The difference between CBT (or cognitive behavioral therapy) and psychodynamic is also in the role of the therapist. In CBT, the therapist takes a role of more of like a teacher and in psychodynamic, it’s a person that is there to guide you to help you process events. So what happens with CBT or cognitive behavioral therapy? You’re going to explore your negative thoughts, those patterns that you keep on repeating. In psychodynamic you’re going to go more into the past and look into what has brought you here. A good analogy that I like to use for this is a band-aid analogy. So imagine that you got hurt and you have this horrible wound now. It’s an open wound, it’s bleeding. So the first thing to do is to go ahead and grab band-aid to stop the bleeding. Well, the band-aid does not do much. It stops the bleeding and it might take a little bit of the pain away, but the reality is the wound is still there and it will keep on hurting and it will show up maybe in other areas it might get infected and show up in other areas. CBT and psychodynamic work sort of in those ways. CBT is sort of like that band-aid – it will give you the tools to help you manage your symptoms that you’re struggling with right now. That doesn’t mean it heals. It will not heal your emotional wound. It just helps you cope with it. Psychodynamic goes more into the wound, deep into the wound to see how it took place and how we can start healing. So I know that I’m a little bit biased on this because I am a psychodynamic therapist, but the reality is that there are two different kinds and you can still (as a psychodynamic therapist) I can provide you with some tools, which I usually do such as breathing techniques to help you cope right away with your, your most intense symptoms.

Some of the great tools that I encourage my clients to use are breathing techniques (which helps those who struggle with anxiety), journaling (which is a great source to relieve some emotional tension), meditation (you don’t have to do 20 minutes on the first time, you can start with one minute a day and there are some good apps out there that help you with that), exercise (it’s great for your health and it’s also great to release some tension), and last but not least, the support network (the use of a support network is very important and it will help you thrive and live a healthier life.

Journaling is a great tool that I encourage my clients to use. Journaling works sort of like a diary except that you want to in there include all the feelings that you struggled with throughout the day. So for example, if you had a hard day at work, what did it feel like for you? What kind of feelings did it bring up for you? The other thing about journaling is that it’s important to develop some sort of routine with it – so maybe it will be something that you do before bedtime. You prepare a nice cup of tea and this will be a bedtime thing that you do. It’s part of self-care. The great thing about journaling is that it allows you to process all of the emotions. So for those who struggle with traumatic events, it really allows them to process those traumatic events. So there are a lot of great things about journaling. I hope this encourages you to start one.

Being present means listening with purpose. Imagine showing up – not just physically but also emotionally and with all of your senses for your partner and most importantly – for yourself. Imagine those simple tasks, how much better they will look when you, for example, wash the dishes and you feel the warmth of the water in your hands or smell soap. Or even better, each morning when you prepare your coffee and you grind those beans and you can smell the coffee about to start getting ready and then you pour yourself a cup of coffee and you feel the warmth in your hands. Imagine each thing being able to enjoy it with all of your senses. Well, that is the magic of being present and how it brings happiness into your life. This is something that you can do with every activity you have each day. Nowadays, we focus so much in technology and we’ve missed this – enjoying the here and now of each day. Why don’t you try it?

A great breathing exercise that I encourage clients to do is the 4-7-8. Four: you’re going to inhale: 1, 2, 3, 4. You’re going to hold it for seven: 1, 2, 3, 4, 5, 6, 7. And then you’re going to let it out from eight: 1, 2, 3, 4, 5, 6, 7, 8. This is a great technique for those struggling with anxiety, panic attacks, and depression and it is a great relaxation technique. If you have children and they struggle with anxiety and they need some breathing techniques as well, there’s a great exercise called the starfish: you tell the child to open their hands wide like a starfish and then they’re going to trace with their other finger – each finger. As they go up, they inhale. As they go down, they exhale. Inhale, exhale, inhale, exhale, inhale, exhale, inhale, exhale. And they can do it about four times, three times – as many times as you think that it will help them – usually three times and they’re tired. This is a great exercise to teach them to also start regulating their emotions as well. I hope you give it a try.

When the symptoms of depression get severe, sometimes the person might struggle to get out of bed or struggle with some suicidal thoughts. The therapist might advise to seek some evaluation from a psychiatrist to see if at this time, medication is needed.

During teen years, teenagers struggle with a lot of pressure – either from school, from their parents, family, or from their friends. It is important that they have the support they need during those years. Some of them might develop some symptoms of depression and anxiety, and this is where group therapy’s a great place for teens to develop some sense of self, develop their identity and boost their self-esteem. It is important that they keep open communication with their parents and the school counselor to be able to ask for the help they need.

