Beyond Blue

Beyond Blue


Are the Puritans Behind the War on Antidepressants?

posted by Beyond Blue

It is an honor for me to publish the following piece by Ronald Pies, M.D., professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine, because I find him to be one of the most fascinating psychiatrists in the Northern Hemisphere (I’m thinking the Southern is full of kooks). He always comes up with an intriguing angle on psychotherapy, antidepressants, the psychology of wellness … you name it, and he–like me–loves the intersection of faith and medicine, as is evident in his book, “Becoming a Mensch.” So, here’s a curious piece about why the we might blame the Puritans for the anti-med movement in the US. Let me know your thoughts, because I know that you will have some after reading this piece. I should probably also tell you that he wrote the foreword to “The Pocket Therapist.” I was once yelled at by a reader for not disclosing that … whatever.

These are not good times for Prozac and its progeny. In the popular media, the use of antidepressants has been likened to swallowing “expensive Tic-Tacs”, while in professional journals, the effectiveness of these medications has been challenged, if not discounted. And even a casual Google search under the terms, “Antidepressants damage” turns up thousands of websites and articles claiming that these drugs cause brain damage, induce suicide, or lead to “addiction.” Yikes!

Most of these claims and concerns are either groundless or simplistic, based on the best available studies. The “Tic-tac” claim, made in a prominent national magazine, was based on a misunderstanding of recent “meta-analyses”—studies that combine data from many other studies in order to reach a conclusion. What these studies show is that the milder the person’s depression, the less difference there is between an antidepressant and a placebo—famously but inaccurately defined as a “sugar pill.” But this is not a novel discovery: it reflects a well-known phenomenon known as the “floor effect.” Antidepressants were never intended to treat normal sadness, grief, or very mild cases of depression. The farther we move away from the “target” condition—serious, clinical depression—the closer we move to the “floor” of normality, and the less likely we are to see a big difference between drug and placebo. Most of the recent meta-analyses show that in the most severe cases of major depression, antidepressants are more effective than the “placebo condition.”

This last term is important, too. When patients enter a large, placebo-controlled study of antidepressants, and are placed in the “placebo group”, they receive much more than a “sugar pill.” They get many hours of attentive listening and evaluation by caring professionals—probably more than many depressed patients get from their primary care doctors! So the comparison is not between medication and a sugar pill, but between medication and a kind of supportive therapy. Furthermore, there is good evidence that when major depression has features we call “melancholic”—such as severe weight loss and a total inability to experience pleasure—the placebo condition is far less effective than medication.

There is also no convincing evidence that antidepressants cause “brain damage” or “addiction” among those who take them. In fact, the most recent evidence on how these medications work suggests that they actually enhance the growth of connections between brain cells—perhaps leading to more adaptive brain functioning. They don’t just “rev up” brain chemicals like serotonin. And, there is no evidence that people get “hooked” on antidepressants in the way we understand addiction to sedatives, opiates and related drugs. (That said, suddenly stopping a long-term antidepressant can lead to uncomfortable withdrawal symptoms, and there may be a small percentage of patients who develop delayed “resistance” to antidepressants, with a return of depressive symptoms).

So why is there so much hostility directed at these medications? (The same question could be raised with respect to psychiatry and psychiatrists, but that’s another story). I believe that a good deal of the animus arises from our Puritan heritage, and its attitude toward suffering, sin, and expiation. For the Puritans of New England, disease was essentially a divine punishment for Man’s original disobedience to God. As historian An Vandenberghe has put it, for the Puritans, ‘Even though there were more than two thousand different diseases…the primary cause of all of them was the “Sin of our First Parents.”’ There was also a strong link between disease and personal sin: the person whose tooth ached probably did something nasty with his teeth!

Now, when psychiatrists see patients with severe major depression, these unfortunate souls often express the view that their illness is a “punishment” of some sort. Some believe that God is punishing them for their sins. But this attitude, in a less extreme form, pervades our society’s views about depression—that it is, in some sense, the “fault” of the depressed individual. Some clinicians who argue that depression has an “adaptive” value often begin with the premise that depression represents the person’s “failure to resolve their social dilemmas”—a clinical euphemism for blaming the sufferer. The logical extension of this line of reasoning is that the depressed individual must somehow “repent of his ways”—for example, by ruminating on his problem until it is solved, or by “pulling himself up by his bootstraps.”

In this view of depression, taking a “drug”—the term “medication” is almost never used by those opposed to antidepressants—represents a weak-willed dodge. Antidepressants are seen as merely “covering up the real problem” or as “a crutch.” This attitude is extraordinarily unhelpful for those struggling with a potentially lethal illness. Although I prefer to begin with psychotherapy in most mild-to-moderate cases of depression, the more severe bouts usually require medication. Often, the combination of medication and therapy works better than either one alone. And I use a non-Puritanical metaphor in framing the issue for my patients. I say, “Medication isn’t a crutch, it’s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that’s the work of therapy.”

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  • http://AddaURLtothiscomment Mary Anne Thompson

    T,
    I love this article and post u shared today, particularly your closing statement: “Medication isn’t a crutch, it’s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that’s the work of therapy.”
    That is something I am going to borrow and start telling people who think that I don’t need anti depressants because I have been on them for so many yrs. I understand the feeling of NOT being able to live without medication and therapy as opposed to having it available to me. When I was in between getting my disability and not having insurance I could not afford to see a psychiatrist or therapist, my medications. I thank GOD that with my Medicaid now I am able to get all the help I need. While I am not thrilled that I have a perm disability there are some benefits that come with being disabled. Having access to Dr’s, help and meds are blessings for me! Thank you again for all you do for us at Beyond Blue. Know that you remain in my prayers and I am looking forward to you being back UP, recovered from your surgery, emotionally on fire again! U have it in it you, sometimes we just have to fan the fire….when it seems it is going out ;) love you T !

