5 Things to Say to Patients With Depression

Depression makes people forget this one, so it’s worth repeating. Most people with mood disorders achieve a meaningful recovery. True, the number-needed-to-treat (NNT) for most antidepressants is in the 4-6 range, but that doesn’t mean that only 1 in 4 recover on them. The NNT leaves out the placebo effect, which accounts for 30% to 40% of the response to antidepressant therapy.¹ The placebo is more than a sugar pill. It includes everything from hopeful expectations to a therapeutic relationship to the natural course of the illness.

This speaks to the passivity of depression. It’s also a necessary reminder for the 70% of patients who won’t recover fully on an antidepressant.² Depression makes it hard to prioritize and easy to feel overwhelmed so start with something simple here.

Give the patient a list of behavioral changes like the one above. Each of those has some evidence to improve depression,³ and I have collected more online. Have them choose only one and build from there. To personalize this further, ask what they want to see different in their life. Once they fine tune that to something specific, concrete, measurable, and achievable, they can work on steps to move closer to the goal.

People with mood disorders are often told that they are too emotional. This leads to stigma, shame, and self-doubt and away from action, acceptance, and recovery. Depression is a disorder of motivation, energy, and neurovegetative functioning. Emotions are normal, and most people with an illness are emotional, whether it is a medical or psychiatric one. Studies are consistent on this one: Mindful acceptance of one’s emotions prevents depression, while judging and brooding over one’s internal states does not.⁴

Functioning is a more reliable measure of recovery than feeling. Recovery is hastened when patients focus on how they are living instead of how they are feeling. Some of the best antidepressant activities are those that put people in a state of flow, or as athletes put it, “in the zone.” They are fully engaged in the sensory details of the task at hand, rather than self-consciously preoccupied with their inner thoughts and feelings.³ Depression is not an emotional disorder and recovery is not the same as happiness. Recovery may not even feel good. When depression lifts, people may wake up to a long list of unfinished tasks and broken relationships to attend to. Recovery is a process, and patients need steady, realistic guidance to move through each stage.

References
1. Furukawa TA, Cipriani A, Atkinson LZ, et al. Placebo response rates in antidepressant trials: a systematic review of published and unpublished double-blind randomised controlled studies. Lancet Psychiatry. 2016;3(11):1059–1066. 
2. Sinyor M, Schaffer A, Levitt A. The sequenced treatment alternatives to relieve depression (STAR*D) trial: a review. Can J Psychiatry. 2010;55(3):126–135.
3. Aiken C (2020). The Depression and Bipolar Workbook. PESI Publishing & Media.
4. Kuyken W, Warren FC, Taylor RS, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. JAMA Psychiatry. 2016;73(6):565–574.

Dr Aiken is the Mood Disorders Section Editor for Psychiatric Times, the Editor in Chief of The Carlat Psychiatry Report, and the Director of the Mood Treatment Center. His written several books on mood disorders, most recently The Depression and Bipolar Workbook. He can be heard in the weekly Carlat Psychiatry Podcast with his co-host Kellie Newsome, PMH-NP.  The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for The Depression and Bipolar Workbook and from W.W. Norton & Co. for Bipolar, Not So Much.