Hope is something that you can find within yourself and around those who love you, so hope is built from that network of support that you have – that’s where you can find hope. Also, it’s great to build hope around your volunteer work. It is said that volunteer work brings more to yourself than actually what you give to others and it’s actually true. So one great way to build hope is to go out into the community and see how you can be of use out of help for others.

Another great technique that I like to use with my clients is the safe calm space – it is a visualization exercise. So for this one, you’re going to close your eyes and imagine a place where you feel safe, relaxed, comfortable. For a lot of people, that place is a beach. You’re going to be there and you’re going to use all your senses. So you close your eyes and the first thing that you feel, what is it? Is it warm sand on your feet? What kinds of things are you seeing? Are there other people there? Are you alone? What kind of sounds do you hear? Is it crashing waves on the shore? What kinds of tastes do you feel? Do you feel the taste of the beach, of the ocean, is it saltiness? What kinds of smells come up for you while you are there? Is it the smells of the ocean? This is a great place for you to go every time you are stressed, anxious, or struggling with situations – it’s a calm place for you to be.

Sleep is the most important thing for physical and mental health. A lot of times parents will bring in their kids and we’ll sit down and talk. They’re suffering from many different symptoms of depression and the first thing I ask is: how many hours do you typically sleep at night? Kids need to sleep eight to nine and when you break that down, that means they have to go to bed at like 9 or 10 so they can get up for school in the morning. That’s not happening very often. Sometimes they’ll look at their fitbits and they say, oh, I guess I slept four hours last night because I was doing homework. Five hours the night before because I had a soccer game and five and a half the day before that because while I was on Facetime with my best friend. What we want to look at is what symptoms that could be causing that looks like depression but might not be. It can cause irritability and fighting with parents. It can cause social withdrawal and being too tired. It can cause poor concentration and doing poorly in school and it can also cause considerable increase in appetite. So we really want to focus on the sleep. It’s worth spending a lot of energy, a lot of time on Google trying to sleep more hours, trying to sleep better. Vice versa, we also need to look at if you do have clinical depression, a symptom of that is an inability to sleep. If that’s the case and you just can’t sleep, you lay there at night, you go to bed at appropriate time and you just lay there – that’s the time to seek out a doctor or a therapist to try and get some medication or get some help sleeping because that might really hinder your depression from getting better.

A bully’s main goal is to isolate you. Either they say something mean to you on the internet or they intimidate you in real life – what they’re trying to do is get you alone. When you’re alone, you feel bad. You crouch down, you withdraw into yourself and they can be even more mean to you. The first thing you want to do is if you have even the tiniest bit of bullying coming towards you: tell your friend. Do it before your self-confidence gets so low that you’re ashamed of yourself. Do it right away. You have got to tell your friend. You have got to tell your parents. You have got to tell your teachers. The goal for you is to get a community around you so you’re not alone. Therefore, you can still think clearly. You can remember: okay, I’m not actually so terrible and bad like they’re saying. I’m not so awful. Because you’ve got people around you who agree with you. If you wait too long to get help, you start to internalize everything they’re saying and doing. You start to crouch down and then they come at you even more.

This is a really common question for adolescents. Throughout adolescence, that’s the developmental phase where you start to question: Who am I? What do I want to be? What have I been? And you start to look at what kind of person you want to be and you can try on 15 different ways. Where I like to start as a project is I ask clients: who are your grandparents? Tell me about your grandparents. Tell me about your grandparents’ relationship with your parents. How were they? Tell me about your parents. Tell me about your parents’ relationship to you. And through doing that we start to see: you didn’t move out of a vacuum. You do have a history. This is who you are today. It certainly doesn’t need to be who you become as you come into your own adult life, but it’s something to know so that you’re making conscious decisions. You can really sit down and pick apart your parents’ values and choose which ones you want to internalize and keep for yourself versus which ones you’d prefer to throw away and that’s not really you. One of the things that I really encourage kids is to dream. Be very creative. Think about yourself a lot. Think about your life and what you want. What might you like to do? Where might you like to go to college? Do you want a small school or big school? Do you want to get married? Do you want to have kids? Do you want to go on a lot of vacations or do you like to stay at home and have a simple life? All of these things are really important and you don’t get to any of the answers unless you just sit there and dream. You come up with all these crazy ideas and you’d be willing to edit them at any point, but it’s important to just sit down and dream.

