I’ve been lonely
I’ve been waiting for you
I’m pretending and that’s all I can do
The love I’m sending
Ain’t making it through to your heart
You’ve been hiding, never letting it show
Always trying to keep it under control
You got it down and you’re well
On the way to the top
But there’s something that you forgot

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
You might need it someday

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you
What about love
Don’t you want someone to care about you
What about love
Don’t let it slip away
What about love
I only want to share it with you

In listening to lead singer Ann Wilson belt out these lyrics from the rock band Heart’s famous song, “What About Love,” I was mindful of how music can capture the emotions we all feel when we are in love. Ann’s rendition of these lyrics poignantly expresses the challenges of establishing and maintaining intimacy. What makes it difficult to establish and maintain long-lasting feelings of love? What are the trials we go through that challenge our ability to sustain love over the course of a lifetime?

Our capacity for intimacy begins in childhood, as we establish the initial emotional bonds with our mother and father. Typically these are our first experiences with another human being, and they have a profound influence on our emotional development, and later capacities to form intimate relationships. For some, these child-parent bonds may be rock solid, trustworthy and secure; in which case our capacity for intimacy will be well developed and stable. For others, during the course of our childhood years our parents may be unavailable, inconsistent and self-absorbed, emotionally volatile, and/or physically or sexually abusive; and in these instances our capacity for later-life intimacy will be damaged. These emotional wounds may be expressed in a number of ways, as our yearnings for a stable love relationship encounter our fears of commitment, feelings of mistrust, and narcissistic injuries that form the residue of the damaging parental relations of childhood. “What About Love” captures the lingering effects of this trauma beautifully, as Ann sings:

I can’t tell you what you’re feeling inside
I can’t sell you what you don’t want to buy
Something’s missing and you got to
Look back on your life
You know something here just ain’t right

As we move into adulthood, love relationships that don’t work out may further wound the human heart. A series of disappointing love affairs, the breakup of a long-term committed relationship, or marital separation and divorce may leave lasting emotional traumas that play out to damage or destroy the possibility of later intimate relations. At times the breakups are the result of making poor choices, for example repeatedly engaging in relationships with people suffering from Narcissistic Personality Disorder. At other times we might select someone capable of providing us adult love, empathy and compassion, yet our own conflicts over intimacy may contribute to or cause a breakup.

As a result of these negative childhood, adolescent or adult experiences a “repetition compulsion” may develop, where one unconsciously repeats earlier traumas through patterns of self-sabotaging behavior carried out in existing or new relationships, time and time again. These unconscious behaviors may interfere with or destroy intimate bonds. Feelings of love and tenderness may develop toward one another, but difficulties in trusting and expressing these emotions directly, out of fear of further hurt, loss, or a lack of reciprocal feelings from one’s loved one, complicate the relationship. The number one hit song by Heart, entitled “Alone” poignantly captures aspects of these conflicts:

I hear the ticking of the clock
I’m lying here the room’s pitch dark
I wonder where you are tonight
No answer on the telephone
And the night goes by so very slow
Oh I hope that it won’t end though
Alone

Till now I always got by on my own

I never really cared until I met you
And now it chills me to the bone
How do I get you alone
How do I get you alone

You don’t know how long I have wanted
to touch your lips and hold you tight
You don’t know how long I have waited
and I was going to tell you tonight
But the secret is still my own
and my love for you is still unknown
Alone

Till now I always got by on my own
I never really cared until I met you
And now it chills me to the bone

How do I get you alone
How do I get you alone
How do I get you alone
How do I get you alone
Alone, alone

In these lyrics the singer describes someone who is deeply in love, who has previously tried to get by on their own without depending on another, and now she or he finds themself alone and feeling somewhat desperate. Perhaps it is because they have not expressed their tender feelings to the one they love, or their loved one is afraid to spend intimate time alone with just the two of them because it feels too close and threatening. Fears of further hurt, rejection, a lack of reciprocal feelings of love, dependency and vulnerability can all play a part in interfering with intimacy.

