September 13th, 2011
11:22 AM ET

What's the next step in fighting depression?

Every weekday, a CNNHealth expert doctor answers a viewer question. On Tuesdays, it's Dr. Charles Raison, an associate professor of psychiatry and behavioral sciences at Emory University, and an expert in the mind-body connection for health.

Question asked by Emma from New York:

I have had depression for almost seven years. I saw a psychiatrist and therapist for eight months, two years ago; it made me feel worse. I started to see another psychiatrist and therapist last November; it only mildly helped. I tried Prozac first, but when the dosage increased, I started to have hallucinations and delusions. I was then prescribed Celexa (disrupted my sleep greatly) and then Cymbalta, which showed no change. I also was given several sleep medications. Medications just do not seem to work; they all have side effects. I just moved and have not found more doctors here. My depression and sleep problems seem to get worse with every day. What should my next step be?

Expert answer:

Dear Emma,

It would be a better world if I could assure the people who read these answers that your situation was unusual. In fact, your story is fairly classic and sadly common.

Many people with depression develop chronic symptoms that are resistant to their best attempts at treatment. Sometimes an answer can be found and relief obtained; other times nothing seems to help and the suffering continues.

There are many possible reasons why psychiatric symptoms don't go away in response to either medications or psychotherapy. I don't know enough about your experience with therapy to hazard a guess about what went wrong in particular.

But looked at more generally, there are three reasons why psychotherapy might fail: the wrong therapist, the wrong therapy, or resistance to psychotherapy.

Before deciding psychotherapy is not for you (i.e. that you are resistant to it), let me encourage you to think about how you felt about the therapist and/or the type of therapy you received.

If your therapist was someone you didn't emotionally connect with or if the treatment didn't seem to really engage you, let me suggest you try again with someone and something new.

With medications there are two primary possibilities for your history of nonresponse. Either you are resistant to antidepressants, or antidepressants are not the right medications for what you've got. The side effects you describe make me wonder if you might not have an undiagnosed bipolar disorder.

Sometimes people with bipolar disorder are helped by antidepressants, but often they respond better to other classes of medication, such as lithium, valproic acid or one of the new atypical antipsychotics. It might be worth talking with a mental health clinician about whether you might have a bipolar condition.

As I've written more than once in these answers, many of us psychiatrists are "two-trick ponies," meaning that when we've provided psychotherapy or some type of pharmacological intervention, we've done what we can do.

Scientific findings increasingly suggest that other interventions may also offer real promise, such as exercise, meditation/yoga and healthy eating. Let me encourage you to educate yourself about these potential sources of benefit.

In addition, it is very important that you sit down with yourself and honestly examine whether you are doing things that we know make depression worse, such as drinking too much alcohol, or taking drugs, or continually putting yourself in stressful, depression-causing life situations.

If you identify any of these factors as being live issues for you, let me encourage you to adopt a take-charge attitude in trying to rid them from your life.

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soundoff (47 Responses)
  1. ib42

    It would not be safe for you to admit the kickbacks you psychiatrists from drug companies receive for pumping these useless and dangerous drugs into hopeful, suffering people as a matter of course. You know that these drugs can kill, that placebos have almost the same effect, yet you continue on your crooked way to wealth, caring little for humanity as a whole. It should be required that MDs with a psyche endorsement on their diplomas take antidepressants for 6 months before prescribing them to patients.

    September 13, 2011 at 11:55 | Report abuse | Reply
    • Matt Lauer

      Easy now, Tom Cruise. You have a new movie coming out soon. Time to tone down the crazy talk again.

      September 13, 2011 at 12:23 | Report abuse |
    • teresa


      October 17, 2011 at 22:45 | Report abuse |
    • annyomous

      The vast majority of people who are on medications would rather NOT be on them. Yet sometimes we have to be, and we realize that. When you have one of these disorders and do not find relief from thearpy alone, you end having to make a very difficult choice: either stay on the medication(s) (or use other medical treatments like ECT) and deal with their potential side effects OR not take medications and deal with the disorder itself. Do you find your disorder WORSE than whatever side effects the medications cause you? This is esp. true for those who are unable to be weaned off their medications. Personally I would rather not have to deal with crippling depression, panic attacks, and severe anxiety. So I stick with my medications.