When trying to treat your own depression, I usually present to clients sort of a hierarchy approach – we need to knock off the most important first that could be most impacting your depression. Number one is sleep. You have got to go to sleep. You got to try your very, very best to get eight to nine hours of sleep per night. A way that I recommend clients to do this is either to get a FitBit that tracks your sleep or you can just use an app on your phone – it’s really not that difficult. The second thing (once you’ve taken care of sleep) the second thing you need to do is you need to exercise. Research shows that exercise about 30 minutes, four to five times a week – it doesn’t have to be super strenuous. It could be a bike ride, could be a run, it could be following a yoga video on YouTube. If you do that, research has shown that it’s equally as effective for depression as antidepressants are. Sometimes you need both, but that’s a really good place to start. The third thing I would go to is looking at your sadness and looking at your anger. Depending on why you feel depressed right now – you might be super sad about a breakup, sad about your parents divorce, sad about your friends abandoning you at school – if you feel particularly sad about that, what I want you to do is write about it. Paint it. Find some creative outlet to use it up. What we want to do is not avoid the sadness and run away from it and try to distract ourselves, but rather: okay, I’m really, really sad today. Let me schedule in my calendar an hour to lay in bed and cry to Grey’s Anatomy or cry to sad music. We need to use it up – not all 24 hours, but just one hour a day. You’ve got to use up your sadness. And the same thing goes for anger. Depression can many times come from anger turned inwards. We’re angry at our parents, we’re angry at people at school, we’re angry at our teachers, we’re angry about a lot of things we can’t control. And so – screw all of it. We get angry at ourselves. I’m awful, I’m bad, I can’t do it well enough. My family’s a mess because of me. We need to try and turn that anger back outwards. That doesn’t mean screaming at your parents and other people, but writing – writing is my favorite way to do it. Write down a list of everything you’re angry about. Journal it. Try and get as much of that anger out of you as you can. Anger is much easier to process than depression itself. And the third tip – if you’ve done all of those things and they don’t seem to be working, next, I would look for a therapist. Talk to your parents, talk to your counselors at school, see if they’re willing to get a therapist and bring you to therapy. If that still doesn’t work, then what we do is we go to a psychiatrist. Psychiatrists can prescribe antidepressants or medicines that can help you feel better. If you’re way up at the top and haven’t tried any of these things yet and you feel really helpless, there’s a lot of things you can still do that we can really try to tackle these feelings and get you feeling better.

Additionally, there are medications that seem to have caused depression in some people – or at least symptoms that look like depression: certain asthma medications, certain blood pressure medications, certain hepatitis medications, smoking cessation medications all seem to cause these types of symptoms in some vulnerable populations and therefore whenever you’re starting a new medication, if you are struggling from depression, it’s a good idea to run the new medication by your doctor to make sure that there’s nothing that would require additional monitoring. Other biological contributors to depression that we think about are substance abuse and really addictions of any sort: alcohol, recreational drugs, gambling addiction, sex addiction – all of these can contribute to symptoms of depression in many individuals and have to be very thoroughly considered in the diagnosis. Psychological factors also have to be considered as potential contributors to depression, so people who tend to think in all or nothing terms (for example: everything is all good or everything is all bad) will often be more subject to depression. People with low self-esteem are at a significantly higher risk of depression. People who don’t deal with adversity or don’t have as much of a coping system may be at higher risk for depression than many others.

When talking about the causes of depression, it is important to note that while we lump everyone together as having major depressive disorder, in reality, these may be very different conditions. A person who has depression related to lack of sleep may be very different than a person who has depression related to low thyroid hormone, may be very different from someone who has depression due to poor coping skills. We generally group them together with the same term as a sort of final common pathway that they’re all showing the same symptoms, but in reality they may be very different conditions that in the future we may better understand and be able to individualize the treatment in a more specific way.

There are a number of red flag symptoms that should encourage someone to seek help for depression right away. These would include things like: thoughts of harming oneself or others, or if the depression is tangibly affecting them in a very direct way. So for example, if someone is in danger of losing their job, losing a relationship due to their depression, they should certainly seek treatment right away. The other general recommendation we give when it comes to seeking treatment is if the depression is not going away. What’s considered not going away? Obviously there are different opinions on how to define that. A general rule of thumb we give people is about two weeks. If a person is having consistent symptoms for one week, that could be a fluke. Once it’s getting to two weeks, that’s already getting closer to the point where it’s probably a good idea to speak to someone just to try to turn the current before it becomes more entrenched.

There are many different mental health professionals who can adequately treat depression in different ways: a psychiatrist is a medical doctor who can prescribe medications and other forms of treatment for depression and can also provide psychotherapy (which is a fancy term for talk therapy) that uses dialogue to improve the symptoms of depression. Other professionals included psychologists, social workers, marriage and family therapists, who are all specialists in providing psychotherapy and can be extremely helpful in treating the depression. So if you’re looking specifically for medication, a psychiatrist would be the way to go. If you’re looking for therapy, any one of those professionals would be a fine way to go.