Examples of self-sabotaging repetition compulsions include the young adult woman who acts out sexually with a series of young (or older) men, in a futile attempt to find emotional intimacy, love and affection. Or the young man who engages in a series of meaningless hookups to prove his prowess, and gain narcissistic gratification, because of underlying self-esteem problems that began as a child, perhaps resulting from repeated disappointments in his relationship with his mother or father where he felt powerless. Some of these young adult relationship themes are captured in the song by Pat Benatar entitled, “Love is a Battlefield”

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield
We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

You’re beggin’ me to go, you’re makin’ me stay
Why do you hurt me so bad?
It would help me to know
Do I stand in your way, or am I the best thing you’ve had?
Believe me, believe me, I can’t tell you why
But I’m trapped by your love, and I’m chained to your side

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We’re losing control
Will you turn me away or touch me deep inside?
And before this gets old, will it still feel the same?
There’s no way this will die
But if we get much closer, I could lose control
And if your heart surrenders, you’ll need me to hold

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

We are young, heartache to heartache we stand
No promises, no demands
Love Is A Battlefield

We are strong, no one can tell us we’re wrong
Searchin’ our hearts for so long, both of us knowing
Love Is A Battlefield

Another example is when one repeatedly and unconsciously picks a fight following intense closeness and feelings of happiness (for example, following highly passionate sex), as a way of creating emotional distance because of feeling vulnerable, a loss of control, and the fear of dependency that is engendered by intimacy. And not uncommon is the adult who has lived through a painful divorce, who dreads what he or she believes may become another conflict-ridden relationship. Consciously or unconsciously they avoid falling in love again, or sabotage the development of intimacy in a new love relationship, because of the unresolved emotional trauma resulting from the prior marital separation and divorce.

And then there are the life stage crises that test the bonds of love and marital fidelity. Our life cycle brings different challenges to the human heart at each phase. These trials may include: a fear of commitment during courtship and early marriage; the demands of child rearing that make intimate moments difficult to establish, with longings to return to a simpler time with fewer responsibilities and more romance and freedom; conflicts over how to raise children; a mid-life crisis where one may have intense doubts about choices they have made, or feel highly dissatisfied with their level of professional or financial accomplishment; periods of financial distress; the death of one’s parents; and the realization of one’s own mortality, and the issues surrounding growing old and dying (such as a loss of power, chronic health problems, and major life regrets).

Sometimes a couple may grow apart as they evolve in different directions, or one member may outgrow the other emotionally or intellectually. This can place significant strains on the relationship, as compellingly characterized in the movie, “The Blue Valentine.”

The human heart is complicated, isn’t it?

Psychotherapy can be very helpful in uncovering the unconscious causes of repetitive failed relationships, and the difficulties in establishing or maintaining intimacy. The therapist engages the patient in a caring and trusting relationship, encourages the patient to free associate about their thoughts, feelings, fantasies and memories related to the current and earlier love relationships, and over time the unconscious conflicts emerge. Both the therapist and the patient need to commit to a longer-term therapy to work through the emerging issues that interfere with intimacy. This takes courage. At times it involves emotionally painful sessions, as the patient intensely relives earlier traumatic relations in what is called “abreaction.”  The therapeutic process uncovers prior experiences of conflicted relationships that damaged feelings of closeness and intimacy, and the development of trust. The patient grieves the loss of what had been yearned for yet remained unfulfilled, and reaches an understanding that puts into perspective the reasons for the earlier disappointments and heartbreaks. This process enables one to let go of the traumatic experiences, bringing with it a freedom to experience healthier adult love. It is very gratifying for the therapist to see the patient emerge from this process happily engaged in a more mature love, with their heart finally released from the emotional bonds created by the past traumas. What is learned in therapy will hopefully be applied time and again over the course of one’s lifetime; because intimacy, once achieved, is fragile.

“Knowing yourself is the beginning of all wisdom.” This quote from Aristotle is the cornerstone of all insight-oriented psychotherapies. I genuinely admire those who engage in psychotherapy and commit to seeing it through – thereby bringing about personal emotional growth and a more satisfying life. Patients enter therapy for a variety of reasons. Perhaps they want to end a pattern of self-sabotaging behavior; where they may deny themselves the experience of true intimacy with another, behave in ways that preclude the possibility of joyful living, repeatedly choose narcissistic personalities with whom they fall in love, or find other ways to unconsciously live out what is known as “the repetition compulsion.” There may also be recurring symptoms of anxiety or depression for which they seek understanding and symptom relief. A life crisis around the end of a love relationship, the illness or death of a loved one, or severe job stress may lead one to seek therapy on an urgent basis, seeking immediate relief.

