Updated: Apr 25
Disclaimer: This post is meant to provide a personal perspective on various interventions for depression including the use of SSRI medications and insufficiently researched treatments like Ketamine and Psilocybin. It is not meant to be taken as medical advice. Consult with your doctor before beginning or stopping any treatment regimen.
Hi. My name is Ted. I've been a therapist for 15 years and I've been battling with depression for as long as I can remember. For most of my life, depression has been a wrecking ball, damaging relationships, putting strain on jobs, and often making day-to-day existence feel impossible. And in my twenties it came dangerously close to killing me on more occasions than I'd like to admit.
Today, it's hard to believe I'm the same person as I was back then. While I haven't cured it and certainly don't have it beat, I've found a way to live a really happy and fulfilling life.I've gotten here without taking depression medication. That's a personal choice for me. I have plenty of clients who take SSRIs and I would never tell them to stop. But, it's worth saying that I've done my homework on these medications along with some other interventions and I want to share what I've learned with you.
I don't talk about my personal stuff with clients. The work is about them. But for this one, I'll speak from personal experience. Why? First, I just want you to know that if you're suffering, someone gets it on an honest human level; someone who found a way out of the worst of it. Secondly, and more importantly, this is about what has worked for me and what is working with my clients. I'm not here to tell you what to do and might say stuff that you disagree with. Take it or leave it.
2006 Ted vs. Today. It wasn't just a bad day. I was convinced I was doomed for life. It's incredible to consider how much things have changed as a result of consistent personal work.
The Medical View
A few months ago I visited a doctor for chronic fatigue unlike anything I've ever experienced. 10 minutes into my appointment, after some questions from a really wonderful but often inaccurate assessment called the PHQ-9, my doctor told me I was depressed, and prescribed me an SSRI depression medication.
The tragedy of SSRIs is that they can deplete the brain's natural production of serotonin. It's why doses need to be increased as time goes on and why coming off anti-depressants can lead to an increase in suicidal thoughts and behavior.
Doesn't seem like a problem right? But wait, I explained my history of depression, told him some things about the diagnostic criteria, and told him I'd ruled it out. He got on his computer to, I assume, check some medical literature. Nope, he was fucking googling depression. And then told me it sounded like I knew what I was talking about.
This kind of off-the-cuff diagnosis and prescription is more common than you might think. Medical doctors are great at acute care - they treat the symptom and get you relief so you can get on with your life. When mental health is treated from a medical model, the goal of the doctor is to 1) see if the symptoms meet the diagnostic criteria and then 2) treat the symptoms and hope he/she got it right before 3) getting to the next patient.
Depression though doesn’t operate like a typical medical condition. It's chronic. This is why SSRI depression meds don’t seem to improve quality of life in the long run. It’s also why treating it with medication could actually make things worse.
The Serotonin Problem
My doctor meant well. He was operating from the Serotonin Theory of Depression which you've probably heard of. This theory is worth about 13.5 billion dollars to the pharmaceutical industry which is why a LOT of money is spent on marketing to ensure that the general public knows what serotonin is. Serotonin medications called SSRIs (selective serotonin reuptake inhibitors) are prescribed under the belief that depression is caused by a "chemical imbalance" and once serotonin is back in balance, you'll be fixed. But this simple understanding simply can't be supported by research.
Serotonin, like other neurotransmitters, is a chemical messenger. It's just passing along signals. It's why you probably felt like you were on drugs last week when the sun came out. And while increasing it seems to work to some degree, it's kind of like spraying starter fluid into your engine cylinder to get your car to start. It gets the job done without considering why there was no gas getting to the engine to begin with. That can create problems in the long term.
It Doesn't Just Influence Mood
Serotonin does a bunch of things outside of mood regulation. It's partly responsible for your sexual desire, helps with wound healing and bone health, works in your gut to help with digestion, and in rare cases can lead to this condition called Serotonin Syndrome if there's too much in your body. So messing with serotonin levels can impact a lot more than just mood. It kills me that people don't seem to understand this and that doctors don't talk about it when prescribing these meds.
Downregulation of Serotonin
The tragedy of SSRIs is that they can deplete the brain's natural production of serotonin. It's why doses need to be increased as time goes on and why coming off anti-depressants can lead to an increase in suicidal thoughts and behavior. This observation completely debunks the "chemical imbalance" story because if it were true, our bodies should welcome and use the extra serotonin. More importantly, if you're really telling me that serotonin is responsible for my happiness, you won't catch me doing anything that could potentially compromise my body's ability to make it on its own.
If you have a therapist, you're probably sick of them telling you, "What we resist persists" but it's true. When it comes to mental health, symptoms usually get worse the more we try to push them away. It's almost as if our difficult emotions are there for a reason and when we suppress them, they turn up the volume to make sure we're listening.
