Treatment for Severe Chronic Depression: The Importance of Hope

Reader’s Question

I was diagnosed with depression when I was 16, and now 7 years later have been diagnosed more specifically as Melancholic Depressive and Borderline Personality Disorder. I would say I have been suicidal for most of my life, with urges and intent increasing and decreasing. More recently I have been overwhelmed with hopelessness and helplessness, and the belief that this is how the rest of my life is going to be, so why bother continuing it? I see a psychologist weekly, who on numerous occasions has tried to admit me into hospital, as I will not go voluntarily. However my consulting psychiatrist does not believe hospitalisation will benefit me. He says I suffer from chronic suicidal tendencies, with the feelings and the thoughts always present. He also does not believe ECT will have any benefit for me either, despite it being very successful with other patients. I have tried numerous anti-depressants and mood stabilisers over the years, all to no effect. My question is: how am I supposed to reach a manageable level in my illness if no treatments or procedures are actually expected to work on me? If my illness and the thoughts, feelings and urges associated with it are chronic and long lasting, how am I expected to continue living in the state that I am living in? I feel my desperation for some relief has reached boiling point.

Our Clinical Psychologist’s Reply

Effective treatment for chronic depression, especially when associated with other disturbances such as a personality disorder can indeed be a challenge. And, a person can end up feeling helpless. But helplessness is not hopelessness. Indeed, the expectation of eventual positive outcome is a very powerful factor in itself and is central to many effective therapies.

There is some evidence (e.g., some recent research conducted by Cheavens, et al at Ohio State University) that hope itself can even be learned. And the researchers are careful to distinguish hope from optimism. Because cognitive-behavioral therapies are often used as an adjunct to medical therapies in the treatment of depression as well as personality disorders, the researchers tried adding hope-enhancing exercises to their talk therapy groups. The “components” of hope they discovered were crucial included goals, practical plans or ways to meet those goals, positive self-talk (whether you believe the talk or not), and strategies to solidify gains that inoculate a person against self-destructive backsliding.

It sounds like too many non-hopeful messages characterize your present experience with treatment. The good news is that we can learn to be more hopeful, and there are concrete measures that can be included in therapy that can enhance a person’s level of hopefulness. I’d talk these issues over with your treatment providers and carefully assess whether sufficient attention is being given in your treatment to enhancing your level of hope.