What is necessary in making this commitment to therapy, in sitting with a psychotherapist and examining one’s life? At its core, the psychotherapeutic relationship requires shared courage on the part of the patient and the therapist. At the beginning of psychotherapy, and from time-to-time throughout its course, the experience can feel quite scary for the patient. Coming to terms with certain realities heretofore avoided is emotionally challenging, and may feel daunting and overwhelming. At times extremely painful feelings, embarrassing or shameful fantasies, and troubling memories will arise during the course of therapy, all demanding the courage to confront, explore, understand, and resolve them.

Then there is the phenomenon known as “resistance” that develops during the course of psychotherapy. Resistance is based in defense mechanisms that protect the conscious mind from experiencing emotionally threatening unconscious memories, fantasies and feelings. Sometimes resistance is experienced as an urge to run – to avoid facing these issues – as it is human nature to seek pleasure and avoid pain. Internal conflicts also arise over feelings of dependency toward the therapist, in opposition to feelings of wanting to remain independent and self-sufficient. This is often manifested by the belief that seeking treatment is “a sign of weakness” and that “I should be able to manage my problems without the help of a therapist.” To the contrary, when one commits to the therapeutic process and sees it through to conclusion, it is a sign of admirable strength of character.

Two novel perspectives on therapy were recently shared with me. A young patient of mine – a tough, charismatic, and highly talented college football player – put it like this, “You have to man up, and face yourself in therapy.” Another patient, a middle-aged professional woman from the financial services industry, described therapy as a place where “You are not a side effect of your life, you are an active participant in your own well-being.”

Patients will commonly develop unconscious and conscious feelings and fantasies toward the therapist, called “transference,” that must be openly discussed in the session, no matter how embarrassing it might feel. The patient “transfers” onto the therapist feelings and fantasies they had toward important figures from their earlier life, such as their parents. These may include longings to be loved, fearfulness, erotic fantasies, yearnings to be taken care of, and so on. If the transference feelings are not candidly revealed, the therapy will grind to a halt. An open and honest discussion will pave the way toward uncovering important unresolved issues with one’s mother or father that, once resolved, enable one to move on with his or her life and love relationships in a healthier fashion.

The therapist in turn will develop a “countertransference” toward the patient. Countertransference occurs when the patient elicits conscious or unconscious feelings, fantasies and memories in the therapist based upon how the therapist was raised by his or her parents, and from other important relationships. It is important that the therapist have engaged in his or her own personal psychotherapy or psychoanalysis, to be able to identify and analyze their countertransference reactions (particularly the unconscious ones), so as to not act them out on the patient, or contaminate the therapy through imposing their own personal neurotic agenda. Among the most challenging and beneficial experiences in my own life were the years I spent on the psychoanalysts’ couches – first as a psychoanalytic institute trainee – and later following the death of my father – both of which helped to forge my identity as a psychiatrist. A personal psychoanalysis enables the psychiatrist or psychotherapist to more effectively empathize with, support, and emotionally “hold” their patient while being mindful of the potential interference from one’s own childhood relationships.

An important element in longer-term psychoanalytic or psychodynamic therapy is analyzing the unconscious causes of self-sabotaging behaviors that often originate in childhood relationships. In the course of therapy, as the patient grows increasingly familiar with the technique of “free association”, he or she will speak whatever comes into their mind, without holding back or censoring their thoughts, fantasies or feelings. As free association proceeds, the patient may re-experience prior events in his or her life with great emotional force, at times so powerful that they literally believe that they are actually living through the experience at that moment. This is called abreaction. As a result of the abreactive experiences, and the caring and empathy provided by the therapist, the traumatic event may be recast in a new cognitive framework, and be viewed without distortion through adult eyes, enabling the patient to finally let go of the trauma and leave it behind.

