One of the most confusing symptoms of depression can be what psychologists call "anhedonia". It literally means the inability to experience pleasure. The way I often describe that to my patients is feeling as though your color television has suddenly gone to black and white. All of the joy, interest, enthusiasm and excitement just drains out of things. You find yourself wandering aimlessly through your previous life, unable to extract even small amounts of pleasure from things you used to love. This leads to a lot of other changes such as weight loss (food has no taste anymore), decreased sexual activity (you have no interest) and social isolation (you don't enjoy being around people anymore and so the energy required to do so just doesn't make sense).
The death of Robin Williams made me think a lot about depression. Like many people I grew up on him. Interviews I read of him sounded so alive, so joyous. He seemed as though he was the kind of person who could have fun with anything, even flossing his teeth. We now know that this was only one side of him. That deep down he struggled with "the black dog" (Winston Churchill's description of depression) as have many famous people throughout time. I found myself wondering how, with all of the resources available to a person of his status, he had not been able to be successfully treated? Depression is common-- one in 6 Americans will suffer it at least once in a lifetime. Many of us more than once. And yet suicide is thankfully rare-- typically one in ten thousand Americans per year (1). How could he have succumbed?
I started thinking about my own practice. Depression is probably the single most frequent symptom that people present with. The causes of course will vary. Divorce, infidelity, job loss, death of a loved one, addiction and any other significant stress or loss you can imagine. But the symptom itself is the same-- persistent sad mood, changes in appetite, changes in sleep, morbid thoughts, guilt, reduced sex drive, impaired mental function and of course anhedonia. While research continues to support the idea that psychotherapy is equally effective to medication for mild to moderate depression, most therapists do acknowledge that for severe, suicidal depressions medications can be life-saving. And yet only about 50% of people who take medications derive lasting benefits from them. The other 50% either never respond, respond only partially or respond at first and then eventually not at all. I have personally encountered a few situations in which this was precisely the case.
A recent research article in Nature magazine (July issue 2014) looked at the neurochemical mechanisms of anhedonia and may give rise to a new and more promising type of antidepressant medication. This is good news because all commonly used antidepressants today are based on modifying one or more of just a handful of neurotransmitters-- serotonin, norepinephrine or dopamine. Once these neurotransmitters have been effectively increased, if the patient does not respond, there is nothing else to be tried. We have been stuck at this plateau in treating depression via medication for more than 50 years. So a new type of mechanism by which to treat depression via pharmacology can be life-saving news for those 50% of people who do not respond to traditional antidepressants.
The article discussed the motivational center of the brain and a hormone called melanocortin. Researchers put mice under chronic stress and then looked at the impact on the melanocortin receptors in the nucleus acumbens, a large part of the reward circuit in mammals. Deep brain stimulation of the nucleus accumbens has helped people with severe depression who have not responded to medications (2). But most people would much rather take a pill than have an electrode implanted in their brain. So figuring out how to achieve this effect via a medication could be a huge step in expanding our armamentarium to fight depression.
After being chronically stressed the rats showed an increase in melanocortin receptors in the nucleus accumbens. And this lead to a decrease in the signal strength of those receptors. The upshot was that the mice showed symptoms of anhedonia. When offered a choice between regular water or sugar water (which apparently mice love) the stressed mice showed no preference. The researchers upped the anti and gave the mice a choice between water and cocaine. Amazingly the chronically stressed mice showed no preference. So even a highly rewarding substance like cocaine, which normal mice will prefer to food and water to the point that they will literally starve to death or die of dehydration, was of no interest to these mice. This is a powerful example of how depression can absolutely suck the enjoyment out of anything and leave one feeling that they have nothing to live for.
While this research is ground-breaking and should lead to new classes of medications for the treatment of depression, it's too little to late for the hundreds of thousands of people who succumbed to the siren's song of suicide. That's the sad reality of the state of science, that we know so little about so many aspects of our own brains and bodies. But I do hope that in the future we will have more treatments available to prevent amazingly talented, kind and descent people like Robin Williams from giving up hope. In the meantime I charge each and every one of us who either struggles with depression or knows someone who does to reach out and ask for help. Even when it feels like there is nothing left to hope for. If there is one thing I have learned in my 20 years in practice it's that people can change, depression (and anxiety and a host of other symptoms) can remit and people can go on to be happy. I have seen it happen over and over. So please hold on to hope, and offer it to those who have lost it. Reach out. No one needs to face things alone and with help people can overcome.
Dedicated to Robin Williams, an amazing entertainer and lost much too soon.