  • http://davidnixon.posterous.com/ David

    Whether churches or religions are for or against antidepressants is beside the point. The body of scientific literature that demonstrates antidepressants are no better than placebos (sugar pills) is huge and growing. Anyone can see for themselves in a summary of this literature by Joanna Moncrieff, The Myth of the Chemical Cure, or in a sustained argument by Irving Krisch titled, The Emperor’s New Drugs: Exploding the Antidepressant Myth. There is just no excuse for justifying huge profits for companies that make antidepressants. Nor should we forget that psychiatrists who write no prescriptions are out of business. It is not just that antidepressants are no better than placebos: they have side effects that can be very serious and life-long in duration. People taking antidepressants have a higher relapse rate than those who have never taken antidepressants. There are two very effective treatments for depression. They are cognitive therapy (a 10 meeting series) and exercise. Both have been shown to be at least as effective as antidepressants (whether acting as drugs or placebos) and they have wonderful side effects: self knowledge and physical health.

  • http://AddaURLtothiscomment Jen

    Like Mary Ann, I love the quote “Medication isn’t a crutch, it’s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that’s the work of therapy.” It’s so true.

    I have been told more than once that God is the Great Healer and if I can go to my doctors, why am I not able to make it to church. Two words: depression (I’ll add a few words here and add probable bipolar II) and agoraphobia. This is totally misunderstood and it’s true that many Believers do not accept the fact that therapy and meds make a difference! I’m curious to know what those people would do given the same situations in which we find ourselves.

    I have not heard of any psychiatrists who are out of practice because they don’t prescribe meds. My thought, though, is that they are MDs, just like a GP or a neurologist. Especially if you are in therapy, the reason you go to a psychiatrist is for meds.

    I’ve seen exceptional improvements in quality of life when people are on the right med/combo of meds. Before going on disability, I was a social worker. To say that meds are ineffective have not spent time, day in and day out to see the changes that meds can make. As with any med, the benefit and side effects have to be weighed, but it is the joint decision of the doctor and the patient if those meds will be taken. There is one non-psych med with such severe side effects that I decided, along with my doctor, that I wasn’t going to fill the prescription. Anyone has the right to do that with anti-deps, but to judge those who make the decision to at least try to see if meds help is, in my opinion, irresponsible and unfair.

    As Christians, we are not meant to judge – that is left to the Lord. I can logically understand the concept of depression being a consequence of sin. However, if that is the case, why are some people completely healthy while others suffer endlessly. We are ALL sinners – it’s right in God’s Word.

    This is not to discount the use of other methods to help oneself get better. There is absolute validity in doing things outside of a medications (although it is wise to advise any doctor). Massage, yoga, meditation, prayer(!), relaxation techniques, etc… they all are important parts of recovery. However, an individual who chooses to take meds shouldn’t be put down because of it!

    It’s a great article to open an interesting debate, Terese. Thanks – again! I pray for you and that you will start to see some light – and soon!

  • http://AddaURLtothiscomment Liz

    I understand the need by some for medication to get by, or ‘as a bridge’. My main opposition to antidepressants is the degree to which they can allow a person to ‘check out’ and not feel their feelings at all, kind of moving through life with no real highs or lows. As long as a person is taking other steps to deal with their depression, medication might make sense – but some use the medication as a solution in itself – as a kind of sedation – and never move beyond it, becoming dependent (maybe not physically but psychologically) on the medication as a substitute for taking any other type of action.

  • http://toodepressed.com Martin

    Hi.

    Thanks for your fascinating piece. I suppose there may be some connection in the popular media with puritanism, although I find that a somewhat strange idea – maybe it just hadn’t occurred to me before.

    I tend to agree with David’s comments above. I think the backlash comes as a result of some good scientific investigative work by the likes of Irving Kirsch and Jay Fournier (University of Pennsylvania) that demonstrates the lack of proven effectiveness of anti-depressants for anything less than very severe depression.

    It is in the interests of the pharmaceutical companies to blur the boundaries and encourage doctors to prescribe (and patients to take) anti-depressants when they are suffering from ‘depression’, without distinguishing between those whose condition is serious enough to justify the medication and those who are not in that category.

    Of course, the placebo effect is real and as you point out, patients on placebos are not without active intervention. In my view that is what indicates that some form of psychotherapy is warranted for patients with lower levels of depression. (And, I acknowledge that that is your preferred course for patients with mild to moderate depression.)

    Nevertheless, I understand that from the point of view of a depression sufferer, if you have taken anti-depressants and they have made you feel better, you may well not care too much if the improvement is derived from the chemicals in the pills or from the placebo effect.

    That was certainly my experience after first taking the medication. However, after a few months the effects seemed to diminish, I felt flat, empty and emotionless and when I tried to stop taking the medication I had some pretty bad withdrawal effects.

    It therefore seems to me that it is not acceptable for patients to be prescribed that kind of medication unless there is a scientifically proven basis for doing so.

    It is beginning to look as if there is no such basis except for those in the very severely depressed category.

    This is a fascinating debate and I hope that it encourages more research to identify better ways to treat this debilitating condition.

    I’m bookmarking this because I’d like to encourage this debate to continue.

    All the best.
    Martin

  • http://sarahrcallender.wordpress.com Sarah Callender

    Ooo, I’m feeling a bit saucy right now. I will speak for myself, though I imagine a few of you might concur: being on the proper medication (and the proper dosage) does not “sedate” me; it allows me to function. It allows me to feel a normal, healthy range of emotions. It allows me to be a better, more present, less whackjobby of a wife and mom.

    Liz, if a medication makes a patient “check out” and not feel any feelings whatsoever, yes, that is a problem. If that’s going on, then the medication should be altered. BUT antidepressants do not, when given the proper amount, “sedate.” They allow the depressed person to function.

    God wants us to lead healthy, productive lives where we can love hard and be loved hard. I am able to do just that because of the antidepressant I take, and will likely have to take for quite some time, not because I am physically or psychologically addicted but because I happen to have an illness that, like many illnesses, requires medication.

    Love the article, Therese. Love your own bit of sauciness, too, about the Yelling Reader.
    We are ALL just doing the best we can, but man, sometimes people are really so unnecessarily yell-y.

    Here’s a hug for you, Therese and all of you others who make me feel less alone. You are all a blessing in my day, every day.

  • http://AddaURLtothiscomment jami

    Wow…my psychiatrist refers to meds as a bridge…I have felt fortunate to have found him for treatment, but now even more so.
    I will not “go there” with respect to my emotional reaction to the “just be tougher” attitude.

  • http://davidnixon.posterous.com David

    If it is bad form here to post a rejoinder, I hope you will accept my apology at the outset.

