The Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression

Introduction
Empowering People with Anxiety and Depression

Anxiety and depression are two of the most serious medical disorders. The
suffering caused by these conditions is not only miserable, grinding, and so
intolerable that suicide can appear a welcome relief, but it is diabolically long-
lasting if not treated. We used to view anxiety and depression as afflictions of
middle age. We now know that they strike the young with equal force and
can be ruinous throughout life unless treated. We used to think that anxiety
and depression were purely mental ills— disorders of emotion, thinking, and
perspective. In fact, anxiety and depression are deeply rooted in the body,
and their corrosive effects raise a person's risk of contracting a host of
diseases, including heart disease, stroke, diabetes, and osteoporosis.
Depression alone is the leading cause of disability in the United
States and the rest of the world. It costs employers an estimated $44 billion
a year in lost productivity, according to a 2003 article in the Journal of the
American Medical Association. Tragically, not only is the true magnitude of
the damage wrought by these diseases widely unknown, but millions of
people do not recognize their own anxiety or depression, or if they do, they
suppress this recognition because of the stigma that stubbornly clings to
psychological conditions of all kinds.
This book is our attempt to fight that stigma, raise awareness
about the true nature of anxiety and depression, help people find optimal
treatment, and empower them so they can better navigate often complicated
health-care systems.
We live in remarkably stressful times, filled with information
overload, demands to perform at high speed, and pressure to multitask. The
terrorism and war that have touched all of us in recent years have also added
uncertainty and tension to our lives. Unfortunately, humans are not built for
this kind of stress. Our brains, our moods, and our emotional responses
evolved over millions of years to deal with the challenges of a hunter-gatherer
lifestyle, in which new information came at a trickle and the pace of life was,
literally, at a walk. The contrast with the demands of the twenty-first century
is so stark that the steady rise in anxiety and depression is not surprising.
Between 1987 and 1997, for example, the percentage of Americans
diagnosed and treated for depression more than tripled. Anxiety and
depression are now the two most common mental disorders, affecting 38
million people in the United States alone.
We urgently want to address these dire statistics by improving
care for those who are anxious, depressed, or both. Until now no
comprehensive and authoritative guide has existed for people seeking the
optimal treatment they deserve. In part, that's because until recently experts
have considered anxiety and depression separate maladies. We now know
this is false: people often experience symptoms of both, and proper
diagnosis and treatment require an appreciation for the interrelatedness of
these two disorders.
This book offers the most up-to-date and high-quality information
available anywhere about the science and treatment of anxiety and
depression. Our recommendations, suggestions, and guidance are grounded
in evidence-based medicine, which simply means that we back up our
assertions with findings from recent well-designed studies published in peer-
reviewed professional journals. We have been fortunate to be involved with
dozens of such studies, thousands of patients, and key national patient-
advocacy groups. One of us, Dennis S. Charney, oversees scores of
research projects every year as chief of Mood and Anxiety Disorder Research
at the National Institute of Mental Health. The other, Charles B. Nemeroff, is
a professor and chair of the Department of Psychiatry and Behavioral
Sciences at Emory University, a leading center for research, training, and
clinical care of patients with mood and anxiety disorders. He has treated
many of the patients whose stories appear in this book. Because of our
prominence in the field, we often consult with leading companies involved in
treating anxiety and depression. In the spirit of full disclosure, we list these
relationships in the endnotes. Such arrangements, very common in
psychiatry, are mutually beneficial and do not compromise our commitment
to writing a book based solely on the state of the science and weight of the
latest medical evidence.
Our understanding of anxiety and depression is not just a matter
of long clinical experience and formal academic training, however. We are not
removed from the conditions about which we write. We have our own human
foibles and have experienced our share of grief, tragedy, and pain. We would
never pretend to know exactly how anybody else feels, but we do have a
profound empathy and compassion for everyone who struggles with anxiety
and depression—an empathy rooted in our own struggles with life's slings
and arrows.
Our fundamental message is hopeful: people can overcome
anxiety and depression and find well-being, zest, and greater emotional
resilience. Everyone can make progress. Everyone can get better. Everyone
can be happier and healthier. We're not saying the path will be easy, quick,
or painless, but we are certain that good information is the foundation for any
successful treatment—and that is what this book contains.
In tackling anxiety or depression, recognize a fact sometimes
overlooked by physicians and the medical establishment in general: nobody
knows more about you than you do, and you may understand yourself better
than you realize. That doesn't mean you are all-knowing or have plumbed the
depths of your own multilayered consciousness. It simply means that you
are the ultimate judge of when you need help, when you feel well, and when
you think a change is needed in your treatment plan. Like most people, you
are wiser and stronger than you may think you are. In the grip of depression
or anxiety, you may minimize or dismiss your ability to change, heal, and
grow, and this self-doubt is in fact part of the insidious nature of these
illnesses.
Though we cannot hear your story directly or tailor what we have
to offer to your particular circumstances, we acknowledge the primacy of
your own unique life and all of the strengths and weaknesses you bring to
bear on dealing with challenges to your health and well-being. There is no
magic formula, no "absolutely effective" therapy, no "best" medication that
works for everyone. You must weigh the ideas, suggestions, and options
presented in this book against your own life, your own values, your own
situation, and then act.

