Depressed Patient

Question.

I have a patient, 24, who has recently become depressed to the point of not wanting to do anything. She mostly just sleeps, and has recently begun having problems at work and in her personal life as a result. Her psychiatrist prescribed Zoloft 100mg, but I am wondering what else can be done for her. She’s got a history of very early sexual abuse, has trouble bonding with people and in general hides her problems from people. A diagnosis of depression was made three years ago. What would you recommend?

Answer.

I would first recommend addressing these very concerns with her psychiatrist, if you haven’t already done so. That you are writing to me makes me wonder if the working arrangement between you and this patient’s psychiatrist has been less than splendid. That’s always a tough position for the therapist-and there’s usually no simple solution. But a good face-to-face meeting (or at least a phone call) can sometimes help. It rarely pays to challenge the psychiatrist’s expertise or treatment regimen-this just alienates the therapist further. But tactfully raising the question of “additional steps” that you and the psychiatrist might take could be helpful.

There are certainly many, many medication strategies that could be considered, depending on what has already been tried; e.g., raising the dose of Zoloft; augmenting it with Ritalin or Wellbutrin; switching to Effexor; etc. But, the psychiatrist is not likely to take kindly to direct suggestions about the medication unless you are an M.D. Still, you can always ask.

Some other treatment modalities to consider: a trial of dialectical behavioral therapy as described by Dr. Marsha Linehan (usually used for borderline personality disorder, but from your description, there may be some borderline traits in your patient); group therapy (to help the patient with intimacy issues); an exercise regimen (or exercise club?) to help with mood and self-esteem; getting her involved with an on-line support group (try www.support-group.com yourself first, to investigate what’s available) or requesting a psychopharmacology consultation.

This last option could be very helpful, but is obviously very tricky from the standpoint of your relationship with the psychiatrist. Sometimes the request is better received when it comes from the patient. Finally, I have found David Burns’ book Feeling Good to be an excellent “add-on” to almost any type of treatment for depression. Good luck with this difficult situation.