    1. The psychiatrist’s point that those who receive a placebo are really getting wonderful care may be true but his conclusion is mistaken. If it applies to those receiving the placebo then it also applies to those receiving the active drug, cancelling the effect. In a drug trial, the contribution made by the active drug still remains the improvement of those in the drug group minus the improvement of those in the placebo group, i.e., very small.
    2. Those making personal testimonials about the effectiveness of their antidepressants fail to see that their recommendation of the drug, based on such experience, is exactly the effect that would be expected to be produced by a placebo. The placebo effect is not a phoney improvement in depression, it is real. That’s why the study of placebo action is so important. If that were all there is to the matter, there would be no basis for objecting to antidepressants because, who cares whether the improvement in depressive symptoms is produced through the action of a drug or through a placebo, so long as the benefit is real? The problem is that these very psychoactive drugs have a powerful impact on brain chemistry that can be both negative and lasting: increased sexual dysfunction, suicides, relapse rates, birth defects and others. But the alternative to antidepressants is not nothing: depression is serious and requires treatment.
    3. Perhaps the most striking reaction is the lack of attention to exercise in the comments. The evidence of the powerful impact of vigorous exercise on depression is well documented. Yet, people seem to opt for a pill, however harmful the long term consequences may be. Maybe the passivity of the pill matches the passivity of depression. Depression is about perception of my helplessness, of my hopelessness. The very act of showing up for an exercise session is profoundly empowering, that is, therapeutic, in itself.
    4. Cognitive therapy is also self-empowering. In it one learns to distinguish between the symptoms of depression, e.g., thoughts like ‘I’m no damned good’ or ‘what’s the use, anyway’ and ‘why don’t I just end it’ – thoughts like that for the symptoms of depression that they are: false statements that are to be discarded in favor of true statements like, ‘I’m having a tough time today but I’m doing the best that I can’ or ‘I accept what I am able to do today as the best that this good person (me) can do.’ All of this is self-empowering and, as such, it is the reverse of depression.
    5. Finally, with every prescription that a doctor or psychiatrist writes and for all the speeches to the contrary not withstanding, the message of the prescription is profoundly disempowering: “Your brain chemistry is messed up. That is a fact of your life. You can stand up, sit down, sing a song or run in circles but you are helpless to change that situation on your own. What you need is the power that this little pill can bestow and you will probably need it for the rest of your life. ” That is a very depressing thought. And it tells me I am hopeless without this little piece of psycho-pharmacology.

    I have experienced depression as serious as it gets, this side of the grave. I have been on SSRIs: up this, down that, combinations and alone. I no longer use antidepressants. I have done cognitive therapy and continue it in my daily life as a mental exercise and I have done and am doing exercise. I am not just better, I am not depressed. At all.

    People, you can do this. You CAN do this.

    Thanks.

  • http://AddaURLtothiscomment Kevin Keough

    Well, it’s very simple. “Protest-ants” (imagine a ton of adults running around “protesting” are at the root of the anti-psychotropic medicine campaign.
    Catholics have lots of problems but we don’t go looking to convert people and we tend to be pragmatists.
    Dr. Ronald Pies is way cool even if he isn’t Catholic—just goes to show there are lots of cool non-Catholics.

    It doesn’t get better than his saying: “Medication isn’t a crutch, it’s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that’s the work of therapy.”

    Sounds Catholic—Irish Catholic to me and how can anyone disagree ? Sure they will whine and protest because they are Protest-ants (folks this is all tongue in cheek….dark humor…no offense intended)

  • http://AddaURLtothiscomment Sam Gyura

    I’m still pissed off with your ‘Southern Hemisphere kook’ jibe. I should just get over it I spose…Besides that, I enjoyed your article.

  • http://AddaURLtothiscomment ME

    The problem is that things like Prozac are overprescribed. If it was never intended for mild depression, adjustment issues, simple sadness… then prescribing it for those reasons is excessive. That’s one issue.

    The long term use of these medications is unknown. They haven’t been in use long enough for anyone to know what the long term effects are – or are not.

    That anti-depressants are prescribed so freely and easily, used as a first resort and in place of psychotherapy as if a medication could change life circumstances that need to be addressed, are real issues.

    I do speak from experience. From the years wasted being emotionally numbed by Prozac (with a required quarterly check in with a CBT therapist),instead of being encouraged to work with an effective psychotherapist.
    Now in psychodynamic psychotherapy, I am making changes instead of being medicated.

  • http://AddaURLtothiscomment Carol

    I don’t think there is much “Puritanical influence” left in our secular society.

    Believers raised or inculturated into hyper-Augustinian Western Christian sects still have “puritanical” tendencies; but they are a minority even within the contemporary ecclesiastical sub-culture.

    Dr. Pies’ observations are valid; but the cause, is more likely to be a confusion of situational depression with clinical depression than puritanical influences in the general population, IMO.

  • http://AddaURLtothiscomment Carol

    As an addendum to my previous post:

    As the economic and social stability in the world worsens, we should expect situational depression to become more common.

    The “cure” for situational depression, like the “cure” for our excessive dependency on drugs, both legal and illegal, is to “make our lives better” by focusing on the common good rather than seeking advantages for special interests at the expense of our common good.

    Clinical depression, unfortunately, does not respond to positive changes in external circumstances, although negative circumstances can trigger or deepen it.

  • http://AddaURLtothiscomment Livin Out Loud

    Besides thanking you, my dear Therese, I thank these daily tic tacs for keeping me sane…hahahaha…

    I think most of those people either had a family member with the wrong medication and had a problem, or just dont know at all..(like T. Cruise w the post partum case)…we know…thats all that counts…Therese, you are truly MORE than a mensch…although, I always thought it should be mensha..haha

  • http://AddaURLtothiscomment Livin Out Loud

    David, the psychologist, I presume…all that is wonderful, in a perfect world…which, of course, you know, doesnt exist..except to the persons that are comfortable enough to enjoy it…with the help of these medications, they are…yes, some people can get help in months or years or …..NEVER right? And you know in your BUSINESS, MOST ARE NEVER!!!!! So the pill helps you get to a proper, workable life, daily,, Yes, optimumly, they are great, AT the SAME TIME..I’m on your side, but its becoming a thesis to some to write about “what could be,” not the truth in real life…think about it?? Thanks…

  • http://AddaURLtothiscomment livin out loud

    David, I apologize..I didnt read the end. Im so sorry that you were so sick..that worked for you, dear David…Unfortunatly, there are too many that could never work at it like you do..or even acknowledge or realize that they have a problem…yes, even that bad of shape. So for those, the pills are mandatory..If you can do the work, fine…but David, just making up your minds to get better doesnt work!! Im glad it did for you…but for most depressed, when I said, IN THE PAST, go for a walk, they would get angry…THEY NEED TO GET UP FOR THE WALK FIRST, and that lil pill makes the difference between living and not for most…so Im glad for you–now be glad for them..peace..