The foundational elements of a successful therapy include tenacity, the development of trust, feeling understood and cared about, feeling emotionally “held” through difficult and painful moments, mutual respect, a high level of technical skill on the part of the therapist, and a shared optimism regarding the outcome. The therapist must also embody a deeply held belief in the human spirit’s capacity for growth and change. Ultimately it takes heart, and a strong belief in the patient’s (and one’s own) courage, to forge ahead into the unknown.

The brain is the organ of the mind. Our ability to think, feel, and experience life is dependent upon neurobiological processes governed by the interaction between our genes and various types of psychological, environmental, and physiologic influences and stressors. New research in the field of “epigenetics” offers compelling support for the combination of psychotherapy, nutrition, and medication management in the treatment of patients suffering from anxiety, depression, or bipolar disorder. Epigenetics means “over or above genetics,” and refers to how both the external environment and internal physiologic environment can interact with the DNA within the nucleus of each cell in the body, to alter how these cells function. In psychiatry, this field brings us knowledge regarding the epigenetic influences on brain cell function in patients suffering from mood disorders and anxiety. This knowledge carries profound implications for how we live our lives.

In mood and anxiety disorders, there is no “depression gene” or “anxiety gene.” One inherits a susceptibility to these conditions through multiple different genes, but the genes alone do not cause the illnesses. The genetic material within the nucleus of brain cells must first be influenced by epigenetic factors that come from outside the brain, such as external environmental or internal physiologic factors. Certain types of interpersonal stress with loved ones, or colleagues at work; inflammation, such as that caused by fat cells; and alcohol or drugs of abuse; can interact with these susceptibility genes to cause major depression or bipolar disorder; or cause anxiety disorders such as generalized anxiety, obsessive compulsive disorder (OCD), or panic disorder.

Two types of interpersonal stress can contribute to triggering psychiatric disorders. The first is called “learned helplessness,” defined as “a behavioral state of a person who believes that he or she is ineffectual, his or her responses are futile, and control over the environment has been lost.” The second is termed “social defeat stress,” and is defined as “relationships characterized by aggression, bullying, chronic subordination and humiliation.” Research has demonstrated that both learned helplessness and social defeat stress are epigenetic factors associated with psychiatric disorders.

Drugs of abuse such as cocaine trigger epigenetic changes in certain brain regions, affecting hundreds of genes at a time. Some of these changes remain long after cocaine has been cleared from the body. Research suggests that some of the long-term effects of drug abuse and addiction (including high rates of relapse) may be written into the epigenetic code (again, the interaction between the environment and the genes). Cocaine not only alters the epigenetic status of genes but also induces specific epigenetic modifications depending on how often the drug is used. Certain genes are switched on by infrequent administration, while others are switched on only after chronic administration (such as in addiction). Some are switched on by both This may relate to cocaine’s ability to “kindle” mood disorders Alcohol abuse has also been associated with epigenetic changes to the chromatin of the DNA in brain cells, predisposing to anxiety symptoms. And at a recent Society for Neuroscience meeting, marijuana use in teens was associated with cognitive deficits, reduced executive functioning (attention, focus and decision making), and changes in brain function in the frontal cortex. Whether marijuana asserts its effects through epigenetic mechanisms is the subject of ongoing research.

Obesity and nutritional aspects of a person’s lifestyle can also have profound effects on mood regulation and the onset of depression. We now know that fat cells release cytokine and C-reactive proteins. These proteins are known to cause inflammation throughout the body, and are associated with psychiatric disorders in the brain. They lead to alterations in neurotransmitter levels, neuroendocrine systems, and how brain synapses function. This leads us to conclude that obesity is also a type of stressor that contributes directly to altered brain function associated with mood disorders – more specifically depression.

How do these multiple internal and external influences interact with the genetic material within our brain cells to initiate the onset of an emotional disorder? In the brain, an important function of the DNA that makes up our genes and chromosomes is to code messenger RNA, which in turn codes so-called neuroprotective proteins. These protective proteins, for example BDNF (Brain Derived Neurotrophic Factor), support and protect normal brain cell structure and function, and enhance memory, learning, higher order thinking, and neurogenesis – the growth of new brain cells which occurs throughout the lifespan.