Depression can be treated in a variety of different settings, depending on how severe the symptoms are. At the highest, most acute level is what we call inpatient hospitalization – meaning that a person goes to the hospital (it may be in voluntarily in some instances) to receive treatment. Sometimes people will voluntarily elect to go to the hospital as well, where they’ll receive more intensive attention, medication therapy, hopefully psychotherapy as well that can help boost them and pull them out of the depression more rapidly. Inpatient hospitalization will be particularly appropriate in situations where there are concerns for safety. So for example, if a person is having thoughts of harming him or herself, it is very important to strongly consider inpatient hospitalization and sometimes this even needs to be pursued involuntarily to save a person’s life. Below inpatient hospitalization is residential treatment. Residential treatment is where a patient will go and live in a particular place – a particular facility. It is not a locked facility, it is not a hospital, but it will often have a doctor or a mental health professional on staff to help with the treatment to convalesce. This may be appropriate for someone where there is not a significant concern for suicidality or other risks to health, but where the symptoms are still too severe to be managed while they’re living at home.

Other times, people will treat their depression in what we refer to as a regular outpatient setting, where they will see their doctor or their mental health professional every week, every couple of weeks, depending on the severity of their symptoms as recommended by their doctor or a mental health professional. They’ll continue going to work, they’ll continue their regular routine, but will have check-in appointments at the specified frequency. Another level of treatment is what is referred to as a partial hospital program, commonly known as PHP or an intensive outpatient program, commonly known as IOP. These are very similar entities and therefore we’ll group them together, which are basically day programs where a patient will be living at home, sleeping at home, but go a certain number of times a week for a good chunk (if not the entire day) to an intensive setting where they’ll receive therapy, group therapy, medication management and other services. Again – meant to provide a more comprehensive package in the treatment of their depression.

When we think of treatments for depression, we often divide them into medical and non-medical categories. Medical categories being ones that generally a medical doctor would be prescribing or administering, and non-medical ones being ones that either a medical doctor or a psychologist, a licensed therapist or a social worker might be prescribing as well. Let’s start with the non-medical treatments first. First treatment would be no treatment, funnily enough. Sometimes a watchful waiting approach, monitoring someone, giving them time to recover, renewing their focus on the bread and butter activities of a healthy lifestyle. For example, focusing on their sleep, deepening their connections, exercising, renewing their commitment to meaningful pursuits in their life. That may be all that’s needed in some instances to lift the depression. The decision to opt for that track should ideally be made by a mental health professional.

Behavioral activation can be very helpful in treating depression as well. Behavioral activation means that a person, even though he or she does not have the energy, even though he or she does not have the desire to go ahead and engage in certain tasks, they will be encouraged by a therapist or by a family member to go through the motions to continue doing their routine, to continue doing things that they enjoy, even though they’re hating every second of it. And there is data that supports that as being an effective weapon in the treatment of depression.

Exercise can be a helpful non-medical intervention in many individuals struggling with depression. Although the data is mixed regarding the efficacy of exercise in helping depression, anecdotally it certainly does seem to help people who are undergoing other treatments for depression at the same time. I usually recommend a minimum of 30 minutes of intense cardiovascular exercise three days a week to start, obviously assuming that a person is capable from a medical standpoint of engaging in that level of exercise. Before you start any program of exercise, always important to clear it with your primary doctor as well.

Meditation/relaxation exercises can be helpful for some individuals who are struggling with depression. Mindfulness (whereby a person non-judgmentally notices the thoughts and feelings that they’re experiencing), focusing on a person’s breathing, stretching – all may have some role (certainly adjunctively – meaning in addition to – regular treatments) for the treatment of depressive disorders. Light therapy, whereby a person uses a light box to provide illumination at certain times during the day for certain intervals, has also been shown to be helpful for some people with depression. While this used to be used more for seasonal affective disorder (meaning people who have depression that manifests more during the winter months or specific times a year) it has been shown that in some people this can be beneficial. The decision to use a light box, though, should always be done with the guidance of a professional as there are some specific details that have to be worked out and it is not necessarily without any risks.

There’s good data supporting the use of psychotherapy in the treatment of depression. The vast majority of people who go through therapy shows some improvement in their symptoms of depression. The effects can sometimes be more enduring than the effects of medication and the treatment of depression, meaning that after a person stops therapy or after a person stops medication, it could be that the benefits of the therapy last longer than the benefits of the medication in many individuals. When considering psychotherapy, it is important to keep in mind that the benefits may take some time to reap. A connection has to be established between the patient and the therapist, which takes time. Therapy can be very therapist-dependent, meaning that the therapist has to be a good fit for you as someone who you feel comfortable with and that you feel can help you. A person has to be at the level of being able to engage in therapy. In some instances of depression, the depression may be so severe that the person is not able to talk or to engage in meaningful dialogue, in which case it may be necessary to pursue other avenues of treatment.