  • http://AddaURLtothiscomment Payje

    As much as I hate taking ANY medication…I am thankful for the people GOD gave the gift of healing too. I thank God for the bridge!

  • http://AddaURLtothiscomment Jean

    I have yet to find the medication that works for me. Still looking for my ‘bridge!’

  • http://AddaURLtothiscomment Stacey

    Though a humanist by nature (and thereby a far, FAR cry from a Puritan), I must give this post a resounding “Amen”!

    I struggled all of my adult life with depression (I’m 46); like many, I blamed myself, was convinced I would feel fine if only I could “think more positively” (hey, that’s what all the books say, right?), and was loathe to take medication.

    After a mild breakdown and months of swirling suicidal thoughts, inappropriate behavior, and uncontrollable anger and crying jags, I was diagnosed with bipolar disorder and clinical depression and began medication. No one on the planet will ever (did I say EVER?) convince me not to allow myself the benefit of meds. The meds have allowed me to regain some of my true self, to see things as they really are, and to realize that life CAN have some sunny, cloudless days.

    I think we’ve come a long, long way in understanding, diagnosing, and caring for those with depression and bipolar disorder (as well as many other mental issues, I’m sure), but we have a long way to go. I myself try to be patient and understanding of those who don’t yet understand! Give them time and information and eventually they will likely come around. =)

    I love and will, forevermore, be using the quote, “Medication isn’t a crutch, it’s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that’s the work of therapy.” It is a perfect way to convey to those who are depressed and those who aren’t and need understanding the function and roll of medication in treatment.

  • http://AddaURLtothiscomment JillB

    I think there are a lot of valid points here. I have to question, though, why mental illness is treated differently than an illness which is seen differently – as biologically based. Depression is a medical illness. Would you tell someone who has to take thyroid meds not to take them and they can “think” their way out of it? Of course not! In my opinion, this is an argument which is common among those with vs without mental illness.

    What about those with schizophrenia? Should that population stop taking meds which make their delusions and hallucinations go away, allowing them to live the best quality of life they can? Most of us have argued for years that depression, bipolar and other mental illnesses ARE biologically-based. There is a chemical component. Severe depression, unrelenting depression, suicidal depression – nobody can say that you do x, y, and z and the depression with “magically” disappear.

    I absolutely agree that anti-deps, especially SSRIs can be given out like candy and people expect to be “all better.” Therapy is vital, even for mild depression or dysthymia and should be the first avenue to explore. As has been mentioned, there are situational depressions! There are also people who have recurrent depression and it can be triggered by situations.

    I think this is an individual issue. Making the sweeping comment that anti-deps are bad for everyone and should never be used is, imo, unfair.

    This really is a great debate and I’m thankful, Terese, that you posted it!

  • http://AddaURLtothiscomment steve durham

    Interesting post, and interesting how many replies it already has prompted … good indication it’s a “hot topic” for we who wrestle not only with depression and kindred sufferings, but each in our own way (probably?) have at least struggled *some* … maybe even if only briefly, when we first made the decision to go on anti-depressants or similar meds … as to whether this was dangerous, debilitating, addictive, a “false surrender” (didn’t need to happen, *that* sense of “false”) … etc. etc. I certainly had those struggles too.

    Three comments …

    [1] In my own experience, Prozac, and now Cymbalta, *is not* a placebo. My initial struggles went entirely the other way — I doubted it would help, I doubted I even needed it, and was told directly by the psychiatrist (who has since died) this was temporary until my own body adjusted (an early interpretation now discredited). I believed it wasn’t necessary, and was absolutely certain that even if it made an effect, the effect was something my own body would learn — “unconsciously” and at tissue-level, and/or consciously as I familiarized myself with the state I needed to learn to induce in myself — and the meds could go.

    I was as wrong as I could be … all of the counter-attitude, the “positive thinking” (not a phrase I would have used, but still …) … *all* of it was horrifyingly wrong.

    If there was a human being alive who could have switched back to different methods, who didn’t really think this was valid, it was me. Any alternative methods ranging, from meditation (I considered myself largely Buddhist then) and/or prayer (formally/outwardly I was a practicing Christian) … exercise, which I have done *all* my life … healthy diet, plenty of sleep, talk therapy, cognitive readjustments, acupuncture, herbal remedies (lots of those) … with the exception of acupuncture, I tried them all.

    It was a disastrous illusion. ONLY the meds altered an inherited physiological state, process, sufficiently to get me functioning again as a *normal* human being.

    This isn’t necessarily to deny the mounting evidence for *some* persons in *some* situation … not *necessarily* deny it; I don’t know (nor do the researchers at this point; it still is in evidentiary stages and subject to collegial critique, differing interpretations, and thelike) … but it *is* to say that for some of us who, like me in at least “those days” (20 years ago), who didn’t need institutionalization and who remained reasonably functional (then; had it continued, I doubt seriously that would be the case now; I’m not even sure I’d still be alive by now) … for *us* the counter-evidence and arguments was, and is, specious.

    [2] My experience has been pretty much that of Sarah (above) — meds restored me, to my utter astonishment in the beginning, to being a normal human being. I expected some kind of “high” … there was none (providentially, and I do mean that, my initial and now-deceased psychiatrist simultaneously picked what proved to be the “correct” anti-depressant *and* correct dosage). I must have said, in sheer wonderment, countless times during my first 6 months — after which the *real* myth took over, that my body would have adjusted and I could (and did) go off, as prescribed, slowly, only to be in a worse pit than ever several weeks later — … during those initial months, saying over and over and over again: “So THIS is what NORMAL
    feels!!!” I just couldn’t believe what I was seeing, and experiencing.

