Does It Make Sense to Treat Depression with Drugs?

Both research and experience have long informed mental health professionals of a strong link between depression and relationship dissatisfaction. So why is psychiatry losing that awareness? One major reason is the disappearance in psychiatry of psychotherapy (talk therapy), in which it becomes obvious just how important our significant relationships are to our mental health. According to the August 2008 Archives of General Psychiatry article "National Trends in Psychotherapy by Office-Based Psychiatrists," the percentage of patient visits to a psychiatrist involving any psychotherapy fell to 28.9 percent in 2004-2005 (from 44.4 percent in 1996-1997), and the percentage of psychiatrists using psychotherapy with all their patients dropped to only 11 percent in 2004-2005.

Psychiatry has increasingly replaced psychotherapy with something called "medication management," which largely consists of symptom assessment and prescription updates. Medication management typically takes 10 or 15 minutes and is scheduled every two to three months.

When doctors only offer medical management sessions every couple of months, they can neglect to ask about a patient's marriage; and even if they do ask about it, they are likely to accept at face value a stoic patient's reply that "my marriage is fine." A competent psychotherapist knows that patients, initially, often avoid acknowledging an abusive or neglectful relationship, the pain of which may be too overwhelming; and that it can take a great deal of time and repeated gentle questioning to discover important truths.

In quality psychotherapy, a mental health professional takes the time necessary to create trust, which is required to effectively explore a patient's relationship life. Miserable significant relationships or the absence of any significant relationships are common sources of depression. And major antidotes to depression are genuine friendships, satisfying intimacy and supportive community.

The Interactional Nature of Depression (1999), edited by psychologists Thomas Joiner and James Coyne, documents with hundreds of studies the interpersonal nature of depression -- and its interactional vicious cycle. In one study, the best single predictor of depression relapse was found to be the response to a single item: "How critical is your spouse of you?"

In another study of unhappily married women who were diagnosed with depression, 70 percent of them believed that their marital discord preceded their depression, and 60 percent believed that their unhappy marriage was the primary cause of their depression.

Depression is fueled by overwhelming emotional pain, and an unhappy significant relationship is one common source of such pain. Other common sources of pain that can fuel depression include workplace alienation, poor physical health and financial difficulties. People use a wide variety of "compulsions" (actions one feels that are not freely chosen) to shut down overwhelming pain or to distract from it. Depression is one of those compulsions (others include substance abuse, overeating and gambling).

In a vicious cycle, the pain of an unhappy marriage can fuel a wife's or husband's depression; then that depressed wife's or husband's negativity can result in their spouse's negative reactions; these negative reactions can make the marriage even unhappier; and the pain of that increasingly unhappy marriage can serve as additional fuel for depression.

Social isolation and loneliness can also fuel depression. Sociologist Robert Putnam, in Bowling Alone (2000), reports, "Low levels of social support directly predict depression, even controlling for other risk factors." Putnam adds that "countless studies document the link between society and psyche: People who have close friends and confidants, friendly neighbors and supportive co-workers are less likely to experience sadness, loneliness, low self-esteem and problems with eating and sleeping."