      If you find the actual side effects worse, it's time to consider other treatment options. This is to be expected because not everyone responds to medications the same way. There's no point in staying on a medication that's making you worse. Of course there are side effects with antidepressants; there are side effects and other risks associated with EVERY medicine, surgery, and holistic remedy. Doctors and patients have to weigh those risks and benefits. If the risks outweigh the benefits, other options are considered... except when there are literally NO other treatment options.

      People like you do not and cannot understand this because you don't have a severe or chronic medical disorder and therefore don't have to make that decision. It's a real catch-22 with no easy answers for those that have to make that decision. People like me end having to choose between what we feel is the lesser of two evils. For many with severe mental disorders the medications are that lesser evil.

      Other problems with your opinion and "facts:"
      1. Not all doctors get kickbacks from drug companies, other than free samples which they use for their patients who cannot afford their medicines. It's not nice to generalize.

      2. Most doctors get involved in the medical field because they DO care. They want to help people. There are easier and less stressful ways to get rich than to pursue a career in medicine if that was their only motivation. Besides how can you explain doctors who work in welfare hospitals or volunteer for Doctors without Borders? There's not much of a profit incentive with those. Like I said, don't generalize.

      3. In addition new laws have been put into effect to prevent or limit the influence drug companies have on doctors in regards to treatment options by promotional items. Only things that directly help patients are allowed. That includes free samples of medications and items like pens, notepads, etc. as they can be used in the doctor's office. Paid vacations to resorts and direct payment incentives are not. (The only doctors they pay are those who directly work for them in research, development, and testing of the medicines because they are their employees!)

      4. The reason doctors like certain antidepressants is due to their experience with them. They've had good results with them and are comfortable prescribing them. Every doctor develops his or her own treatment protocol that they use as an outline for each disorder and which can be changed for each individual patient as warranted. For instance, they may turn to, say Prozac or Lexapro, first before trying other antidepressants. If the patient does not respond favorably to either of those, another antidepressant is tried. (Sadly it's a process of trial-and-error in finding the right medication in mental disorders because of how not everyone responds to them the same way.) This protocol use is normal in treating many diseases and for using other medicines. The reasons WHY doctors first start using a newly released antidepressant varies though since they obviously don't have the necessary experience with those yet. Sometimes it's due to drug companies' promotional papers. Other times, it's due to results other doctors have reported via medical journals. Medical journals are peer-reviewed, and questionable results can be criticized. That means drug company sponsored studies are scrutinized by doctors and researchers who have absolutely NO connection to said drug company.

      5. We already know that not everyone with depression needs to be put on medications; that's nothing new. Studies that focus on comparing antidepressants and placebos (or other treatment options) simply confirm that. In addition the studies with the results you're talking about only focus on those with mild depression, not those with severe depression. More proof that antidepressants are not the only answer for everyone. Studies on those with severe depression find the opposite to be true: antidepressants are always found to be more effective than placebos in the majority of those with severe depression.

      6. That placebo effect happens with other medications and even non-medical remedies. It's not unique to antidepressants. Some people just expect to get better from taking a pill that they do... despite the fact that they were only given a sugar pill. It's so well-known that it's to be expected that a few people will experience it in every study and medication trial. Those who have it are usually removed from the study... except when the placebo effect itself is being studied, like comparing the effectiveness of a certain medication to a placebo. Another factour in regards to mental disorders in particular and the placebo effect is that a small minority of people will go into remission (recover) on their own... no matter what you give them. That means they did not even fall victim to the placebo effect. Those sorts of remissions are not very common though.

      7. Why in the world would you force people who DO NOT have depression or an anxiety disorder and therefore DO NOT need antidepressants to take them?? I thought you were upset by their use and were against them.

