Major Depression: An Interview with Dr. Eric M. Plakun page 3

Let’s talk about that human experience. What else can you tell us about what depression feels like, and how depressed people think and feel?
There are people who have written beautifully on this question, who have described it better than I could: the blackness of mood, the sense of paralysis, the sense of utter worthlessness and stuckness — of being at the bottom of a deep well and feeling unable to mobilize or to find any energy or pleasure in life. I’m thinking of Kay Redfield Jamison’s book, An Unquiet Mind, and William Styron’s Darkness Visible.

One other literary gem stands out in my memory. When I was in college, I read a great deal of A.E Houseman. He has this little piece:

When the bells justle in the tower the hollow night amid,
Then on my tongue the taste is sour of all I ever did.

This little two-line poem captures the sense of bleak despair and regret that haunts people with depression all the time, often especially in the night, when they find no peace in sleep, and instead ruminate about painful regrets from their past..

Many people with depression either aren’t aware of it themselves, or try to hide it. How might you spot depression if someone is “in the closet,” so to speak?
You look for someone who seems withdrawn to the point of isolation; someone who seems unable to get pleasure from things; who seems to lack energy and be tired, or just not look well in the absence of medical illness. Depressed people have that sense of being exhausted and run down, and that’s often evident to others. These aren’t just changes in affect. There are actual biological changes. People with major depression actually move more slowly. They have more blank facial expressions. They are just flatter. They may sigh a lot more.

And, obviously you want to watch out for someone who talks about how life may not be worth living, or who says things that suggest that they’re getting to the end of their rope.

Tell us about the treatment for this condition in the therapeutic community at Austen Riggs? And how is it different from treatment in other contexts?
I’d say our residential treatment approach for depression is like treatment elsewhere, but we add to the usual more interventions. In residential treatment of depression a person is really getting an experience of immersion in treatment rather than going to one or several outpatient sessions a week.

We use medications, but we won’t limit the treatment to that. We really look at the person broadly in terms of how they adapt to the whole world and where their difficulties are, with a particular emphasis on character structure. That is, we want to know how they characteristically engage with the rest of the world, and how those habitual ways of dealing with people and events have become a problem. The treatment at Riggs thoroughly engages the whole person. Although individual therapy is a powerful way to get to these issues, the therapeutic community, with its emphasis on “examined living,” really means the patient is immersed in treatment 24/7, using clinicians and peers as engines that drive the treatment process. And then there are family work, groups of various sorts, substance use services, and the “treatment free zone” of the activities program, where patients go as students rather than patients to develop their creative potential.

All these together can bring real benefits — among them, I should point out, in the efficacy of medication. Of course, part of the benefit of an anti-depressant like Prozac or Celexa is the so-called placebo effect, where part of the benefit of a treatment comes from the expectation of benefit. And the placebo effect is useful. The trouble is that a lot of people who come to us have a negative placebo effect. Instead of getting, say, a 30 percent bounce from their belief that the medication will be helpful, they get a negative 30 percent bounce. They actually get worse on medication. This is called the “nocebo” effect.

Where is this coming from? In our follow-along study of 226 patients , something like 60 percent of people have really serious adverse experiences that can range from abuse to death of a parent or some other very serious deprivation, neglect or loss. Those are experiences with the primary authority figures in one’s early life that may leave a person with the deeply held belief that the people they need won’t support them. Naturally, they don’t trust authorities afterwards. And that mistrust means that, unlike the so-called healthier person who goes to a doctor with an expectation of being helped, swallows a pill, and does indeed feel better, our patients instead have an expectation of harm. That’s what moves the placebo effect in the opposite direction—the negative bounce, if you will. That’s why we see people who are extremely sensitive to medication side effects, or who are able to tolerate only small doses, or who even get worse on medication. We need to turn that around and help these folks see that they can improve and that doctors can be trusted to help them. That’s much more easily said than done, though. And it often begins with looking carefully at the losses and bad experiences that shaped them in the first place.

What are the challenges for the therapist and the staff in treating major depression? And what would you say are the main challenges for the patient?
The number one worry is suicide, because that is the number one worst outcome in depression. When we work with somebody with major depression, we’re absolutely focused on the issue of suicide. About half of people who come to Riggs having made significant suicide attempts. In a world in which the care insurance companies approve is pretty minimal these days, we’re actually seeing suicide attempts become more frequent in our patients as a mark of desperation. People get to where they feel there’s nothing left to try.

So the question becomes, how do you respond to this desperation? We’ll certainly use the appropriate medications. But we really focus the treatment in a way that tries to shift the view of suicide from simply a symptom that needs to be eradicated by the doctor—which has the inherent problem of creating a potential stand off in which the doctor’s advocacy for the patient staying alive leaves the patient as the advocate for death—to something that has interpersonal meaning between a therapist and a patient. Viewed this way, and if someone has hired us to help save their lives, an upsurge of suicidal thinking means they’re thinking about ending that work. So we need to ask them, “What’s happening here” — meaning, here in the therapeutic relationship — “that makes you want to kill yourself?” “What’s happening between us and to the agreement we had to work together that we both entered into in good faith?”

“Oh,” they’ll say, “it’s not you. I’m just getting worse.” And we’ll respond, “But wait, we’re talking about this in a context. We were talking about X yesterday”, or You seemed to have a reaction to Y in the session last time, what’s up?” You see, we need to consider the context of the work in therapy as a factor. This goes back to what we were discussing earlier, about how our patients often have an expectation of harm. If we engage these folks to try to help them get hold of that, the treatment is not simply about trying to be a more reliable authority figure who won’t fail the patient — although we do try to be as reliable as we can be. In some ways, psychodynamic therapy is built on the notion of the inevitability of recreating the experience of failing them. I may think I’m a reliable, good authority figure, but a patient will inevitably point out, “No you’re not. You’re going away. You’re going to this dumb meeting and you’re abandoning me.” So while we try to be reliable, we also recognize the inevitability that we will fail them — and that failing becomes an opportunity for the problem they have to come alive in the relationship. We can deal with it in an intimate and genuine way if the relationship is solid enough, trusting enough.

This is the way we’ve been approaching suicide for decades when it is part of major depression comorbid with personality disorders at Riggs. Others are coming to it as well. Transference Focused Psychotherapy (TFP) does something similar, as does Dialectical and Behavioral Therapy (DBT). I’m involved with a project at the Group for the Advancement of Psychiatry to look at the different psychotherapeutic approaches working with suicidal patients. The idea is to look at what they have in common, and what differentiates them. It’s interesting to see there are significant areas of overlap, between TFP and DBT and what we do at Riggs, which we sometimes refer to as ABIS — Alliance Based Intervention for Suicide. All these treatments tend to use that carefully negotiated alliance between therapist and patient as a way to get leverage on the issue of suicide by making it an event with meaning in the therapeutic relationship. If the patient wants therapy, the deal is they have to stay alive to get it.

And it often works, though it is certainly not for everyone. There is evidence from the Riggs follow-along study that we have good outcomes with suicidal patients. And there’s evidence with TFP and DBT that they help suicidal behavior, too.

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