    My experience, and I wouldn’t even consider generalizing it to a medical theory or practice … but I will never let it be allowed to be ignored in any “debate” about whether these drugs are “really” necessary.

    [3] There is a kind of “spiritual energy” that is passed from generation to generation, even if the initiating ideas and teachings (I mean Puritanism here). Maybe by our epoch that energy survives only as an otherwise ill-defined “resonance” within the thought processes, the emotional and cognitive structures, we inherit from the same psycho-social sources as we inherit (learn) most if not all other ways of perceiving the world, and ourselves in it …

    But whatever “it” is, Puritanism still is with us, even if not by that name. It survives quite nicely, and even viciously, *outside* churches and, for that matter, any and all other religious institutions, Christian or not.

    One example among dozens I could offer … I spent a lot of time on Twitter during the London riots. The tweets fell into two broad groups, the largest of which was to condemn the rioters as “thugs” and “hooligans” (these seemed largely to be UK tweeters).

    Without taking a stance on that situation at all, what seemed clear to me was, and is: these people are lazy shiftless criminals who do not WORK … they are damned sinners, therefore … and are worthy of full condemnation.

    God wasn’t mentioned, unsurprisingly; and there was no note of divine judgment here. The condemners, the judges, are *us*.

    It still is Puritanism, stripped largely of its outer, religious trappings … but the refusal to work, and work damned hard, and to sacrifice all for the glory of (in this case) Respectable Consumer Society and Middle-and-Higher-Class values and norms … and to be judged as “criminal” at best, virtually subhuman at worst for clearly NOT working and working hard … that is Puritanism. God is curiously absent as the judge; well-educated and affluent tweeters have taken God’s place.
    (Of course, neighborhood residents did a lot of judging too, but they included justified dreadful fears about their own homes, businesses and personal safety.)

    There were equally Puritanical tweets from the “other side.” These were largely liberal-to-further-left folks who empathized, if not with the rioters and riots, then at least with the conditions that they argued lay behind the riots. They tweeted, angrily, over the alleged rage that, like some sort of ebola virus, rampaged out of the toxic alchemy of poverty, poor housing or homelessness, hunger, racial and religious prejudices, etc.

    In that case, the Puritanism was the same, but this time directed at the morally corrupt “work” of the rich and powerful — specifically of large corporations, banks and other large financial institutions such as the IMF and World Bank, and the like. THEY had failed in honest hard work — in this case, on behalf of the poorest, weakest and most vulnerable persons and groups in society — and, so judged, stood condemned.

    And again, in place of God as judge and condemner over morally fetid “work,” it is a community of humans.

    Either way, it is *a* central strand of a Puritanical outlook. (There are other strands; and I’d hasten to say here that Puritans *do* get an unfair rap in the popular imagination and its stereotypes — their reality, like *all* our realities, was vastly more complex than the images we hold onto — c.f. work by historian Perry Miller — but those are different stories.)

    Sorry for the ramble … and the bandwidth I have wasted :-)(smiling because I think I just Puritanized my own post here LOL).

    Excellent discussions up there, all, and as always, Therese, excellent blog.

    grace & peace,
    steve

  • http://AddaURLtothiscomment steve durham

    After posting my previous comment, I skimmed it and realized how many typos there are, incomplete sentences (where somehow I managed, not just to leave a sentence before it was finished, but somehow actually to delete part of it) … etc. … too late to rewrite. For any who care(d) to read it all, hope it’s still *largely* readable :-/

    sd

  • http://AddaURLtothiscomment Joy

    What a wonderful article! I love the bridge analogy, and have found it to be so true. Medication gets you to the point where therapy can begin to work. I literally thank God for Cymbalta and the difference it has made in my life. For the first time that I can remember in my whole life, I am free from the undercurrent of anxiety that had pervaded my existence. I’m finally becoming the me that I was meant to be!

  • http://AddaURLtothiscomment laura g.

    I started taking Prozac many years ago and now take one of the newer medications. I think of my need for medication like this: there is a defect in the chemicals in my brain and I need to take this medication to keep me from feeling awful. My grandfather committed suicide. My brother and my sister where alcoholics, before their untimely deaths at 45 and 50. So are those my two other choices, death or alcoholism? If I only drank to excess I wouldn’t need the “crutch,” the medication that helps me function and be a productive member of society. We don’t blame the people who take Lipitor because they can’t control their cholesterol level through diet and exercise. Does that make them weak? I think not. It is no different with these medications. There are some of us that need these medications like others need medications to help them live longer, healthier lives.
    Thank you Therese as always for you courage and inspiration!

  • http://AddaURLtothiscomment Margaret

    This is excellent. I feel sorry for those who think God is punishing them. It is NOT true; God loves us.

    Dr. Bernie Siegel says, ” God doesn’t sit in Heaven with a clip board and saying to Himself,’ hmmm, who can I ‘get’ today.'”

  • http://AddaURLtothiscomment Your Name

    Antidepressants saved my life.

    I have problems with them being handed out to those who don’t need them (the mildly or transiently depressed) or to people for whom they might be harmful, e.g. pregnant women or children in which the drug was not tested previously/adequately for pediatric depression, but I think they are lifesavers for many and an important type of medication to continue to research, and add types that may help additional people, to.

  • http://AddaURLtothiscomment Belleo

    Prozac did not help it made him violent .In time he was bipolar . Did the Prozac bring that along ? According to drmercola.com antidepressant can do that .

  • http://AddaURLtothiscomment snowbird

    Loved this article. I am having a delayed response to an intense emotional relationship end. It is likely situational depression with attendant anxiety. Since I have MCS (chemical sensitivity), I am one of the most anti-chemical people on the planet.. I recently began taking “Rescue Remedy” and Fish Oil (for the Omega-3s) to help ease my pain. I also started a lo-dose SSRI, to help me get over the hump. I walk my dogs several times a day and practice yoga a few times a week. I need a little help and really don’t care if I’m actually having a psychological response to the SSRI b/c I believe it will help. I plan to use it for 3 months, then wean. Using something in moderation is assisting me in a grieving process that will end at some point. I understand the debate, but I choose not to throw out the baby with the bathwater. Each individual needs to be responsible for their own healthcare as much as they are capable of so doing.