      8. 'Psyche' is not an abbreviation for psychology. It's used in reference to soul, personality, and mind. The abbreviation for psychology is 'psych.' The word 'psychology' is derived from 'psyche' though. Sorry. Silly mistakes like that can make you look even less informed on the issue.

      Yes there are problems with antidepressant use, but they also help people with depression and anxiety disorders. Most studies find that the antidepressants help the vast majority of people of those who take them with the serious side effects you describe to occur in only a small proportion of people. Should we stop using a treatment option that helps more people than it harms? What even gives you the right to make this decision for other people or take away something that works for them?

      You need to learn to respect someone's decision in treatment options when it helps them... even if you don't agree with their choice. The results are more important than your personal beliefs on the matter.

      January 18, 2012 at 16:12 | Report abuse |
  2. ABP

    You might also try Deplin in combination with an antidepressant. Deplin is l-methylfolate, which in laymen's terms is high dose of folate. It is also the only kind that can pass through the blood-brain barrier. Deplin is listed as a "medical food" by the FDA and multiple random clinical trials have shown it's effectiveness at the 15mg dose for those with treatment-resistant depression.. There are no known side effects. It has worked well for me at the 7 mg dose.

    I hope this helps and that you are able to find relief soon. Best wishes.

    September 13, 2011 at 21:19 | Report abuse | Reply
  3. Patty (iambipolar2) Hauer

    Thank you for such a usefull tool. It is especially nice that...people are telling you what to do. For those who are referring to studies as a reason not to take medications they need to experience unmedicated bipolar. If perscription medication isn't safe then an affordable alternative has to be available, since the depression phase of bipolar has a deadly reputation. If you have never been there you can't understand why so many of us don't want to go back there any time soon. It isn't in the deepest depression that it is dangerous but when we start coming back up and are able to find the enrgy to consider taking our lives. I say do some serious research about Bipolar and learn all of your options then move forward!

    September 13, 2011 at 23:18 | Report abuse | Reply
  4. Keri Kilpatrick

    I'm wondering why this expert suggested that this patient might have bipolar disorder. I see nothing in the description of her symptoms that sounds like bipolar disorder.

    September 14, 2011 at 00:53 | Report abuse | Reply
    • Ryan Sultan, MD

      In response to the bipolar concern:

      A classic response to solely taking a SSRI/SNRI (Prozac, celexa, cymbalta) in a pt with bipolar disorder is the development of manic episode after starting the medication (if it is given without a mood stabling agent... such a lithium).

      The pt describes the development of , " hallucinations and delusions". These can represent a psychosis of Mania. The expert concerns are reasonable in this case.

      September 14, 2011 at 13:39 | Report abuse |
    • Keri

      Thank you so much for answering my question years ago! (Would you mind removing it now, though?) ☺☺☺Thanks again!

      July 3, 2015 at 01:46 | Report abuse |
  5. ambipolar3

    having survived lots and lots of bad drugs for depression, I can heartily recommend lithium and lamictal as a treatment for bipolar. Obviously, you don't want to take more lithium then you need to because of kidney issues but, it's a great drug for protecting the gray matter.

    For unipolar depression, nothing worked until I tried "Dawn therapy" using a light that simulates the slow brightening at dawn in combination with a completely dark room with eight hours of uninterrupted sleep. That cracked a lifetime of unipolar depression in three days. Bloody miracle. I haven't stopped smiling. Since then, I've gotten a divorce because I had enough energy to face a mess I was in, got a better job, and found a girlfriend that is a much better match as a partner.

    there are some tricks working with light therapy and bipolar depression. You need to combine a long dark sleep with the light and you sometimes need to play around with color. Start with white, try blue, then try green. They each have different effects. I work best with green light. White and blue give me migraines.

    my psychiatrist recommended looking at this site for information on medications and research. http://www.psycheducation.org/ you can find a good bit of information on light therapy used with bipolar and unipolar depression. It's cool to see treatment that's as effective as SSRIs with fewer side effects and much cheaper (cost of a special controller and a lightbulb)

    keep trying. It is so wonderful when the depression is gone and you can smile. And that's the test of successful treatment. If you feel like yourself and you feel happy

    September 14, 2011 at 22:15 | Report abuse | Reply
  6. Christianna

    Americans are being bored, having everything in life; that's why so many of them are depressed. Ship them to Afghanistan and let them volunteer there and let them get real life.

