I’m a middle-aged man who is depressed…again. Over the last eight years, I’ve experienced "off and on" depression, but lately, it’s more than just "good days and bad days" for me. I can’t concentrate at work and my productivity has gone down. I don’t enjoy life as much as I used to and I feel so discouraged about the future. Medication doesn’t seem to help; counseling and support groups helped a little, but my bouts with depression continue. I’m sick and tired of being sick and tired. Is there anything else that might help?

The first step is a careful evaluation of the diagnosis and past treatment. Often, people present to me reporting that "every" medication has been tried and that therapy was not helpful but a careful review reveals options that were not previously considered. An effective alternative to medications and counseling is electroconvulsive therapy (ECT). This medical procedure, involving the administration of anesthesia and the induction of a seizure by electricity, elicits a good response when medications fail. Furthermore, the response is usually more rapid than the response to medications or therapy. ECT is safe and usually well tolerated although the usual course of 6 to 12 treatments is more intrusive than medications or therapy. Repetitive transcranial magnetic stimulation (rTMS) is an experimental treatment that involves the use of a powerful magnet to induce brain activity. Although the effectiveness of this intervention is uncertain, rTMS is less intrusive than ECT. Finally, there is interest in stimulation of the vagus nerve as an antidepressant treatment. Also experimental, this treatment involves the implantation of a stimulating device in the back that delivers electrical stimuli to a region of the brain called the vagus nucleus. Regardless of the use of any of these techniques, it is likely that medication and therapy will play a role in producing and sustaining a good response. 

Keith Isenberg, MD
Washington University School of Medicine
Professor of Psychiatry
314-362-5227

It sounds like you are really struggling with your "recurrent depression." Relapse is very common for people with depression, as some recent estimates have noted relapse rates ranging from 50 to 80%. It may be comforting to know that there are many options for you. An approach that has been around for thousands of years but just recently formalized in the treatment of depression is "mindfulness meditation." This means learning to pay attention in the present moment. To be mindful is to be aware of subtle sensations, thoughts and feelings as they happen and not change, judge or criticize them. You learn to observe your thoughts rather than ignore, worry or dwell on them. Consider a metaphor of the mind as having and "in" and "out" door where thoughts can be observed as they pass through without lingering. The breath helps create a base or anchor to focus the attention. You are encouraged to take note when your mind wanders and then gently bring your attention back to breathing. This is a very solid approach, especially when combined with cognitive therapy, another successful treatment for depression, which works to help you change your problematic patterns of thought and negative beliefs. Mindfulness teaches you to respond in a skillful way rather than react out of stress, anger or anxiety. You can be taught to meditate in one session and can work through a full mindfulness meditation program in 8 to 16 sessions. Individual and group approaches are appropriate assuming it is done by a person trained in the area.

Ryan M. Niemiec, Psy.D.
Saint Louis Behavioral Medicine Institute
1129 Macklind Ave.
St. Louis, MO 63110
314-534-0200 Ext. 413

Want to see other Open Mind columns?  Click here for archive index.