  

I like CBT (you can read why and how it works here) but what worries me is that research is biased because many studies take place in hospitals that only have CBT and so many studies just totally ignore other approaches.

However, I have a nice study for you.  In 2021 researchers from Vrije Universiteit Amsterdam, Netherlands conducted a meta-analysis of 331 trials involving 34,285 people comparing all kinds of therapies.

They analysed studies that used cognitive-behavioural, interpersonal, psychodynamic, problem-solving, behavioural activation, life-review, and "third wave" therapies like mindfulness.

They also reviewed ‘supportive counselling’ which is based on being nice and listening. Often this is what untrained volunteers at charities do but some therapists offer it too.  

Then they compared all these approaches to doing nothing, waiting lists, and placebo pills.

They reported that:

·         Doing something is better than doing nothing, waiting, or taking a placebo pill.
·         All the various therapy approaches yielded similar results.
·         Supportive counselling had some effect but wasn’t as useful as having a therapy approach.
 
 The researchers concluded that most therapies work well for treating adult depression, and differences are small. Choosing a useful therapy may depend more on personal preferences, availability, or tailoring treatment to the individual.

What Next?

In summary, when it comes to managing adult depression, the choice of whether to pop a pill or go for talk therapy is often less about which method is the most effective and more about finding the right fit for you.

·         Some people find talk therapy works for them.
·         Some people take an antidepressant and they feel good again.
·         Some people have to try out different drugs in order to find one that works for them.
·         Some people find they need a mix of antidepressants and therapy.

Do what suits you best!  And if you want to try talk therapy, send me an email.

Thanks for reading ❤️

Updated: 23rd January 2025

   
Photo credit: Image by Gordon Johnson from Pixabay     

How To Find A Therapist In Malaysia Or Other Developing Nation

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I work online and in any country you like, but supposing you don't want to work with me, how do you go about finding a qualified therapist?

It's not easy to find a qualified mental health practitioner in Malaysia. There aren't many of them, and there are very few laws that govern the professions.
   
If you want a psychiatrist, a medical doctor who specializes in the diagnosis and treatment of mental disorders, you're okay. There's an association and everyone who's a psychiatrist has to join.
   
There's a counselor association but not everyone who joins has the same kind of training and not everyone practices.  Also, they don't accept foreign trained professionals, or those who want to practice online.
   
In Malaysia the term counselor is legally restricted (although not enforced, from what I see) but there are no laws that cover the terms psychologist, therapist and other mental health worker descriptions.
   
In a word, it's chaos. I have a friend with an Australian counseling degree who can't join the professional organisation here unless she retakes the whole thing in a local school, and there's a quack with no training whatsoever who advertises psychology services in the newspapers. We also have people with fake degrees practicing.
   
My clients from the Middle East, Africa and Far East tell me they have exactly the same issues in their countries, so I believe that Malaysia is the rule rather than the exception.

I don't expect matters to improve soon because accreditation is a problem everywhere. 

First, groups tend to be exclusive rather than inclusive. This means that if your degree says 'psychology', you may not be able to join a counseling organization, and visa versa. 

Second, working cross borders is a complete nightmare. In the European Union, a Polish degree works only in Poland; in the USA licenses tend to cover just a single state.
   
What does it mean for you? If you live in a country where mental health practice is still fairly new and unregulated, and you want help, I suggest you do this:
   
1. Ask your family doctor or GP to list the practitioners she knows. She may not know straight off, but she'll know how to sort out the quacks and cons.
   
2. Go to a government hospital and ask for recommendations. They tend to be better at screening than for-profit hospitals.

3. Ask a psychiatrist for reliable associations and practitioners. They should know who to talk to but they tend to be awfully busy so be prepared for a bit of a wait. If the practice has a nurse or receptionist, ask her or him.
   
Good luck!

Credit:Image by Gerd Altmann from Pixabay