Below is a picture of how depression and anxiety are triggered by the interaction between various types of stressors and the DNA found in every brain cell. As depicted from left to right, multiple different genes predispose the patient to developing depression or anxiety, as they are exposed to one or more of the stressors cited above. The genes are necessary but not sufficient to cause the illness by themselves. In response to the stressors, the genes are suppressed in their ability to manufacture the neuroprotective proteins such as BDNF; and Bcl-2, which prevents brain cell death. As the levels of these protective proteins drop, the brain cells begin to function abnormally; and the energy centers of the cells, the mitochondria, begin to malfunction as well. This in turn affects the function and structure of the brain cells that form information processing circuits, which then results in the changes in mood, behavior and thinking we see in those who suffer from depression, bipolar disorder, and anxiety.

Neurogenesis is also critically important in the recovery from mood disorders, and can be positively affected by exercise, antidepressant medication, and through psychotherapy. Psychotherapy enables the patient to overcome the causes of learned helplessness and socially induced defeat-stress, characterized by repeated experiences of being overpowered and feeling helpless and trapped, whether in relationships at home or at work. Therapy empowers patients and enables them to leave behind destructive relationships from the past which have been internalized (for example damaging childhood experiences with a parent); and to modify or end current relationships that are characterized by repeated emotional battering. These emotionally damaging relationships may originate in one’s immediate or extended family, or in the workplace. In learning how to better manage or separate oneself from these types of stressful internal and external relationships, it can lead to increased resilience, new and richer social experiences, and result in neurogenesis.

Healthy nutrition can also play a key role in the recovery from a major mood or anxiety disorder. Reducing one’s body fat percentage to reasonable levels, for example 21% to 24% for women, and 13% to 17% for men, will reduce the release of the inflammatory proteins from fat cells. This not only has a salutary effect on brain cell function, but also reduces the likelihood of developing Type 2 Diabetes, coronary artery disease, hypertension, and stroke. Diets rich in lean protein, such as chicken, fish, egg whites, turkey, and whey protein shakes blended with fresh or frozen fruit; and filled with low glycemic index carbohydrates, such as fresh fruits and vegetables; with the use of olive oil (and not other vegetable oils or butter); combined with aerobic exercise three to four times per week; can assist in achieving these important goals of reducing body fat percentages. A sustainable program with proven success in accomplishing these objectives is The Joe Dillon Difference. Joe Dillon has coached many business executives, professionals and their families, in addition to 22 Olympic medalists who have won 60 medals, in a lifestyle for busy people with demanding schedules, that provides for increased energy, improved mood, and less anxiety and stress. I met with Joe along with other professional and executive colleagues of mine. Many of us have adopted his lifestyle recommendations, achieved positive results, and hold him in high regard.

Through the use of therapeutic interventions such as psychotherapy, healthy nutrition and aerobic exercise that reduce body fat percentage, and antidepressant medication, the destructive epigenetic processes may be reversed. As demonstrated in the picture below, these healing influences can activate so-called DNA “promoters” that enable the brain cell to code the RNA responsible for the production of neuroprotective proteins, resulting in increasing levels of these proteins. This restores normal cellular and mitochondrial energy functions, which in turn improve the information processing capabilities in multiple interacting circuits of the brain. This results in the normalization of emotional, cognitive and behavioral functioning.

These events are illustrated in the picture below. On the left hand side, the DNA is “promoted” to produce increased levels of BDNF. On the right hand side from top to bottom, in response to increased BDNF, the dendrites of the brain cells then regrow their branches, and the axons of the brain cells become re-enriched with dense packets of neurotransmitters. This restores and enhances healthy emotional functioning.

In viewing this process of regeneration, one can imagine that the implementation of psychotherapy, proper nutrition, and antidepressant medication is akin to the arrival of Spring, when tree limbs (and the human spirit) blossom, and experience a rebirth!

It seems like almost every other week that we are introduced to a new antidepressant medication through an ad on TV. For patients suffering from depression and their worried family members, they may wonder, “Why are there so many antidepressants on the market? What are the differences in how they treat depression? How do they work? How do I know if my antidepressant treatment should be modified, or changed altogether?”