A common question that’s asked is: should a person start with therapy or with medication? As with so many things, there’s no one-size-fits-all right answer, but there are some things to consider: therapy works well. Medications work well. The combination of the two seems to work better than either one by itself, and so oftentimes they will be combined. I often recommend it to patients if the clinical situation is appropriate to start with therapy. Therapy being a little bit more of a conservative option without the side effects that you necessarily could see from medication. If a course of therapy really doesn’t seem to be helping, then consider adding on medication. That being said, every situation is unique and it has to be assessed individually, so there are no hard and fast rules, but that is one potential way to consider.

Cognitive behavioral therapy is a type of therapy where the therapist and the patient focus on the patient’s thoughts and behaviors that may be contributing to the symptoms of depression. Interpersonal psychotherapy is very similar to cognitive behavioral therapy, but places an emphasis on the relationships in a person’s life and how they’re contributing to depression. Psychodynamic therapy, psychoanalysis are both related types of therapies which focus on the subconscious of a person and attempt to improve symptoms of depression by addressing some of the underlying issues such as resistance or defenses that may be contributing to their symptoms. Supportive psychotherapy is a type of therapy where the patient and the therapist work together and the therapist uses the medium of empathy (of listening closely, listening attentively, providing support to the patient) to help his or her symptoms. Group therapy is a type of therapy where many individuals who are struggling with depression will sit together in a group and a group leader will facilitate and the medium of the group will help people in ameliorating symptoms of depression.

Medical treatments for depression include medications as well as other procedures that may sometimes be helpful for people who are struggling with depression. Let’s talk about medications: there are many different types of what we call antidepressants – medicines that seemed to help certain individuals who are struggling with depression that can provide a significant amount of relief. The most common type of antidepressant medicine that we encounter and that we prescribe is what’s called an SSRI and that is short for Selective Serotonin Reuptake Inhibitor. These are medicines you may have heard of like Prozac (also known as fluoxetine) or Zoloft (also known as Sertraline.) They’re prescribed for depression as well as for anxiety, and they seem to help a lot of people. Basically, they are thought to work by increasing the amount of Serotonin – one of the neurotransmitters or chemicals in the brain in the spaces between brain cells. That being said, the actual mechanism is probably a lot more complicated than that.

People who take these medicines will start by taking them usually daily – your doctor will tell you if you should take it at night or in the morning. They’ll take it for a while, so patients will often take it for a few days and say it’s not doing anything. It’s not helping at all. To which the doctor will usually encourage them: keep taking it, stick with it every day, and usually what will happen is that after a number of weeks of taking the medication (and that can vary from person to person), they’ll come back to the doctor and say: You know, hey, come to think of it – I do feel a little bit more myself. I don’t know when it happened. There was no light switch that went on, a sudden moment of feeling better. But kind of just gradually in the background, something has been kicking in and I feel a little bit more back to myself. I’m sleeping a little bit better. I’m eating a little bit better. I’m not as numb as I used to be. We usually recommend taking the medication between four and six weeks to gauge an appropriate response to the medicine. Some people may show a response earlier than that. Other people may take longer than that to show a response, but it is important to give it a significant amount of time to kick in before dismissing it as being ineffective.

Another category of medication that is very similar to the SSRI is what’s called the SNRI, which is Serotonin Norepinephrine Reuptake Inhibitors. These include medicines like Ephexor (also known as Venlafaxine) or Cymbalta (also known as Duloxetine.) These work in a manner very similar to the SSRI’s, but there may be some subtle differences as well, both in terms of the effect that they have as well as some of the side effects that they have. Another antidepressant medicine of a different class (a different mechanism) that is sometimes prescribed for depression is called Welbutrin (otherwise known as Bupropion.) This is a medicine that doesn’t really work as much with Serotonin as much as some of the other neurotransmitters in the brain. It usually works by giving people a boost of energy that people, for example, who were telling me that they can’t get out of bed in the morning, that they have no energy to get through the day, that their depression is really sucking the life out of them – taking Welbutrin may sometimes endorse a little bit more pep during the day. Remeron (also known as Mirtazapine) may be helpful for depression as well. It works through a different mechanism relative to the other antidepressants and seems to help people not only with their depression, but also with sleeping and with appetite, in that it boosts appetite (makes people eat more). If that’s a symptom of their depression, they benefit from that effect of the Mirtazepine.