Not Just Treatment, but Optimal Treatment

Sadly, millions of people with anxiety and depression are not achieving the
relief they deserve. Only about one in five of those with major depression gets
adequate treatment, according to a 2003 study. "Adequate" was defined as at
least eight half-hour sessions of counseling with a mental health professional
or four visits with any type of physician for prescription and management of
an antidepressant drug, used for at least thirty days.
Many people simply don't realize they are sadder, more tired, or
more anxious than they need to be. Others know they suffer but don't seek
treatment out of fear, embarrassment, or shame. Such concerns persist
despite decades of testimony by people from all walks of life that anxiety and
depression are medical conditions just like any other. Nobody is
embarrassed to admit they have high blood pressure or diabetes, and nobody
should be embarrassed to admit they are dealing with anxiety or depression.
Almost all medical diseases involve complicated interactions between mind
and body, and no clear distinction can be drawn between "physical illnesses"
and "mental illnesses." Unfortunately, this relatively new way of looking at
illness has not become common knowledge.
Even people currently receiving treatment often do not get optimal
treatment. Their psychotherapy may be stuck or simply not working. Their
medication dose may be too low, it may have lost its effectiveness, or
perhaps it wasn't effective to begin with. Efforts to adopt a healthier lifestyle
may be bogged down because of lack of time, money, or energy. This book
offers many suggestions for overcoming barriers and getting the treatment
one deserves.
It's also true that despite the breakthroughs of the past two
decades, treating anxiety and depression is a complicated and still inexact
science. Don't get us wrong—we have the tools, both psychotherapeutic and
pharmacological, to heal most of the people who seek help. But clinicians
need skill and experience in order to use these tools correctly, and patience
and commitment on the part of both the patient and the clinician are
essential. Often people need to try a number of approaches until one, or a
combination, works. If the search continues for months, people may stop
before they have wrung the most from today's arsenal of treatments. Don't
accept a "quick fix" approach. A brief medical history, a fifteen-minute chat
with a family doctor, and a prescription for an antidepressant or anti-anxiety
medication are seldom enough. Everyone deserves more—a true therapeutic
alliance with attention to the subtleties, both physical and psychological, that
determine how well and rapidly a person will overcome anxiety or depression.

Using This Book

We have organized this book in three parts. Part I covers basic information
relevant to everyone and is important for understanding later chapters. Part II
covers the diagnosis and treatment of anxiety and depression. Part III
explores how anxiety and depression affect people at different stages of life.
The appendixes contain valuable information about special topics such as
complementary therapies, how to evaluate health information claims, and
where to find nearby psychiatric help.
The stories of real people and their struggles with anxiety and
depression are woven into every part of the book. Some patients have allowed
use of their real names because they want to combat the stigma lingering
around anxiety and depression. Others have chosen anonymity out of
concern for the privacy of others involved in their story. We are deeply grateful
to all of them for sharing some of the most difficult or painful times of their
lives. We believe these stories add an invaluable dimension to the factual
information we present.
A few anxiety-related afflictions are not addressed in this book.
For instance, we do not discuss obsessive-compulsive disorder (OCD)
because current research suggests it is a distinct psychiatric entity that
should not be lumped with other anxiety disorders. Although patients with
OCD need as much help as any, this subject is better treated in a book of its
own. Interested readers might consider The Boy Who Couldn't Stop
Washing: The Experience and Treatment of Obsessive-Compulsive Disorder,
by Judith Rapoport. We also do not specifically cover so-called simple
phobias— abnormal reactions to specific things such as snakes, spiders, or
blood. Such phobias are relatively uncommon in the general population (as
opposed to simply disliking or fearing snakes or spiders). In addition, simple
phobias are seldom disabling, and their treatment is relatively straightforward.
We have written this book because we know that healing and
happiness are possible, and people can lead more rewarding, satisfying, and
pleasurable lives by taking advantage of everything we know about anxiety
and depression. By opening this book you have already taken the immensely
important step of seeking help and information. We wish you courage,
patience, and tenacity as you apply what you learn here to your own life and
loved ones.

Copyright © 2004 by Dennis S. Charney and Charles B. Nemeroff. Reprinted
by permission of Houghton Mifflin Company.