Low mood and hard feelings

Most antidepressants share a family resemblance. Bupropion does not, so much of what you have read about the others simply does not apply to it.

It works on the systems carrying drive and alertness rather than on serotonin, which is why its effects, wanted and unwanted, sit at an angle to the…

A medicine that lifts drive is not the same as one that settles anxiety, and for some people the energising kind makes the worry louder.

Bupropion is the clearest example: often good for flatness and lack of motivation, often unhelpful on its own when anxiety and a racing, sleepless…

If you know something about a person's history that the prescriber may not, say it. A past eating disorder or a single seizure can change what is safe to prescribe.

Bupropion lowers the seizure threshold, and in someone who is purging, restricting or very underweight that risk climbs meaningfully. The therapist…

When the same medicine keeps turning up for unrelated problems, that usually means one action touches all of them. It does not mean somebody has found a cure for everything.

Bupropion appears in depression, in stopping smoking, in a weight loss combination and sometimes in attention problems, because the system it works…

If the usual antidepressants have not reached you, there are treatments that work on an entirely different system in the brain. They are worth asking about.

Esketamine, given as a nasal spray in a clinic, acts on glutamate rather than on serotonin or noradrenaline, and the change it brings can arrive in…

The newer thinking about depression is less about topping up a missing chemical and more about connections that have thinned out being rebuilt. Recovery looks more like regrowth than refilling.

Long stretches of depression seem to leave parts of the brain less richly connected, and some treatments appear to work by helping those links form…

If a treatment reliably produces strange sensations, describe them beforehand. Expected strangeness is far easier to sit through than strangeness that arrives unannounced.

With esketamine, feeling oddly detached from your body or the room is the drug doing what it does, not a sign of harm, and it usually clears within a…

When a treatment is offered, it is fair to ask whether it is the licensed version or a use that sits outside the licence, and what monitoring comes with it.

Ketamine for depression is the live example. The doses used are far below anaesthetic ones, the nasal form has approval for treatment resistant…

Before anyone concludes that nothing works, go back over the ordinary explanations: a dose that never went high enough, a trial that stopped after three weeks, doses missed on the hard days.

Treatment resistant has a technical meaning, which is that at least two proper trials at a proper dose and length have failed. A great deal of what…

Put something in before you take something out. Removing the only way a person has of coping leaves them with nothing, which is not safer.

In practice this looks like smaller steps than a promise to stop: cutting the frequency, changing what is used, agreeing to wait ten minutes and do…

When someone says they feel nothing, find out where the nothing reaches. All the time, or only towards good things, or only here, in this conversation, when criticism is in the air?

The three answers point in quite different directions. Numb everywhere, day and night, is worth taking to a doctor. Numb to good things while the bad…

If a medicine has taken the edge off everything, including the good things, that is worth raising with whoever prescribed it. Taking the sharpness out of pain is one thing. Feeling nothing at all is not a way to live.

It matters practically as well as personally. Anything you are trying to change, in a relationship or in yourself, needs some feeling to work with,…

The same sentence lands completely differently depending on who says it. If nothing stirs when it is described second hand, let the person it belongs to say it to you directly.

A therapist repeating what your partner said is information. Your partner turning to you and saying it, in their own voice, is an event. That is why…

Rather than arguing with someone who says they feel nothing, say plainly what would ordinarily hurt about it. Hearing that the person you love is disappointed in you is a hard thing to hear.

Said warmly, this is not a challenge. It sets out what a person would usually feel and leaves them to notice the gap between that and what they are…

Going still and needing nothing is usually something a person worked out young, somewhere it was the sensible answer.

If reaching out met dismissal, or worse, then not reaching out is not a flaw of character. A child who stops asking, stops showing what they feel and…

Pulling back makes you harder to reach, which makes people give up on reaching, which looks like proof that nobody was coming. The loop closes itself.

Being told to open up rarely breaks it, because opening up in one go is exactly the risk the whole strategy exists to prevent. What breaks it is…

Name one hard thing today and ask what it might be growing in you: patience, humility, nearness to God.

Not denying the difficulty. Finding the meaning inside it that makes it bearable.

When a thought lands hard, ask whether you know it for certain, and what you would actually put forward if you had to make the case. Then go looking for the bits that point the other way.

Do this once you have settled a little, not in the worst of it, or the questions become another way of arguing with yourself. Write the answers down…

Notice the standard you are holding yourself to, then ask whether you would hold anybody else to it. If what you blame yourself for happened when you were a child, ask honestly whether a child could have carried that.

Shame usually rests on a rule that was never said out loud, something along the lines of I should have known, or I should have stopped it. Written…

Picture somebody you love saying this exact thought about themselves. What would you say back, and why is none of that available to you?

Most of us are far kinder outward than inward, and the kind version is usually the more accurate one as well as the warmer one. Say your answer to…