The meds will likely take care of this. But creating a pattern of pushing pain away by reaching for something external is a known cause of worsening mental health. I can see some making good arguments for why taking meds might not fall into this category but for many of my clients, taking meds is a doctor-sanctioned way to "just make it go away" and I've seen it lead to more pain for them.
What I've learned is that the mask I wear when I'm feeling depressed is the worst part of it. Feeling fundamentally broken while working overtime to pretend everything's fine is one of the best ways I've found to feel completely alone, detached, and separated from the things I need most. And with depression, SSRIs can become just another clever mask. When we shoot the chemical messenger, we get results but we don't actually change the situation that caused depression to begin with. And somewhere in some dark corner of the mind, that seed is still germinating. This has been described to me by many clients with depression as numbness, detachment, or feeling sedated.
If Not SSRIs, Then What?
Despite not taking meds, I enjoy a quality of life that my 23 year old self would never have thought possible. I still have bad days, weeks, and months and I don't know if depression will ever go away but I have learned that I can manage the ever-living shit out of it. Here are some things that I think can really help:
When trauma is present, this intervention is similar to my college roommate throwing up on the floor before Thanksgiving break, putting a newspaper over it, and pointing the fan out the window before going home for the week (yes this really happened).
The Defectiveness Schema
Almost everyone I've talked to that suffers from depression, myself included, has a thing called a defectiveness schema. It's a persistent story about how you're a failure, that you don't belong on this planet, and that you're somehow fundamentally broken. It's not your fault - thesee stories can stem from trauma or be passed on from parents. And honestly, most of our defectiveness schemas likely come from a backward culture that won't ever let us feel worthwhile as a strategy to sell more skin cream.
The schema will grab ahold of things like medication or therapy and point to it as proof that you're broken. So you need strategies to disarm it. The best way to deal with this nasty schema is to invite it into your psychological house, learn to hear it when it comes up, and use cognitive behavioral strategies to weaken it.
I named my defectiveness schema. When he shows up I greet him. I thank him for the input. I acknowledge that he's trying to help in some misguided way. And I politely decline his advice. That might sound corny to you. But for me, it's powerful.
Trauma is often misdiagnosed as a whole host of things including depression. If trauma is at the root of depressive symptoms, SSRIs are almost definitely not helping. The amygdala screams at the brain that it is in danger and the SSRIs respond, "Just think happy thoughts." When trauma is present, this intervention is similar to my college roommate throwing up on the floor before Thanksgiving break, putting a newspaper over it, and pointing the fan out the window before going home for the week (yes this really happened).
For people who have suffered trauma, the overactive amygdala needs to be dealt with directly. If we're only diagnosing with the PHQ-9, that trauma will certainly be missed. If a competent and trauma-informed clinician does a diagnostic intake, they can help clients through therapies like EMDR and Cognitive Processing Therapy which are incredibly helpful.
There are a lot of promising studies coming out that support the use of substances like psilocybin and ketamine as treatments for depression. Based on what I've seen anecdotally, these therapies can be incredibly helpful for those who use them in the right way. People who use these substances will often describe feeling like they've done months of therapy in a single session. And the results only improve when coupled with competent psychedelic integration.
Having sat for integration with quite a few clients at this point I can say this: I believe these chemicals create relief for people because they allow them to sit in a lot of pain and make meaning out of it. In this way, they work completely opposite to the action of SSRIs which seem to have the goal of simply making the bad stuff go away. In my experience, toward is the path to real healing.
These substances are only legal in a few places, they are often misused, and they carry their own risks. I can't, in good faith, recommend them professionally until better research and better regulation make them safer. But for now, it's worth saying that the experiences of those who use these chemicals support the idea that working toward being with pain has a lot of mental/emotional benefits.
Building Positive Mental Health
In my lifetime I would like to see mental health become something we strive for rather than something we pathologize. People come to me in crisis with the hope of making the pain go away. They stop the work when the pain is gone. But just like exercise leads to a longer healthier life, mental hygiene leads to more happiness and less depression/anxiety in the long run. Moving to Salt Lake City completely altered my mental health for the better. Why? Because the culture is in support of exercise, being in the mountains, and engaging in outdoor activities that require a partner or two for safety. This isn't rocket science. We're social animals. The social side needs community and the animal side needs movement and connection to our environment. And when I got those things, my body stopped sending out so many depression alarms. I believe those simple changes could help a lot of people.
I don't take depression meds and I likely never will. I believe they can be extremely helpful for acute, short-term care. Especially for extreme cases of depression that keep a person from leaving the house or holding a job. Outside of that condition, they have the potential to cause harm that I just want people to be aware of.
If you take SSRIs and they work for you, I am fully in support of that treatment. Please don't stop taking them. But if you want to really take care of depression in a way that can be longer lasting, I'd like to suggest coupling it with therapy so you can work on the underlying stuff and get to a life that is truly peaceful and full of joy.
If you've got a handle on your depression, whether you take meds or not, let us know what works for you in the comments.