    September 15, 2011 at 07:09 | Report abuse | Reply
    • Regina

      You haven't a clue. Why don't you direct your comments to subjects you actually know about.

      September 17, 2012 at 09:11 | Report abuse |
  7. jennifer phillips

    I been dealing w/depression for years & I've tried almost everything. Right now I'm taking Cymbalta & n therapy but still having symptoms. I'll definitly look into some of the suggestions given in the earlier comments, never know, one of them could be the answer so thank u for advice, it's nice to know I'm not alone. Let me add that few months ago a friend suggested I start volunteering my time whenever possible even if it's one day or
    one weekend a month,
    she says it changed her outlook & made a difference n her struggle w/depression so I started looking into volunteering around my community & I'm looking forward to beginning asap.

    September 16, 2011 at 08:20 | Report abuse | Reply
  8. Davidr11

    Have any professionals mention folate levels? A growing trend is that low folate levels may hinder how some anti-depressants work. Please look into this subject, hope it helps!

    September 16, 2011 at 16:52 | Report abuse | Reply
  9. Steve

    It's really important that other causes are ruled out, before you start on these drugs. Once you've been on them for awhile, it can be very difficult to stop.
    Has your thyroid and other hormones been properly checked? Iron deficiency? There are lots of others i am sure.
    I was on these drugs for years before a doctor finally helped me get my hormones straightened out.
    The withdrawal was horrible, but i did my own research on how to quit and showed the psychiatrist how it is done.

    October 4, 2011 at 19:50 | Report abuse | Reply
    • annyomous

      Those other conditions are supposed to be ruled out BEFORE you are even diagnosed with depression or any other mental disorder, never mind before being put on an actual medication for them. It's part of the diagnosis criteria for ALL OF THEM: the symptoms cannot be due to another medical condition or due to medication or drug side effects. That's why Charlie Sheen can't be diagnosed with bipolar disorder, for instance, based on his manic behaviour from last year; he was going thru withdrawal at the time from an illegal drug that is known to cause mania during the withdrawal process.
      (It's still possible that he is bipolar though; we just can't use last year's behaviour as evidence for it. Besides it's up to a doctor to diagnose and treat him. Hopefully he's not and won't have to go thru this again.)

      Some doctors just like to take short-cuts and only eliminate the most likely culprits (like hypothryriodism for depression). Some just opt for the meds because many patients get relief from their symptoms in two weeks of starting them, which is less time than actually testing for everything that needs to be. (Might as well try something, I guess) And then there's the cost aspect: not everyone can afford all those tests. That's why only the likely culprits are eliminated.

      I'm glad you found what your actual problem was and have been successfully treated for it though.

      January 18, 2012 at 16:43 | Report abuse |
  10. teresa


    October 17, 2011 at 22:45 | Report abuse | Reply
  11. blue light therapy

    Its like you learn my mind! You seem to grasp a lot approximately this, such as you wrote the book in it or something. I think that you could do with a few p.c. to pressure the message house a little bit, but instead of that, this is great blog. A fantastic read. I'll definitely be back.

    May 18, 2012 at 19:50 | Report abuse | Reply
  12. Regina

    I figured right away this person was bipolar because of the hallucinations on taking Prozac. I took about 25 years for me to be correctly diagnosed and correctly medicated. I was under a psychiatrist's care for about 10 of those years. I was considering ECT. Read everything about mental illness you can get your hands on. And keep up the fight–that's all you can do.

    September 17, 2012 at 09:15 | Report abuse | Reply
  13. Nardil Champion

    I have been on the anti-depressant nardil for 10 years and it cured my depression and social anxiety. Previously I had tried all the SSRI's without success. Nardil simply works and it saved my life.


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