It happens right? We're referred a depressed client, and our first step is to conduct a detailed psychosocial assessment. Conceivably, we ask all the right questions during the data gathering process. We then begin treatment armed with an arsenal of psychotherapeutic interventions that not only have served us well with previous clients, but are also well grounded in the literature. With this particular client however, after having dug deep into our treatment bag of tricks, three months of weekly sessions have proven fruitless in that depressive symptoms are unremitting.
There are numerous reasons as to why the above mentioned scenario may be occurring, but all too often, the failure to consider the possibility that medical disorders or substance abuse may be responsible for, or at the very least, contributing to the depressive symptoms is the most salient explanation. So consider this: Think of depression not as a diagnosis, but instead as a constellation of symptoms with many possible causes.
Medical first. The natural order of the treatment process is to first rule out medical disorders as possible causes of depression. I strongly encourage all clients that I am treating for depression to schedule a physical examination complete with blood work, as some medical disorders can alter neurochemical function in the emotional brain - the limbic system. Thyroid disorders more often present for the first time in a mental health setting than in primary care, usually as depression. Undiagnosed anemia, diabetes, chronic pain and congestive heart failure are but a few other examples of medical illnesses masquerading as depression.
Prescription drugs associated with depression. Antihypertensives (medications for high blood pressure), antiparkinsonian drugs and corticosteroids can produce side effects that mimic symptoms of depression, such as low motivation, fatigue, irritability, sadness and insomnia. As is the case with general medical conditions, these drugs are also thought to disrupt the biological synthesis of neurochemical activity in the emotional brain. The beta-blocker Inderal (propranolol) for example, is notoriously linked to depression. Always ask clients for a complete list of all medications that have been prescribed for them. If any of the above medication types are on the list, a referral back to the prescriber is warranted for a possible switch to another medication, a dosage reduction or even possibly discontinuation. Instruct clients that under no circumstances should they discontinue any medication without their prescriber's consent.
Depression, drugs of abuse potential. Substance abuse complicates almost every aspect of care of the person with depressive symptoms, and whether the substance abuse is causing the depression or vice versa, it's an immaterial debate. These individuals are typically very difficult to engage in treatment, and assessment is tough because it takes time and considerable patience to unravel the interacting effects that substance abuse has on mood disturbance. Since drug abuse is the quintessential manifestation of self medication, it must be addressed for treatment to move forward. Direct confrontation invites denial as a likely response, so in the absence of irrefutable evidence, we clinicians should proceed in a careful, deliberate manner. Regardless of the substances - alcohol, anti-anxiety drugs, opiates, hallucinogens, and so on - meaningful, outcomes focused treatment cannot and should not proceed unless the affected individual is assessed for the quantity, frequency and duration of use with abstinence or careful monitoring of use as the eventual goal. Without exception, substance abuse has always been the ten ton gorilla in the treatment room.
Thoroughness means evaluating the "whole" patient, and highly skilled practitioners, irrespective of their professional discipline, immerse themselves in the culture of medicine as an integral part of the assessment process because comprehensive care truly is BIO-psycho-social.
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