One of the questions I get asked a lot about antidepressant medication is how long should someone stay on the antidepressant medication? Is it okay to discontinue it right after the symptoms get better? Should they stay on it for life? Or is there some in-between area that is really the ideal length of time? And the honest answer is that there is no clear consensus on this and it does depend on a variety of factors that you should discuss with your doctor. Some of the things that your doctor may consider are the number of depressive episodes that you’ve had in your life. For example, is this the first time that this is happening or is this the seventh time that this is happening? That might impact on that decision. The severity of the depressive episode might impact on the decision of how long to stay on the medicine. The side effects on the medicine might impact on whether you’d want to stay on it long-term or not. Whether you’re involved in psychotherapy might affect that decision. And the level of support that a person has in his or her life. Family members, friends versus living a more isolated life without those sources of support and people who could encourage to come in if symptoms redeveloped, might also be a factor in considering the decision. It is really important to talk with your doctor about that.

Every medication in the field of medicine can potentially carry with it side effects. Some of the side effects are relatively minor nuisances, if you will, but things that people are fine tolerating and will continue taking the medicine despite that and others may be more significant and a reason to consider avoiding or switching a particular medicine in any given situation for any given patient. While it’s impossible to get into every single potential side effect from every medication in this form, it’s really important to talk with your doctor after he or she recommends a particular medicine about some of the side effects to anticipate. Broadly speaking, some of the common side effects to many of the antidepressant medications that we see are mostly mild ones at the beginning. So for example: nausea, upset stomach, some people may report a mild headache. These sorts of things usually get better with time. Most doctors will encourage patients to continue taking the medicine for a couple more days in the hope that some of those side effects will go away. Some of the antidepressants can affect a person’s sleep, making it harder for them to sleep or affecting the quality of their sleep. If you notice that, it’s very important to talk about it with your doctor. Some antidepressants can affect sexual function. If you notice that, it’s also important to talk to your doctor as there may be ways to address that issue. Many of the antidepressants also carry a warning for individuals up to the age of 24 that some data seems to suggest that there may be an increase in suicidal thoughts in these individuals. This is something that is important to talk with your doctor about and to weigh the risks and benefits of the medication in that particular population.

In addition to medications that are prescribed, there are various other natural herbal supplements that may or may not be beneficial for depression. Some of the more popular ones include something called SAMe (which is short for S-Adenosyl Methionine), Omega-3 Fatty Acids, St John’s Wort, Vitamin B6, Vitamin D, Saffron Extract – to name a few. Regarding the potential benefits, lack of benefit or harm, it’s really important to talk with your doctor individually about specific supplements. While they sound healthy, they sound natural, they sound like a good thing (and they may be in some instances) sometimes they’re not always benign and some of them can carry some significant side effects as well as significant interactions with other medicines you may be taking that could then become dangerous. It’s therefore really important to look into these but to also ask about them and to make sure that they’re an appropriate fit for you in your specific situation. The other thing to keep in mind with many of these substances is that they’re not FDA-approved for the treatment of depression and therefore they’re not regulated in the same way that a medication might be. And therefore, when it comes to a medication, the companies go under a very rigorous scrutiny to ensure that purity, that what you’re receiving, is what is advertised. With many of the supplements, there is significantly less regulation and there is the possibility that you may not be getting exactly what you expect to be getting. So that’s another level of caution that a person should maintain when exploring these options.

Let’s talk about some other medical but non-pharmacological forms of treatment – meaning things that your medical doctor or the psychiatrist might recommend, but that are not in the form of an actual pill that a person would take. One of the treatments that’s medically offered for depression is called electroconvulsive therapy or for short known as ECT. ECT works by applying a small amount of electric current to the brain while a person is obviously under anesthesia in a controlled setting to induce a seizure, which is sort of an electrical overactivity of the brain. This is a treatment that has been around for a while and has been refined over the years in terms of its safety profile. From a data perspective, ECT does seem to help a lot of people who are struggling with severe depression, but from a practical perspective it is often reserved for the more severe cases of depression. People who have tried lots of other interventions (for example: therapy, a number of medications) and nothing seems to be helping them and they are in a very severe state (for example: suicidal or not eating and losing dangerous amounts of weight, having psychotic symptoms like they’re hearing sounds or voices, losing touch with reality.) In those cases, it might be considered. Its use is restricted because A. it’s not a practical form of treatment – it requires going under anesthesia several times a week for usually about four weeks or so. And B. there are some significant side effects that have to be considered. This is something to talk with your doctor about in terms of the full list.