With admiration and respect,
1. American Foundation for Suicide Prevention, www.afsp.org
2. Bewernick, B. H., Hurlemann, R., Matusch, A., et al. Nucleus accumbens deep brain stimulation decreases ratings of depression and anciety in treatment-resistant depression. Biological Psychiatry', 2009 67: 110-116.
One of the most surprising things about being married can be the fights. I think most people figure that in a good marriage there isn't much fighting. Or at least if there is fighting that things get resolved. Neither are necessarily actually true. Dr. John Gottman, a famous couple's researcher, put couples in a research lab that was set up like an apartment and videotaped their interactions for an entire weekend. He collected lots of data on couples and followed up with them years later. Some of the things that he learned are that most couples fight, that fighting does not predict happiness in the marriage (or divorce) and that about 2/3 of what we fight about never gets resolved.
If you had told me that before I got married I might not have made it down the aisle. It just doesn't sound that encouraging.
But in the end I think for those of us who want to stay married we need to face up to these facts. That fighting doesn't have to be bad. It doesn't have to hurt the relationship. It also doesn't have to, nor should it, go on for hours and hours and ruin the rest of our day/night/weekend/vacation. And in the end there cannot, I repeat there cannot, be a winner and a loser. In a properly conducted marital fight there can only be a compromise on both sides. Anything else is heading for dark waters and eventual Splitsville.
I recently came across a great article in Esquire Magazine in their "Hitched" section (yes, I read everything, even Esquire). The article, entitled A Philosophy of Fighting, by Tom Junod, talked about how fighting is inevitable in relationships. Now, being nerdy I feel the need to point out that there are relationships in which people don't fight. Some of those relationship are healthy and some are not. Remember fighting does not indicate health or un-health or staying together or getting divorced. It's HOW the fighting is done that predicts those things. Fighting dirty = misery > divorce. Fighting fair = 50% misery + 50% bliss > celebrating 50+ wedding anniversaries.
Junod says "You never fail to be surprised by [the fights] and you never fail to be amazed that your marriage has survived them." I would add that you also never fail to be surprised that you are having the same dang fight about the same dang thing yet again. But, as Junod points out, if you are committed to the marriage you stay the course. "You know couples who called it quits after the first big fight, because they didn't like what they saw in the other person when they were fighting, and they particularly didn't like what they saw in themselves....Now you see their point. The first fight is the same as the second fight, and the second fight is the same as the last. If you want to stay married, you don't have to be able to stop fighting; you have to be able to keep fighting, in the same way. When you see elderly couples, you are amazed by the durability not only of their love but also of their animus — because from what you know of marriage, you know they are still fighting." So it's about changing our perspectives on what that long-term bliss looks like. When you see that elderly couple sitting on the park bench together and they seem so serene just picture her throwing his dirty socks at him because he's been leaving them on the floor for the last 50 years. Or picture him chastising her for riding the breaks or not using her turn signal. You get the picture.
Junod also points out something that is too often overlooked. If you were to conduct an autopsy of a deceased relationship it might surprise you to see the actual origin of the demise. It often happens long before "the big one" where someone drops the Divorce bomb. It starts with the small ones, the ones that don't seem too serious. As Junod puts it, "You think that some fights are trivial, because they are over trivial matters....[but] there are no trivial fights, because each fight has the potential to grow into the kind of fight that ends your marriage." I often find that people don't understand the care that relationships need to stay afloat. They feel free to dig deep into each other during fights about things like chores or vacation locations, really letting the nuclear warheads deploy over things that simply should not be worth that kind of damage. People seem to forget that our relationships need care and love and nurturance and that they cannot survive continued bombing and plundering. Each argument needs to be conducted with the rules in mind. No winners, no losers, no prisoners and no nuclear weapons. Period.
Here Junod and I agree again "A fight to the finish is what finishes a marriage. That's because over the course of married life, people supply their spouses with precisely what's required to finish them off. The question is not who can win, because anyone can win if they're willing to go far enough — if they're willing to win at the cost of love and respect. The question is who can abstain from winning, who can resist the temptation of winning, which, like any other marital temptation, is always there."
Or, as I try to tell couples that I work with "you can be right or you can be close". When being right takes precedence over being emotionally close and happy with your partner it may be time to re-evaluate your commitment to your marriage. You really can't have it all in that department. But hopefully you can discover that being close feels so much better in the long run than just being right in that moment. And remember, if you are anything like those couples studied by Gottman you are going to have that same argument over and over again anyway. So even if you "win" this time, you may lose the next. In the end it's just not worth it. Play nice. Follow the rules. Give ground. And stay close.
Krista Jordan, Ph.D.
Dr. Jordan has been in private practice for 20 years in Texas. She is passionate about helping people to overcome hurts and obstacles from their past to find more happiness and health in their current lives.