  • http://Antidepressants Mary Lou

    I’ve seen first hand the damage antidepressants do to people. I know of one young woman who was on antidepressants for years that commited suicide. My daughter has been taking antidepressants for years and she has been having more problems than when before she started taking them. I think antidepressants are dangerous.

  • http://AddaURLtothiscomment Ronald Pies MD

    I very much appreciate the thoughtful and heartfelt comments from readers, and I want to thank Therese Borchard for giving me this opportunity to present my views.

    There are, of course, no simple “bumper sticker” answers to many of the excellent questions raised by readers, and my standing internet policy is to reply directly only to emails that are signed with full names. (I understand that isn’t comfortable for many readers).

    Nevertheless, I will try to provide some substantive, general responses to the concerns registered by several readers, regarding the safety and effectiveness of antidepressants. I expect to post these within the next 2 days.

    Finally, I very much appreciate the kind comments about my “walking over the bridge” metaphor!

    Best regards, Ronald Pies MD

  • http://AddaURLtothiscomment Mark

    I personally suffered from depression as did many members of my extended family, some of which took antidepressants and some of which didn’t.

    I think everybody has the right to decide on their own what kind of treatment they will receive, be that therapy, drugs or some other method of healing.

    Saying that, although I know from experience that antidepressants can lift the symptoms of depression, I would like to add that there is not one single scientific proof that would prove that either unipolar depression, bipolar or even schizophrenia are biologically-based diseases.

    These are hypothesis which scientific community is leaning towards, but which have never been really proved. Saying that mental disease is biologically based is therefore a just a belief and not a scientifically proved fact. I know this is hard to take for most as this belief has become quite ingrained in the minds of most, but I invite you to take the
    time and look up the scientific research being done in this area and you will notice this amazing fact yourself (note all the language such as “suggests”, “could”, but none of it saying “proved”).

    Now to take this further, even if antidepressants temporarily relive the symptoms of depression and if they do that by changing the chemistry of the brain, this in itself is not a proof of a biologically based disease hypothesis.

    Likewise your TV set can break down and be fixed by mechanical intervention, but does that prove that the program itself originated from its hardware? No, it’s much more complex that that.

    I personally believe that most mental disease is psycho-dynamic in nature. But its roots go much deeper than most people in the traditionally oriented psychotherapeutic community are familiar with or are even willing to acknowledge. Still there are some who do and I think those represent the true hope for the future of all of us who suffer from these symptoms. For those who’d like to learn more of the cutting edge psycho-dynamic research I heartfully recommend the works of psychiatrist Stanislav Grof; his book Psychology of the Future is a good start.

  • http://AddaURLtothiscomment Diane

    wonderful

  • http://AddaURLtothiscomment Michele

    WOW! This is alot of information. Been diagnosed for 21 yrs with bi-polar and while I disagree with the diagnosis (not that there isn’t some kind of chemical imbalance), I come from the Puritian midset, and I bought it Hard! I am analytical, and as I read the King James (limited translation) and educated with pastor who did not finish High School, I had a very child-like view of reward and punishment. So I did all the “right” things, kept myself pure, went to college (of my faith, sent by parents–where I studied theology and wanted to be a leader-preacher might be a better word–that was NOT allowed)and met a boy who professed his “whiteknighthood” of virginity, also.
    After our first child, he decides to tell me his escapes of his past….I am shocked into silence. I feel betrayed, lied to, cheated on…or at least now I knew he could. Where was my sanctified, pure marriage.
    In the meantime, I am in my second pregnancy (morning sickness, including deep depression). This is my second Ceaseran, and I had mastisis 6 times in 4 mo, temps going up to 103 degrees.
    Never did drugs or alcohol, so imagine my surprise after about a week of not sleeping being put in the hospital for a nervous breakdown. Ask me? Having spiritual warfare, because my mind was all over the theological, universe board…and I had always had a VERY disciplined mind.
    Now I’m sacred. I can’t control the anayltical, min-answering mind thoughts..but I KNOW I don’t want THEM (doctors) to control them with meds/drugs.
    My mother constantly whispering in my ear…don’t take the medicine..I am LITERALLY out of my WITS trying to be responsible with all this. So I leave the hospital 10 days later with 9 meds, and I’m so “doped” up I cannot make sense of any of them or why I’m taking them….just know I HAVE to. My husband will not help with med dispension nor the two kids, so my whispering mother takes the kids, and I spend at least half hour in the morning and half hour at night trying to read the instructions and figure out which med is which, how much do I take, and what is it for?? To top it all off, I live in a samll town where they medicate everyone as though they are dual diagnosis. I am over-medicated, my brain is fried from all the “trials” in the hospital and there hasn’t been enough time for everything to balance, but I’m expected by family/friends to perform up to par. To top it all of, I live in a small city where they medicate all as though they are dual diagnosis.
    Christians in my faith community can’t understand what has happened (you should be in my head) and so, of course, they determine I have been possessed and steer a clear path around me. Talk about feeling SUPER rejected. And I was a “favored” one before this. So I turn the place I always have when troubled and alone, God. Where do you pray to Gid from? Mind. What is screwed up now? Mind. Talk about a trip! Trusing God has a whole new meaning for me.
    This circus has been going on for 20 yrs, including a divorce (more mind swirling) and being a single Mom of 3 sons for 15 yrs. I’m in WA, family all in AR. Decide to “test” the Putitan values and right off end up in an affair with a married man (he showed me value and respect)and my three sons got to watch their Mommy “break” the rules. Thank God for Grace! and it is finally penetrating that Grace is for me, too. NOT all the Puritan rules, and NOT license to do whatever I want. We all sin, no one has ever been perfect except Jesus Christ…but i was on my way :)
    I could not cope mentally with the permission and non-permission my mind kept sending. I would go from holiness to immoral sex in an instant. How do you mentally cope with all of this? Drugs? Medication? Scripture? Counseling?
    First….Great Love, not only from the Father when YOU get past the fact He’s not a reward/punishment God and the Great Love and acceptance from others. Mine began with a married man (who may have seen me as another conquer) but he was genuine in his encouragement and edification (yes, I’m using that of a non-“church” man)and THAT was why I gave my heart away. He valued ME, not what I had done, or could do for the church, He saw ME.
    The Trinity sees us this way, but if your doctrine and theology are messed up then you don’t get it and you run around trying to earn, please, be “without” sin. I have to laugh now that I thot if I lived without sinning,that Jesus wouldn’t have to die for me….HELLO!! He ALREADY DIED!! Already paid that price. And how truely Pharisitical of me, to think that if “I” then Jesus would have to die for everyone else but me! WOW! Some real mind/heart issues there.
    Again, I believe there was some “mis-firing” going on in the wiring, but I don’t beleive that bi-polar and the meds helped me regain quality life. Yes, I saw several counselors over the years, not sure what helps and what doesn’t. I do have a strong will and press on no matter what, but I would like some peace. For me, that is somewhere in my belief system.

