Depression Symptoms Treatment

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Question. I have been depressed ever since my grandmother died three years ago. I have tried drugs and therapy, but nothing helps. I have no zest for life. My sex drive has all but disappeared. Though pornography still arouses me, I have problems sustaining an erection. Is my problem with sustaining an erection a physical or mental one? Which kind of a specialist would be able to investigate the physical aspects of it and what kind of tests need to be done? Should I visit a urologist? Would you recommend any kind of therapy or counseling? What about alternative medicine?

Answer. You certainly have all the hallmarks of a resistant major depression, though I cannot exclude medical factors that may be contributing. My guess is that there are still unresolved feelings surrounding your grandmother’s death, and that these need to be worked through with a mental health professional. In addition, it appears that your medication regimen is not optimal, and will require adjustment. As for your sexual dysfunction, I am not in a position to say if it is physical, psychological or both. Erectile dysfunction used to be attributed to psychological causes almost exclusively, but in recent years, the majority of cases have proved to be due to physical factors, such as decreased blood flow to the penis. On the other hand, depression per se can certainly decrease one’s sexual drive and arousal.

My recommendations are as follows: 1) Ask your psychiatrist or prescribing physician to refer you to a urologist for a complete evaluation, including measurement of testosterone levels. There are many effective treatments for this problem, whether the cause is physical, emotional or both, as is often the case. 2) I would certainly recommend that you enter into a form of psychotherapy; indeed, I am disappointed to learn that your prescribing physician has not made this a part of your care.

You may want to find out who specializes in the treatment of depression in your area. A clinical psychologist or psychiatrist would be a good start, but psychiatric social workers and clinical nurse specialists could also be fine. The specific school of therapy is far less critical than your sense of trust and comfort with the therapist.

In terms of the research, cognitive-behavioral forms of therapy (CBT) have proved very effective in depression, but exploratory approaches may also be effective; in your case, someone familiar with grief reactions might be very helpful. It is perfectly all right to ask the potential therapist about his/her areas of expertise. You may wish to contact your local branch of the American Psychological Association or American Psychiatric Association for referrals.

As far as medications go, I would first consider Wellbutrin at a maximum dose of 450 mg/day (in divided doses), as tolerated. This particular antidepressant is especially good for patients with sexual dysfunction, since it actually improves it in many cases. Trazodone is probably OK, and may actually improve erectile function, though in a very small percentage of cases (about 1 in 5000), trazodone can lead to abnormal, painful, prolonged erections (priapism) requiring immediate medical attention. The addition of a small amount of methylphenidate to the Wellbutrin may also be useful. There are many alternatives, including venlafaxine (Effexor) and mirtazepine (Remeron), and I would not rule out a course of ECT. I sincerely hope you give yourself whatever time is necessary to get well. I believe that if you do, your prognosis is good.