Managing Your Depression (9 page)

CHAPTER 4
Managing Your Mood Disorder

Following Your Treatment Plan

Treating your depression and bipolar disorder is ideally a collaborative effort between you and your doctor(s) that often includes both medication and talk therapy, also called psychotherapy. Most people seek treatment to feel better and to function better. Treatment can also help you learn new skills, understand and manage your emotions, and deal with difficulties in your relationships.

Most people with depression or bipolar disorder are treated in an outpatient (office) setting. Usually, a psychiatrist is the doctor who prescribes medication and works with you to create an overall treatment plan. In some cases, an internist or a family doctor prescribes the medication. Depression is most often treated with an antidepressant. Bipolar disorder may be treated with mood-stabilizing medications, such as lithium or others. It may take 6 to 8 weeks after starting a medication for you to begin to see improvement. You may have to try several different ones before finding the most effective medication or combination of medications for you.

It is essential to stay on the medication once your symptoms have started to improve. Stopping it too soon puts you at risk for recurrence (return) of your symptoms. This does not mean that you are dependent on the drug. Unfortunately, research has shown that non-adherence (not sticking) with antidepressant medication is a common problem, with only half of patients continuing an adequate dose of therapy in the short term. Those patients are at risk for not getting better or for having their symptoms return. This is why it is important to continue to see your physician, preferably a psychiatric specialist, on a regular basis until your symptoms clear.

Psychotherapy (talk therapy) is a significant treatment for mood disorders, and alone or combined with medication, it has been effective in preventing further episodes of depression. It is a type of guided therapeutic conversation that focuses on your psychological and emotional problems, distorted thinking, and troublesome behaviors. The mental health professional who specializes in talk therapy is usually a clinical psychologist, who will work with you to create a psychotherapy treatment plan. The success of psychotherapy depends on building a trusting relationship with a therapist who is a good fit for you. Psychotherapy takes time and effort to see results. It is not a passive treatment—you need to do a lot of hard work to gain from it. Sometimes you benefit from the work you do during appointments (individual or group therapy). Often the benefits come from work you do during the rest of the week, when you have the opportunity to apply to your daily life what you have learned in your sessions. Treatment often involves making some change in the way you think or behave, and that may be uncomfortable. Changing to something unfamiliar can be both scary and hopeful. It is scary because you are doing something different and perhaps a little uncomfortable, and hopeful because the purpose is to feel better. Psychotherapy may also stir up unpleasant emotions. Dealing with these emotions is important to your recovery.

There are many different types of psychotherapy, each with a different name. The type you receive depends on your problems and your needs. Cognitive behavioral therapy (CBT) is a form of talk therapy that has been extensively tested and shown to be very effective in treating depression and reducing the risk of relapse (return of symptoms). Mindfulness-based CBT is a somewhat different approach that is also effective for some people. Another type of psychotherapy, dialectical behavior therapy (DBT), teaches concrete cognitive behavioral and mindfulness skills in four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. It has been shown to be an effective augmentation
(additional) therapy to antidepressant medication, resulting in improvement in depression symptoms.

Medication therapy and psychotherapy alone are each effective in treating depression and reducing the risk of relapse and recurrence. In combination, they offer an even greater benefit against relapse. They are seen as therapies that complement each other. Psychotherapy offers a broader range of benefits, such as improving your level of functioning, diminishing residual symptoms, targeting specific symptoms (such as guilt, hopelessness, and pessimism), teaching coping skills, improving interpersonal relationships, and targeting different brain sites than antidepressants do. The effects of psychotherapy are longer lasting and sustained beyond the end of treatment.

Sometimes the symptoms of your mood disorder worsen to the point where treatment in an inpatient hospital setting is needed. Inpatient care is a more intense form of treatment, where you receive daily individual and group therapy as well as medication management. Entering the hospital can be a scary experience the first time you are admitted, especially when you do not feel well and do not know what to expect. It can also be difficult if you do not feel the support of family or friends, who may not understand your illness or its treatment. However, an inpatient unit provides a safe environment during a rough time. This is especially important for those who have disorganized or suicidal thoughts. Most people treated in a hospital find it to be extremely helpful and even lifesaving.

On the inpatient unit, you work with a team of mental health professionals who review your current treatment plan and may suggest modifications. The inpatient team usually includes a senior psychiatrist, psychologist, nurse, social worker, and sometimes an occupational therapist. A teaching hospital will also have psychiatry residents, medical students, and sometimes nursing students. Your inpatient treatment plan is a collaborative plan between you and your team; you have the right to decide what feels appropriate
and helpful for you, as long as it is safe. In some cases, treatments such as ECT (electroconvulsive therapy, also called shock therapy) may be recommended as part of your plan. You will also receive the support and input of other patients in group therapy sessions.

