Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Alyssa,

I see that my recent blog about depression has not had the effect I intended.

Let me be as clear as I can about this: Just because depression is bad does not mean there is no hope. There is always hope. In fact, as I write these words I'm seeing the face of my colleague and friend Dr. Rakesh Jain, whom I consider to be one of the top psychiatrist clinicians and educators in the U.S. He often takes his audiences (and sometimes me) to task over the catastrophic dangers of therapeutic nihilism. As he likes to say: We as clinicians should never give up, and you as a patient should never give up. This is probably the deepest truth in psychiatry and one of the greatest strategies for maximizing our likelihood for optimal long-term treatment outcomes in depression.

There are several very important reasons to heed Dr. Jain's warning about therapeutic nihilism. First, any psychiatrist worth his or her salt could spend the entire day telling you stories about people who had failed multiple treatments, only to have an outstanding response on the next try. Second, if you've been reading my blogs you know that depression is a probabilistic disorder, which means that outcomes are widely various between individuals. This means that you have significant power to affect the long-term outcome of your life. And third, one of the best ways to take this control is to make it a daily practice to cultivate a sense of hope in your life. Remember that hopelessness is a core symptom of depression, so when you notice feelings of hopelessness you need to challenge them and recognize that the feelings are a symptom of the disorder, not a statement of fact!

Let me address a few of your very reasonable, and highly practical, concerns. I can't answer the question of whether you will need to be on antidepressants for the rest of your life, because -- of course -- no one knows the future. I can tell you, however, that many studies show that, with four past episodes, your best shot of avoiding a future episode is to stay on these medications indefinitely -- as long as they keep working. In this way, depression is a lot like diseases such as diabetes or high blood pressure. People with these conditions typically live full and normal lives, but they need to stay on medications chronically to accomplish this. In other words, the conditions can be managed but not cured. Sometimes that is how it is with depression. Rather than worrying about staying on the medications, I would -- if they are working -- attempt to cultivate a deep sense of gratitude that they have helped you.

It is true that childbirth is a risk factor for depression to recur. Something like one in five women, in fact, will have a depressive episode within six months of giving birth. But let me immediately assure you that current data suggest that you will be able to stay on medications throughout pregnancy without harming your child. In fact, I know of data not yet published that strongly support doing this in terms of the well-being of your future children. So this is not a reason to lose hope.

The Buddhists have a saying that I like: "If you want to know your future, look at how you are living today." I think this is very true for depression, as well. I recommend you take a two-pronged approach toward a future that will be less depressed than your past has been. First, avail yourself of any treatment modality that helps keep the depression at bay, including medications, diet, exercise, managing stress, getting regular sleep and obtaining therapy if and when you need it. I would also recommend purchasing a self-help book on how to challenge negative thoughts, because learning to see the world in a hopeful, positive light is one of the strongest protectors against depression. A classic book in this regard, although there are many others, is "Feeling Good" by David Burns.

So yes, there is great reason for realistic hope, Alyssa. And when it comes to hope, I hope my buddy Dr. Jain doesn't read this blog or he will be after me, big time, for unintentionally creating gloom and doom.