My name is Dr. Zev Wiener. I received my medical degree from Harvard Medical School and completed residency at UCLA where I served as the Chief Resident of the Resnick Neuropsychiatric Hospital at UCLA. I presently work as an attending psychiatrist at UCLA where I see patients and help train resident physicians and I also run a private practice on the side, as well.

Colloquially, we often use the terms sadness and depression interchangeably. People will say, for example, that they feel so depressed that summer vacation is ending or they feel so depressed that their car broke down. In medicine, when we use the term depression, we’re referring to Major Depressive Disorder – a specific condition that is very different than regular sadness. Sadness is part of the human spectrum of normal emotion. People feel sad at certain times and it’s appropriate to feel sad and certain times. Depression, on the other hand, is a mental illness that warrants treatment in many situations.

Sadness, oddly enough, can sometimes even have a richness to it. When people are crying, for example, they feel a cathartic element, as if they’re connecting to something very deep within them. There’s even something that may (oddly enough) feel good about a good cry, about feeling sad in certain situations. There’s nothing rich about depression. Sadness can be a motivating factor for a lot of people. If they’re sad, they’re unhappy about a particular situation, it may inspire them to want to get up and do something about it. Depression is usually the exact opposite and that it saps a person’s will. It saps a person’s motivation to feel that there is nothing that can be done about a particular situation. People who feel sad (if you ask them) will usually admit that there is a chance that a year from now, regardless of what’s going on, they may feel a little bit better. But in depression, hopelessness is one of the core symptoms where people will feel that there is no chance of things ever improving and the way they feel right now is how they’re going to feel forever.

Sadness is an emotion. Depression, on the other hand, is a complete emotional shutdown. Rather than people saying that they feel sad, they’ll usually say they feel numb, detached, cold. Sadness may be a component of it, but it’s certainly not the dominant theme that comes across. People who are sad may hurt a great deal internally, but will usually continue to eat, will usually continue to shower, to take care of their basic needs. People who are depressed may stop doing all of these basic functions and in severe instances may even consider taking their own life and may begin to experience symptoms such as auditory hallucinations where they’re hearing things that other people don’t seem to hear. A patient of mine once remarked that in their mind, the opposite of depression is not happiness but alive. That depression saps them entirely of their vitality, of any sense of feeling alive.

Depression is a very common illness. Some numbers estimate that as many as 6-7% of American adults may experience a depressive episode in any given year. In my experience, it’s very rare to meet someone who has not come in contact with depression either personally, through a family member or through a friend. Depression can affect people regardless of gender, age, race, socioeconomic level – it cuts across all boundaries. There are some trends, though, that have been observed: women seem to be diagnosed with depression significantly more frequently than men. It’s not clear whether this represents an actual difference or if the diagnosis and reporting are different between men and women. Depression seems to become a little bit less frequent as people age, and there may be some regional variations between different countries and different civilizations regarding the prevalence of depression, though this is somewhat debatable.

Depression can come in many different flavors. The standard of depression – when we say major depressive disorder – is referring to a condition which is severe but remitting, meaning that people will feel depressed for a number of weeks, perhaps months, sometimes even longer at a time, but then it goes away and they may feel better for quite a while and then there’s a risk that it could dip down again for a while. But it’s a block of depressed, not depressed, depressed, not depressed, for sustained periods of time. There are other though, models of depression that are seen as well. Persistence Depressive Disorder (formerly known as Dysthymia) is more of a low grade but chronic form of depression where rather than having these blocks of yes, no, yes, no all the time – just feeling really not good but not necessarily at the same level of severity as someone who is having a major depressive disorder.

It is very important when we’re talking about depression to distinguish between what’s called unipolar depression and bipolar depression. Unipolar depression is really just a fancy word for depression – for major depressive disorder – people who either feel their normal self and then dip down for a month for a week for however long it is, and then emerge and they feel at their normal level. In bipolar depression, people will have depression (just like in unipolar, it’s pretty much indistinguishable) so they’ll dip down, feel very depressed for awhile and come out of it. But then at other times in their life, rather than just being at their regular baseline, they may have what’s called a manic or hypomanic episode where their mood actually lifts to a level that is very much out of character with their usual state of being. They may not be sleeping. They may be saying very bizarre things. They may be having bizarre ideas, acting very recklessly, and that is an entirely different condition, then, called bipolar disorder, which has the depressions and the manias co-occurring.

Depression with mixed features is another flavor of depression where rather than just feeling down and numb and hedonic without any interest, there may be a mixture of other emotions as well. For example: severe anxiety, severe irritability, or an elevated mood at times as well.