It is important to note that depression is a major health problem worldwide. The World Health Organization (WHO) predicts that by 2020 depression will be the second largest cause of the global health burden – and major depression is already the central nervous system (CNS) disorder with the highest prevalence. There are about 40 million diagnosed cases in the United States, France, Germany, Italy, Spain, United Kingdom, and Japan. The lifetime prevalence of major depression across the population ranges from 3% in Japan, to 17% in the United States, to 30% of men and 40% of women in the Netherlands and Australia.

In 2008, global sales of antidepressants totaled $20 Billion. In the United States, the use of antidepressants doubled over one decade, from 1996 to 2005. Antidepressant drugs were prescribed to 13 million people in 1996 and increased in number to 27 million by 2005. In 2008, more than 164 million prescriptions for antidepressants were written in the U.S. alone. It is fair to say that there is an epidemic of depression in the civilized world, and fortunately our understanding of how to treat depression has become increasingly sophisticated, through advances in molecular biology and neurophysiology that tell us how brain cells function in their normal state and in a depressed state, leading to more effective and targeted therapies.

Given the prevalence of depression throughout the world, and the deep and pervasive emotional pain it causes to patients and their loved ones, it is not surprising that the pharmaceutical industry would endow physicians with an extensive armamentarium of medications to treat major depressive disorder. As a result there are multiple drugs within each of several different classes of antidepressants, that boost levels of certain neurotransmitters such as serotonin, dopamine, or nor-epinephrine in the mood-regulating regions of the brain. Mood regulating brain cells are organized into circuits, within which the cells interact with one another using electrochemical mechanisms. The mechanism by which they interact, and how antidepressant medications work to enhance these interactions is simple, yet elegant, as illustrated in the picture below:

When the first brain cell (the presynaptic neuron) “fires,” it releases neurotransmitters into the synaptic cleft. Some of these transmitters then travel across the synapse and bind onto receptors of the next brain cell (the postsynaptic neuron), which can then cause that cell to fire (as illustrated in pathway #1 in the picture above). Other transmitters do not make the journey safely across the synapse, because they are reabsorbed back into the first cell (called “reuptake”) or are degraded by enzymes such as COMT and MAO (as illustrated in pathway #3 above). If the neurotransmitter levels are low in depression, it makes sense to block the reuptake, or block the enzymes that degrade them, to increase their numbers in the synapse, thereby increasing the likelihood that they will bind to the next brain cell

The most popularly prescribed antidepressants are the “SSRI” or “SRI” group, standing for serotonin-specific reuptake inhibitors. Examples are Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), and Lexapro (Escitalopram). A different antidepressant, Wellbutrin (Bupropion), inhibits the reuptake of dopamine. Another class of antidepressants works to boost both serotonin and nor-epinephrine. These “SNRI,” serotonin/nor-epinephrine reuptake inhibitors include medications such as Cymbalta (Duloxetine), Effexor (Venlafaxine), and Remeron (Mirtazepine). Still another class is called the “MAOI” or monamine oxidase inhibitor antidepressants such as Parnate (Tranylcypromine) or Nardil (Phenelzine). These work by blocking the enzyme MAO (monoamine oxidase) that breaks down the neurotransmitters, but these are not widely used because they interact with many foods and drugs.

Successfully treating the symptoms of depression with an antidepressant is both an art and a science, and the choice of antidepressant can depend upon a variety of factors. Family history of response to a particular medication among genetically-related family members can be a helpful predictor, as can the presence of certain symptoms to target, which are known to respond to increases in one or more of the neurotransmitters noted above. For example, panic attacks may respond to SRIs or SNRIs and be worsened by Wellbutrin. Social anxiety and obsessive–compulsive disorder symptoms may respond to SRIs and also be worsened by Wellbutrin. ADHD symptoms may respond to the dopamine increase provided by Wellbutrin, but not to SRIs. In patients with depression, social anxiety, and ADHD, an SNRI may be helpful by boosting both serotonin and norepinephrine to address their broad spectrum of symptoms.