  • http://AddaURLtothiscomment Ronald Pies MD

    I very much appreciate the many comments from readers, and I will try to respond briefly to the most pertinent issues. Please note, however, that my commentary was not intended as a broad defense of antidepressants, or as a thesis on the “biological basis” of depression. These are huge and complex issues, and I have provided a few references in my responses, for readers who want to delve.

    The main point of my commentary was just this: certain unconscious, cultural attitudes and prejudices—derived, in part, from our Puritan heritage— help shape our emotional reactions to the use of antidepressants and related medications. Now for some specific responses to readers:

    “The psychiatrist’s point that those who receive a placebo are really getting wonderful care may be true but his conclusion is mistaken. If it applies to those receiving the placebo then it also applies to those receiving the active drug, cancelling the effect….”
    • The reader is correct regarding the design of most antidepressant vs. placebo studies. My point was that the term “sugar pill” is grossly misleading. As Dr. Sheldon Preskorn has noted, those in both the active treatment and the placebo group receive up to 12 hours of supportive and educational intervention. And so, differences between the two groups should be due to the medication, as the reader notes. I would have stated things more accurately if I had said, “The comparison in antidepressant studies is between (a) medication with supportive professional contact vs. (b) supportive professional contact alone.” I would add that, in recent years, the placebo response rate has been increasing in clinical studies, perhaps due to recruitment of non-clinical and less “sick” volunteers; the result has been to shrink drug/placebo differences. Even so, not all studies show a “very small” difference between antidepressant and placebo groups; much depends on what “very small” means, and there is controversy regarding how many points on the Hamilton Depression Rating Scale (HDRS) constitute a clinically significant change. (This is a critical issue in the Kirsch et al research, which has been re-examined by Fountoulakis & Moller—see Int J Neuropsychopharmacol. 2011 Apr;14(3):405-12. Epub 2010 Aug 27. The authors concluded that “…Kirsch et al.’s meta-analysis suffered from important flaws in the calculations; reporting of the results was selective and conclusions unjustified and overemphasized.”) Indeed, in depressed patients with melancholic features (the most severe type of major depression), antidepressants are clearly superior to both placebo group and to psychotherapy [see Brown WA: . Treatment response in melancholia. Acta Psychiatr Scand Suppl. 2007;433:125-129]

    “…The problem is that these very psychoactive drugs have a powerful impact on brain chemistry that can be both negative and lasting: increased sexual dysfunction, suicides, relapse rates, birth defects and others…I have done cognitive therapy and continue it in my daily life as a mental exercise and I have done and am doing exercise. I am not just better, I am not depressed. ”
    • It’s certainly true that antidepressants—like anticonvulsants and even cancer chemotherapy drugs—can have a powerful impact on brain chemistry, and cause significant side effects in a minority of patients. This is why I recommend using these medications primarily for patients who have not responded to psychotherapy; or who have severe (especially melancholic) major depression. I happen to be a big supporter of cognitive therapy, and agree it can be quite effective for many, but not all, patients. Also, when considering the side effects of antidepressants, we must also consider the “side effects” of major depression itself, including up to a 4% mortality rate from suicide. This is far in excess of any reported suicide risk associated with use of antidepressants. Indeed, with the possible exception of children and young adults (in whom risk of suicidal ideas and attempts –though not completed suicide–may be slightly increased with antidepressant use) antidepressants may actually reduce suicide rates, especially in older populations—see Gibbons et al, Am J Psychiatry. 2007 Jul;164(7):1044-9. In addition to suicide, untreated major depressive disorder is associated with increased risk of cardiovascular disease, diabetes, stroke, and perhaps accelerated aging (see Wolkowitz et al, Dialogues Clin Neurosci. 2011;13(1):25-39.) This doesn’t even begin to describe the “human toll” on personal life, family, job function, quality of life, etc. in major depression.

    “People taking antidepressants have a higher relapse rate than those who have never taken antidepressants.”
    • I believe the reader is (inaccurately) paraphrasing the results of a controversial new study by Andrews et al (Front Psychol. 2011;2:159. Epub 2011 Jul 7.) Andrews et al recently published a meta-analysis that appeared to show that “…the risk of relapse after antidepressant discontinuation was higher than the risk of relapse after remission on placebo.” Several experts I have spoken with have raised questions about this study, and I think the jury is still out. In any case, the study may tell us more about discontinuing antidepressants too rapidly than about their effectiveness in long-term treatment. Most of the data show that, at least during the first 6 months after resolution of a major depressive bout, antidepressants provide protection against relapse, when compared with keeping patients on placebo [Briscoe B, El-Mallakh RS: The evidence base for the long-term use of antidepressants as prophylaxis against future depressive episodes. Poster NR2-65, American Psychiatric Association Annual Meeting, 2010]. That said, the longer-term prophylactic effectiveness of antidepressants (after the first 6 months) is still a matter of some controversy.

    “The problem is that things like Prozac are overprescribed. If it was never intended for mild depression, adjustment issues, simple sadness… then prescribing it for those reasons is excessive.”
    • Well, yes and no. There is actually evidence of both some over-prescription and considerable under-prescription, in some populations. (Bear in mind that the vast majority of antidepressants are prescribed by general physicians, not psychiatrists). As Mojtabai and Olfson (2011) put it:

    “In general medical practice, antidepressant use appears to be becoming concentrated among people with less severe and poorly defined mental health conditions. Prescribing antidepressants without a psychiatric diagnosis is especially common in medical practices that prescribe the medications to a larger percentage of their patients. Yet paradoxically, a large proportion of patients with common mental disorders do not receive needed treatment because their primary care providers do not detect their conditions. The widening misalignment between diagnosis and treatment suggests the need for a deeper inquiry.” (Health Affairs 2011; 30: 1434-1442).