Another type of depression is one which varies from season to season. Formerly, we would refer to this as Seasonal Affective Disorder, where people, for example, in the winter months when the days get shorter would experience intense symptoms of depression. But then as the days become longer, the sun comes out again in the spring and the summer, the symptoms might remit and the treatment for that might also be a little bit different in some instances than other types of depression.

Treatmexnt-resistant depression is basically a depression that does not seem to be getting better. There is no official consensus on what constitutes treatment-resistant depression and why does this person have it and this one does not, but a general rule of thumb that a lot of professionals will use is if they’ve tried two different antidepressant trials – so if they’ve taken one medication, adequate dose, adequate time, and it didn’t help them, they tried another medication at an adequate dose and an adequate time and neither of them seemed to help the symptoms – many professionals will then consider them to be treatment-resistant. It’s significant when we label someone as treatment-resistance rather than regular depression because some of the medication and treatment options that we consider may be different between the two categories. Additionally, if someone is having depression that just doesn’t seem to be getting better based on the conventional treatments, it should prompt the professional to continue to explore and consider other potential diagnoses that may be masquerading as depression and that’s the reason why it’s not getting better with depression treatments.

Premenstrual Dysphoric Disorder is another form of depression occurring exclusively in women that can occur in about the week or so prior to the menstrual period in which a woman may experience symptoms of depression transiently. So more sadness, irritability, numbness, and that usually goes away a week or two later. The treatment model for that would be different. Sometimes depression can occur specifically around the time of childbirth, Peripartum Depression, either before childbirth or in the weeks following childbirth. And this again is a unique form of depression that has many similarities to the other types but is treated distinctly as well.

Depression can be associated with many different medical conditions: heart disease, diabetes, cancer, Parkinson’s disease, stroke – to name a few – do travel quite frequently with depression. The big question that emerges in every situation is whether or not depression increases the risk of these conditions. So for example, if someone is depressed, they may not eat as well and they may be more prone to develop heart disease or diabetes. On the other hand, we might say that maybe heart disease and diabetes in some way contribute to depression both in terms of the stress that it can put on a person and the fear for their wellbeing, the need for many medical appointments, etc., as well as perhaps on a biological level that’s not really well understood at this point. Finally, you have to consider the possibility that maybe both the associated condition and the depression are the result of some common underlying cause that manifests in both of these different ways. So there’s definitely a lot of research that remains to be done, but for the time being, we definitely see that these conditions do seem to go together with depression.

The gold standard for diagnosing depression is a clinical interview with a mental health professional – a face to face discussion where they will review with you all the symptoms that you’ve been having. They’ll review your prior history and try to put all the pieces together to come up with a diagnosis. Sometimes they may provide screening questionnaires where you check off boxes to calculate a total score, but that really should never be the substitute for an actual face to face discussion to really elucidate what their diagnosis is. There is no lab test that can definitively diagnose depression. Nor is there any imaging study that can definitively diagnose depression. That being said, doctors will often order a full lab panel of blood tests at a first visit to rule out any contributory causes. So for example, if your depression is being caused by too little thyroid hormone, it would be important to know and to check that to rule that out. Therefore at the first visit, your doctor will probably want to see what’s called a TSH – a check of the basic thyroid functioning in the blood.

Imaging studies are not used to diagnose depression, but your doctor may choose to order some imaging depending on the clinical situation. Again, to rule out other contributory causes that might be a part of the symptoms that you were experiencing.

Some patients who take medications may find that no medication is working for them or that they are extremely sensitive to side effects even at very, very low doses of the medicine. If that is the case, you might want to discuss with your doctor the possibility of genetic testing. This is a new area that is still being explored, but what we call pharmacogenetics: The way that a person’s genetic profile might affect the way they metabolize or process and medication can be significant in some individuals. While this is not usually pursued as a first line or a first step in treatment, it may be something to ask your doctor about if you are in that situation.

There are a number of very important symptoms to look out for when we’re concerned that someone may have depression. Sleep disturbances are a big one, so people will often report that they’re not sleeping well at night, specifically that they’re waking up early in the morning – what we call early morning waking. That can be a very common sign of depression. Sometimes people will sleep too much – they’ll say they can’t get out of bed even after sleeping for 14, 15 hours. When you probe a little further, you may find that they’re not even sleeping that entire time, but spending a very large amount of time in bed. Interest is another thing we look at with depression. People who used to have a variety of interests who used to love going out doing this and doing that. When they become depressed, they become what we call Anhedonic – meaning they’re not interested in anything. Nothing brings them joy. They have no desire to get out. They have no energy to get out. Guilt is another very common symptom of depression. People will often assume that it’s their fault that things beyond their control are their fault and take the blame in an unhealthy way for many, many things that are going on in and out of their lives.