Not uncommonly, the patient’s depressive symptoms will only partially respond to the first medication selected, or they may not respond at all. In the event of a partial response, and where there are no troubling side effects, the medication is not switched but is “augmented” to make it more effective. Adding one or more “augmenters” to the antidepressant is analogous to adding a turbocharger to a car engine – they both provide a boost – they add power. Antidepressant augmenters include Folic Acid (a B vitamin), Omega 3 fish oil, thyroid hormone, testosterone, lithium, a second antidepressant from a different class (e.g. adding Wellbutrin to an SRI), an atypical antipsychotic medication (e.g. Abilify), and N-Acetylcysteine. The use of each of these augmenters may have a different rationale – for example Abilify may be used in the depressed patient struggling with many negative thoughts or mood instability – while Wellbutrin could be used to boost the energy level of a patient who has partially responded to an SRI, but continues to suffer from a lack of motivation and drive. In the more treatment-resistant patient, multiple augmenters may be used.

If there is no response whatsoever to the initial antidepressant, and it was given an “adequate trial” (defined as six weeks duration of treatment, at the maximum dose of the medication compatible with not causing side effects), then a different class of medication should be considered. Sometimes medications will be combined to boost all three neurotransmitters – for example using both Cymbalta and Wellbutrin – in certain patients with a treatment resistant depression that is not responding to the methods described above.

Our knowledge of antidepressant treatment continues to advance. Having been trained in “The Golden Age of Psychiatry”, I have been inspired by the evolution of pharmacologic treatment of depression over the past several decades – from the unsophisticated early days which offered limited choices of medications that caused dry mouth, constipation, lightheadedness, and other unpleasant side effects – to our present-day level of advanced knowledge with the ability to choose among many “clean” drugs that are tolerated so well that most patients forget that they are taking them. While researchers in some circles doubt the effectiveness of antidepressant medications, my experience over the years is that the efficacy of antidepressants is unequivocal. Responses to these medications range from enhanced self esteem and improved quality of life for those patients who are mildly to moderately depressed, to restoring basic daily functionality and providing lifesaving benefits for those who are moderately to severely depressed.

Used alone, or in combination with psychotherapy, antidepressants are life-altering; and offer the hope to millions of patients and their loved ones that they can climb out of that deep dark hole into daylight, and even into radiant sunshine.

Marriage may be the most challenging relationship in one’s life. Loving feelings are precious, and can be fragile and difficult to sustain. Many times when a couple enters the office in a crisis, the issues and problems they bring up in therapy have developed over a period of years, and have become compounded by a recurring cycle of disappointment, feeling wounded, and being ignored or taken for granted. Often times the drive, energy and focus devoted to one’s career and children are exhausted, and little is left over to nurture the marriage. As a result of this neglect, a valuable life together built upon the foundation of marriage begins to crumble. Every divorce is tragic, even when justified.

Marriage counseling is designed to surface and explore the root causes of marital conflict and distress; reconstructing how, when and where the relationship went off-track; hopefully bringing understanding to the inevitable misunderstandings that have been created and amplified over time; and learning how to implement new tools, for more effective emotional connection and problem resolution. Understanding one another can help to reduce the feelings of anger and hurt, and break the negative cycle that threatens to destroy the marriage. How are feelings of love restored in a battered marriage? The most important ingredient is listening, truly listening to one another. Exactly what does that mean in practice?

Listening has an enormously powerful effect when a loving relationship has been damaged. The most effective type of listening is best characterized as empathic and compassionate. Listen from your heart. Pay attention without interrupting. Take note of what is being said, and really try to understand what you are being told, even if you don’t agree with it. Put yourself in your partner’s place and work hard to understand what he or she has experienced. Listen with a spirit of cooperation, of jointly embarking on a journey of discovery, even when it is painful. Convey your understanding without hostility, and whenever possible, and where it is true, take responsibility for what you are being told about your own destructive or neglectful behavior.

Empathic, thoughtful listening creates a feeling of safety in the relationship. A readiness to blame your partner is the surest way to reinforce feelings of vulnerability and rejection, and discourage the honest sharing that is needed. How often in our lives do we feel listened to and understood by those we care about? The healing power of empathic and compassionate listening should never be underestimated. Injecting a needed dose of hope into the relationship, it enables one’s partner to feel special, and loved. It helps to restore a caring emotional connection and positive momentum.

Mignon McLaughlin once said, “A successful marriage means falling in love many times, always with the same person.”Falling in love once again with your spouse protects and enhances the life you have built together, and is energizing and rejuvenating. It can bring newfound satisfaction and joy to the other areas of your life as well.