In addition to taking medications and participating in psychotherapy, taking steps to manage your illness in your everyday life is essential. Helping yourself in this way offers the best chance of recovery and of staying well. You can learn to manage your illness in this and the next few chapters.

The Relationship with Your Therapist

The success of your treatment, particularly psychotherapy, depends on building a trusting relationship with a therapist who is a good fit for you. How do you find this therapist? That answer varies among individuals. One place to start is to ask your psychiatrist or primary care doctor for a recommendation. Depending on who is available in your geographic area, he or she may refer you to a clinical psychologist, licensed therapist, or licensed clinical social worker. Try to find one who specializes in treating patients with depression. If you live near a large teaching hospital, most academic Psychiatry Departments have a specialized Depression Unit that can refer you to a staff member. Get several names and then interview each one
face to face
to see if you feel comfortable speaking with this person. Not everyone will be a good match for you, so keep looking until you find someone you think will work. Do not be afraid to ask questions of the people you interview. Inquire about their training and background. Find out if they can schedule your appointments around your work hours. Ask about the method of payment and whether or not your health insurance company will pay for it. Make sure that the person you choose will coordinate your care with your other doctors (psychiatrist, family doctor, etc.).

What Makes a Good Therapist?

There are many different therapists, each with a particular style, personality, and training. They may also practice different types of psychotherapy. Those differences do not prevent them from delivering good quality care.

You should expect that a good therapist

• listens and pays attention

• is empathetic and understanding

• is not judgmental or dismissive

• shows respect

• builds trust over time

• offers sound professional advice

• maintains boundaries

• does not impose his or her personal biases or viewpoints on you

• helps you to see your way through a problem and does not do it for you

• builds on your strengths

• offers you a regular appointment at the same time and day

• begins and ends appointments on time

• does not take telephone calls or allow other distractions during your appointment

• is available to you by page or telephone after hours for emergencies

• maintains your privacy and confidentiality

What Makes a Good Patient?

What do you need to do to get the most benefit from your therapy? Show by your actions that you are interested in and committed to talk therapy. Participating in therapy is a two-way street, and you have to do a lot of the work. You also need to keep up a good professional relationship with your therapist. Helping yourself in this way provides the best chance of recovery and of staying well.

These guidelines will help you be successful in therapy:

• Follow all treatments as prescribed. This includes taking medications and acting on other recommended therapies.

• Keep your appointments as scheduled. Do not skip appointments or cancel them at the last minute unless there is an emergency.

• Go to your appointments on time and stay for the entire session.

• Arrive sober. Do not show up to your appointment under the influence of alcohol or drugs.

• Be honest with your therapist.

• Make an effort.

• Do the “homework” assignments that your therapist asks you to do.

• Come prepared for each session with an idea of what you would like to discuss or work on with your therapist.

• Turn off your cell phone, iPad, and other electronic devices during your appointment.

• Listen.

• Pay attention to the conversation. Catch yourself if you begin to daydream off the subject.

• Take notes if you are having trouble concentrating or remembering what is being discussed.

• Show respect.

• Maintain boundaries. This is a professional relationship, not a casual friendship.

• Control your anger and outbursts during the session. If anger is a problem for you, your therapist will make addressing it part of your treatment plan.

• Learn to trust the therapist and understand that he or she has your best interest in mind.

• Avoid making phone calls to your therapist unless the situation is urgent.

• Call your therapist or go to the nearest Emergency Department if you are feeling unsafe or suicidal.

Managing Depression and Bipolar Disorder

Managing your depression or bipolar disorder effectively is critical to maintaining your emotional balance and stability. It can help you feel and function better. People who participate actively in their care and work to manage their illness have a better chance of recovery and of staying well. Some people find that the symptoms of depression interfere with what they must do to manage their illness. For example, the symptoms of fatigue, poor appetite and sleep, and lack of interest can interfere with your ability to get the physical exercise necessary for a healthy life. This makes managing your illness a challenge, but it can be done. And it will make a difference.

What does it mean to manage your illness? It means that you learn about the illness and that you use certain methods, strategies, and skills each day to respond to the symptoms you have. These strategies are discussed in detail in this chapter. Developing the tools to deal with your illness will help you recover, prevent worsening, and avoid relapse (a return of symptoms).

Managing your depression effectively requires that you pay attention to your symptoms and monitor them, challenge negative thoughts, use problem-solving techniques, make adjustments, and avoid negative behaviors (see
chapter 5
). It means that you regulate your daily routine and make efforts to improve current relationships. Effective management also includes attending to self-care, following a healthy lifestyle and diet, getting physical exercise, and following the treatment plan you developed with your provider.

Self-management is best done in collaboration with your health care provider(s), who work with you and guide you along the way. You need to be partners in the process and participate in making decisions about treatment, interpreting and managing changes in your condition, coping with emotional reactions, implementing behavioral changes, and using medical and community resources wisely. Actively managing your illness may enable standard therapies to work better and may decrease the risk of relapse.