    Importantly, Mojtabai and Olfson noted that “…These results do not clearly indicate a rise in inappropriate antidepressant use…”. There may be conditions seen by primary care physicians that don’t meet the full criteria for major depression, but which may still benefit from antidepressant treatment.

    There is also a large body of evidence showing that depression is under-recognized and under-treated in geriatric patient samples– often with inadequate dosing of antidepressants–as well as among some minority populations. And—the real shame—most depressed patients in this country get no professional treatment at all! [see Wang SS. Studies:Mental ills are often overtreated, undertreated. Wall Street Journal. January 5, 2010. Available at: http://online.wsj.com/article/SB10001424052748703580904574638750777038042.html. ]
    That said, I would certainly agree that antidepressants are over-prescribed in bipolar disorder, where they usually do little good and may cause considerable trouble for some (especially rapidly-cycling) patients. Of course, there are always exceptions, and each patient must be evaluated with an open mind.
    Finally, a careful risk/benefit discussion is always required when any medication is prescribed, and no psychiatric medication should be prescribed after only a cursory 10-15 minute “evaluation” of the patient!

    “…not one single scientific proof that would prove that either unipolar depression, bipolar or even schizophrenia are biologically-based diseases.”
    • I think the distinction between “biology” and “psychology” has been greatly overblown. Everything that comprises our psychology (our beliefs, wishes, fears, etc.) is embodied in our brains. When good and bad things happen to us, their effects are registered and stored in our brains. We simply can’t understand major depression, bipolar disorder, or schizophrenia without understanding the brain—and in that sense, there is no question that these are “biologically-based” illnesses. But that doesn’t mean they are “all due to a chemical imbalance”, as I try to explain in my essay posted on the Psychcentral website [see http://psychcentral.com/blog/archives/2011/08/04/doctor-is-my-mood-disorder-due-to-a-chemical-imbalance/. Nor does it mean that we can understand the patient’s experience of these illnesses without taking time to explore his or her psychological issues, social supports, spiritual beliefs, etc.

    Thanks again to everyone who has contributed to this discussion—I enjoyed the exchange!

    Ronald Pies MD

  • http://AddaURLtothiscomment Melanie

    It’s interesting to me that those who say “I got better without anti-depressants and you can too” seem to assume the world is populated by clones.

    I’m happy for those who find relief from depression, with or without medication. I humbly ask those who tell me “do X, it worked for me and will work for you” to consider this fact: I am not you.

  • http://AddaURLtothiscomment Rich B.

    My own experience with anti-depressants is that most of them were intolerable in terms of side-effects. Mostly severe nausea, loss of blood pressure, spaced out feeling. I found one, Remeron, that I was able to tolerate but my weight shot up 30 pounds. I was on this for several years. I also tried Zoloft and Serzone. They made me a non-performer sexually and never did help me. My episodes of depression are largely event caused starting with anxiety which leads to the depressive state. Now we are seeing advertisements from lawyers about the nasty birth defects and other bad things that they are happy to sue big pharma on our behalf. The upshot is that its still hit and miss. Most doctors I speak to ask me what kind of pill I want. There is no screen to identify which type of drug may work. Depression has many forms and some kind of tool to determine which medication would be best needs to be developed. Simply raising the levels of neurotransmitters is only partially dealing with the problem.

  • http://antidepressants Jillian

    Thank you for this insight. I used to feel that God was punishing me for unknown sins.
    Antidepressant medication has kept me out of institutions and has kept me alive.
    Now that I can function I am able to do the hard work of living well.
    I know that it is difficult for people who do not suffer from major mental illness to understand inner hell. If the antidepressants are a crutch it is to make me able to walk through the pain to the other side.

  • http://AddaURLtothiscomment alexandra

    why would a loving god punish us? Some of us have an inperfect brain, some don’t, it’s not rocket science. Antidepressants when used correctly can make a positive difference in someone’s life like it has done to me, I wouldn’t be where I am today if not for antidepressants, I am lucky my doctor found the right one for me. If the use of antidepressants is not abused I don’t see what all the hoo ha is about. There is a need for western medicine and if exercise and cognitive therapy works for you then great but if it doesn’t it is not shameful to take antidepressants. Everyone has their own story….I think not enough people take antidepressants…..

  • http://AddaURLtothiscomment Ronald Pies MD

    For those who want more information on antidepressants (pros and cons), and more on the “Puritan” view of illness, please see reader comments and my replies on the Psychcentral website. Thanks to all who wrote in, and to Therese, for her kind hosting!

    psychcentral.com/…/are-the-puritans-behind-the-war-on-antidepress…

    Best regards,
    Ronald Pies MD

  • http://AddaURLtothiscomment Black Panther

    What I can’t believe is that although every psychiatrist on the planet will tell you there is a “chemical imbalance” in the brain.

    Not one can prove it… It is totally subjective and based on zero scientific evidence. Its one hypothesis.

    My mother was prescribed powerful psycho stimulants which resulted in a long and sad tale of suicide attempts and permanent damage to her brain.

    When I went to see the Psychiatrist and requested that he prove categorically that there is a chemical imbalance in the brain, he told me there is no test.

    The chemicals in these drugs often cause permanent damage to vital organs and seriously affect the workings of the whole body and its ability to uptake vitamins.

    Personally I feel the drugs have damaged my mother beyond repair and she will never be able to regain the abilities she has lost due to what the drugs have done.

    From having studied science very thoroughly and knowing exactly what is involved in proving a theory, I think the human race have waited long enough for some answers from Psychiatry.

    I think its a cosy little relationship between the drug companies and the psychiatrists.

    The list of side effects on these drugs are actually effects of the drug that Big Pharma dislikes and to cover their backside, make sure they put it on the tin.

    Has anyone read the DSM (Diagnostic and Statistical Manual of Mental Disorders) The conditions listed in that book increases year on year and to me seem nothing other than normal behaviour under certain conditions.

    I’m not doubting that people run in to difficulty in life, however, do think that there are much less toxic and more effective ways than drugs.

    I’d be interested to see if anyone has any comments to add to my note.

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