I am constantly meeting patients who have been evaluated by multiple psychiatrists and/or multiple therapists. Nevertheless they have no clear idea what the practitioners thought was wrong with them or why they were being given certain medications and/or therapy. My quarrel with the fragmented American mental health system is that no one who is capable of diagnosing and prescribing accurately seems to have the time or the inclination to do the explaining, and educating is such a vital part of any successful psychiatric intervention.

In the first few meetings with any patient, I am almost always teaching the same little course I’ve been teaching for years about the four types of depression, two inherited and two acquired, and about their interaction with ADD. This simple information about the symptoms, the course, and the types of medications for each depression is something that every person with depression and/or anxiety should know.

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The first type of depression, based on imbalance in the neurotransmitter norepinephrine, also called a stress depression, is very common in people with ADD. Panic attacks (danger anxiety), middle insomnia, and indigestion/loss of appetite are most common. Agitation, exhaustion, and poor concentration are also present. Older tricyclic medications (Nortryptiline and Desiprimine) target norepinephrine alone, and newer medicines like Effexor, Cymbalta, and Remeron work on both norepineprine and serotonin. This type of depression is acquired, not inherited, and can thus be “cured,” but it can also be present alongside the inherited types.

The second type of depression, based on serotonin, is definitely inherited. There are five separate subtypes which can occur in any combination: obsessive, socially phobic (stranger anxiety), female hormonal, seasonal, and reverse polarity depressions (sleep too much, eat too much, irritable). There may be trouble falling asleep, but also trouble with waking up in the middle of the night. These depressions/anxious states are treated with selective serotonin reuptake inhibitors (SSRIs) and with the combined serotonin norepinephrine reuptake inhibitors (SNRIs) mentioned above. These illnesses can be influenced somewhat by lifestyle, learning, and climate, but generally ongoing medication is the standard here.

The third type of depression is based on dopamine and can also be called a pleasure depression. There is a loss of interest, energy, and motivation, as well as trouble with concentration and enjoyment. This depression, in which sleep and appetite can be normal, can also hide among the more overt symptoms of the previous two. It is best treated with Wellbutrin, and it is common in people with ADD and with substance abusers. This one is also acquired and thus can also be “cured.”

Lastly are the bipolar depressions, the most complicated type. They are probably electrical as much as chemical in nature involving racing thoughts as well as disturbed mood, a chameleon that can take on aspects of any of the other types, but which responds to mood stabilizers (Lithium plus a range of antiepileptic drugs) or the newer antipsychotics (Risperdal, Abilify, Geodon, etc.) rather than antidepressants.

I do not consider a psychiatric treatment to have truly begun until I have explained these subtypes and enlisted the patient’s assistance in determining which of these is currently present, which have been present in the past, and which patterns are recognizable in their family tree. Perhaps most importantly, I want to frame whatever medication I am offering in terms of which systems it is designed to affect and which specific symptoms are likely to remit in which order.

The really useful evaluation for depression has not been completed, however, until issues of attention and trauma have been addressed and woven into the treatment plan. Unacknowledged and unaddressed attentional issues around disorganization, procrastination, and time management are fertile ground for creating the stress and overwork, the repeated “failures” to “manage” modern life that lead to acquired depressions. These same sets of problems are also going to be present in those who have been traumatized intensely or chronically enough to interfere with the natural maturation of the relationships among different parts of the self. Again, I find that it is imperative that I explain and contrast these two types of human difficulties to prepare the patient to become my collaborator in devising reading lifestyle changes and psychotherapy that should and must be part of a complete psychiatric treatment plan.

At its best, a psychiatric evaluation should be an opportunity for learning and the initiation of a collaborative partnership. As we are all sadly aware, institutional America, medical schools, hospitals, insurance and pharmaceutical companies have managed to create a job very few Americans are willing to take, as well as services that very few Americans can find or that their insurance will cover even if they do.

For more on these ideas and approaches, please see my new book Getting Unstuck: Unraveling the Knot of Depression, Attention, and Trauma available on our website theattentiondoctor.com.

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