Depression: when is psychotherapy not enough?

In doing intensive psychotherapy or analysis with patients who suffer both personality and affective disorders, one must simultaneously maintain psychologic and biologic perspectives. Cooper, when talking of patients suffering from panic disorders, states that analysts must distinguish between psychologic efforts to cope with miscarried brain function and the psychologic efforts to cope with disturbances of the intrapsychic world. This is also true of patients who have affective disorders. For instance, patients who suffer from untreated affective disorder often speak of their experience of themselves as being out of control. They complain that they can never predict the stability of their emotional states. This aspect of their illness must be conceptualized not as reflecting faltering defensive operations and inadequate compromise formation but as the reaction of an otherwise healthy personality to the experience of being intermittently overwhelmed by biologically generated mood states. Cooper also states that biologic illnesses must be regarded as having influences that are both developmental and ongoing. The psychoendocrine work of Puig-Antic demonstrates the existence of endogenous depression in latency age children and Carlson and Kashani's recent clinical observations in preschool children support the notion that this illness can arise during periods of development. For such patients, the normal developmental tasks of childhood and adolescence may be severely compromised. For instance, extreme mood fluctuations of inexplicable origin may serve as a major disruption in the consolidation of a healthy sense of object constancy. Before closing, I would like to briefly mention two examples of the difficulties encountered when attempting to medicate and analyze the same patient. Ostow mentions patients who may attempt to use what he refers to as the "drug cure" to reinforce their resistance to psychotherapy. The analyst must be ever alert for this. An example occurred during my analysis of a 35-year-old novelist who had entered treatment for writer's block. She had been on medication for a number of years, had a strong family history of depression, and had relapses each time the medication had been discontinued or decreased. During the eighth month of analysis she reported that she had an interesting experience. She had forgotten to take her evening medication, something extremely unusual for her. She knew that antidepressants suppressed rapid-eye-movement sleep and that stopping tricyclics was often associated with vivid dreams and nightmares. Thus, she thought that the nightmare she experienced that night, something to do with being beaten up, could be explained pharmacologically.(ABSTRACT TRUNCATED AT 400 WORDS)