When I was 16, my family doctor asked me the questions that would change my worldview. Having treated me since childhood, she had noticed patterns. She asked me whether I was experiencing the list of symptoms associated with persistent depressive disorder.
I had all of them — feeling down, feeling hopeless, sleep problems, avoidance of social activities, low self-esteem and the rest of the laundry list of warning signs. My doctor explained to me that persistent depressive disorder, also called dysthymia, was a type of “functional depression” that lasts for years and often for a lifetime. I had probably had it since early childhood.
I burst into tears, finally knowing there was a reason I felt this way.
Knowing what I had didn’t take away my depression — more than 20 years later, I am still living with this condition — but getting a proper diagnosis started me on a path to better management of my symptoms.
I am not alone. According to the National Institute of Mental Health, 1.3 percent of American adults will experience persistent depressive disorder at some time in their lives.
The disorder differs from other depressions in several ways.
As the name suggests, it is long-lasting. As they did for me, symptoms can appear in childhood and last into, and throughout, adulthood. The Mayo Clinic notes that symptoms can change in intensity and come and go over a period of years, but typically they don’t disappear for more than two months at a time.
“The first signs are often subtle,” says Dan Goodman, a psychiatrist at Manhattan’s The Midtown Practice who has published research about the nature of the disorder. “This can result in folks with persistent depressive disorder not even recognizing that something problematic is going on with them, which in turn can prevent them from seeking treatment.
“For folks with early onset, they may perceive their chronic depressive symptoms as lifelong and they may seem totally normal to them,” he said. “[This] can in turn lead to nihilistic thoughts or a perception that chronic unhappiness and self-critical thoughts which accompany persistent depressive disorder are just part of who they are.”
Symptoms can also include avoidance or loss of interest in activities and lack of energy, according to the Mayo Clinic. People with this condition may feel sad or hopeless, and they may be self-critical. Trouble concentrating and irritability are also common, as are changes in appetite and sleep habits.
The condition, often overlooked, can be difficult to treat. Goodman says that antidepressants may not be as effective as they are for other depression disorders.
For some people, episodes of major depression occur alongside persistent depressive disorder, forming double depression — a potentially serious condition.
While someone with major depression will probably notice something is wrong and consequently be more likely to seek help, people with persistent depressive disorder tend to accept symptoms as hopeless to improve. The belief that things will never get better puts people with the disorder and particularly with double depression at risk for suicide.
I can’t deny having reached those crossroads several times during my life.
Although I have never attempted suicide, I have absolutely questioned the point of continuing if nothing would change.
For several decades after my diagnosis, I bounced between medications that worked “well enough.” There was never a time that I wasn’t keenly aware of my depression and the effects it had on me, but the medication was enough to keep me functional. For a long time, I felt this was all I could hope for.
I had heard the stories of how antidepressants had been life-changing for some people. For me, antidepressants were like glasses with an old prescription — things were still out of focus, but they helped make things clear enough to be workable, and they were better than nothing. I was an advocate for medications to treat mental illness, but I had given up on finding something that was perfect for me.
Rapidly approaching 40, and feeling the push to make positive changes, I went back to my doctor. I told her that I wasn’t okay with just feeling okay, and I wanted to find something better. I was already taking escitalopram (brand name Lexapro), so my doctor suggested adding bupropion (brand name Wellbutrin.)
I had no reason to believe this new course of treatment would be any different from the countless previous ones. I had long ago accepted that viewing the world through the cloudy lens of depression would be my normal. Still, I was committed to giving it a chance, and I added the bright blue pill to my daily regimen.
The first thing I noticed was increased patience with my children. I was better able to talk them through meltdowns without feeling completely drained afterward. I could even handle those 20-minute stories about Beyblade toys that generally make me want to rip off my ears.
Some changes were dramatic.
I started getting out of bed every day. Before this medication change, that was not a given. I also stopped spiraling — the experience of having one small trigger turn into feelings of hopelessness, tears and frequently a loss in the ability to function. I handled small irritations — a disagreement with my husband, a minor disappointment, a hurtful comment on social media — in isolation instead of seeing them as proof that everything, related or not, was terrible and pointless. The simple ability to deal with something and move on with my day has been monumental to my overall well-being.
Some changes that appeared small were symptomatic of big mental shifts. I started keeping my room clean. This seems like something even a 5-year-old could handle, but it was a task at which I had failed my entire life until starting this medication combo.
The all-or-nothing thinking became much more moderate.
I made more realistic goals, and forgave myself for occasionally missing the mark in their execution. One setback no longer caused me to abandon the entire project or plan. Making positive life changes became more attainable once I stopped seeing my successes and failures as indications of my worth as a human being.
I felt clearheaded, focused and hopeful without fear. This combination of medication was working — really working — and I caught myself feeling content. For the first time in my life, I felt normal for more than a fleeting moment.
While escitalopram paired with Wellbutrin is not the only treatment that can successfully treat depression, it is one that doctors look to under certain circumstances.
“This combination of medications is often used to treat people who have an inadequate response to antidepressant mono-therapy and it is effective and well-tolerated,” says Ash Nadkarni, instructor at Harvard Medical School and director of Wellness, Department of Psychiatry at Brigham and Women’s Hospital.
Goodman recommends trying one antidepressant first before starting any combinations. If that medication alone doesn’t work, he then recommends changing medications, or trying a combination of medications that could include escitalopram and Wellbutrin. He also recommends psychotherapy alongside medication, which tends to be more effective than medication alone.
Which treatments to try depends on the person, their symptoms, their medical history, their tolerance to side effects and other individual factors. I am not suggesting that the combination of escitalopram and Wellbutrin is a cure-all or would be effective for everyone. I also recognize that though this treatment is working well for me, I am not cured of my depression. I will probably have persistent depressive disorder for the rest of my life. I will have to come to terms with this.
But for people who have struggled to find treatment that is more effective than “good enough,” it is worth bringing up this combination with their doctors to see if it is right for them.
Persistent depressive disorder is difficult to live with and its symptoms are hard to manage — but they are manageable. If you are feeling as I was, that you have tried so many things and nothing has fully helped, keep trying. Keep advocating for yourself and stay on top of new treatments.
You deserve to feel better. With help from your health-care team, you can get there.
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