How JustAnswer Works:
  • Ask an Expert
    Experts are full of valuable knowledge and are ready to help with any question. Credentials confirmed by a Fortune 500 verification firm.
  • Get a Professional Answer
    Via email, text message, or notification as you wait on our site. Ask follow up questions if you need to.
  • 100% Satisfaction Guarantee
    Rate the answer you receive.
Ask Dr. Mark Your Own Question
Dr. Mark
Dr. Mark, Psychotherapist
Category: Mental Health
Satisfied Customers: 5334
Experience:  Dr. Mark is a PhD in psychology in private practice
Type Your Mental Health Question Here...
Dr. Mark is online now
A new question is answered every 9 seconds

For dr. ; I have tried the behavioral route for over 20

Customer Question

for dr. mark;
I have tried the behavioral route for over 20 years. I do not get good results, although I have funded quite a few docs in the process. I will take your advice and contact my doc regarding what I have done in terms of combining the meds. I have found several individuals online in forums that have been on this cocktail, and dosage, and have had no problems. I suppose it is entirely individual. the reason I stopped cymbalta was my concern regarding the length of time i had been on it, and its effectivenes. It is so very hard to know if the meds are doing what they are supposed to...
Submitted: 5 years ago.
Category: Mental Health
Expert:  Dr. Mark replied 5 years ago.
You know, our brains are so complex (just try to get anyone to explain accurately the relationship of brain to mind, for example!) that psychotropic medications are like primitive weapons at this point. It's not like blood pressure medicine: your numbers are higher than an established standard, you take Exforge or some other med. If the numbers don't conform, you up the dosage. Side effects? Try Azor. That's it. You are just monitoring a set of numbers and some side effects.

But antidepressants are required to do so much more. And then all of a sudden, they stop working as they did before. And we don't know why. We hypothesize it's hormonal changes in both men and women as we age, but that doesn't fully explain it by any means. And upping dosages does unexpected things. And combining them does unexpected things. Because in the end: we're all individuals and somehow unique.

That's why I'm so concerned about you doing this on your own: you will maybe get good results and maybe not. But you will certainly alienate your doc if you do this without his/her advice and consent. That counts for a lot in my book because starting over with doctors is just that, starting over. It's like in therapy. So make sure he/she is on board with this. I'm not a big fan of Wellbutrin because of my personal experiences with the people in my practice. Some have a whole different set of experiences. See how it works?

So, that's on meds. I am a big believer in combining meds with therapy. The studies are all conclusive about the better results. They are mostly about CBT therapy. I don't know what type of therapy you've had. From what you've written, I would say probably some of lots of different kinds. It's even more personal than meds. But if you've tried a lot of different therapies and want to keep trying even though it might mean enriching another psychologist, I'd now go toward psychodynamic therapy. That's therapy based on gaining insight from your childhood and youth as the forces shaping your emotions as an adult. You clearly need someone who's smart, street smart, and sensitive. So make sure to interview the therapist first to make sure that he/she meets your needs. More on that later.

You would come up with a coherent program that includes medications and therapy treatment. The five components of a total care program are: medications, possibly herbal remedies, diet, exercise, and psychotherapy. I also want you to know that at the end of the posting I'll paste in for you a technique you can use to help when you are in that dark hole of depression and anxiety. When you are feeling depressed and in a dark hole, this is something you can use to help with some relief and you can use it over and over.

Herbal remedies: St. John's Wort is the only herbal remedy that has any clinical evidence supporting its effectiveness for depression. Other "products" claim to, but in the psychological literature, this is the only remedy accepted as having significant evidence. IMPORTANT: do not take St. John's Wort with any antidepressants. You're on antidepressants which rules out St. John's Wort. So if you want to try this option, discuss it with your doctor as an alternative ONLY, not as an addition, to the Wellbutrin and/or Cymbalta. But this is important. Any other herbal remedies are going to be a matter of whether you want to try it for the cost. Remember: no "natural" remedy is going to have the quick and powerful effect you will see from the medications--but not the side effects or withdrawal effects either.

For anxiety, I'm going to make two herbal recommendations. This is because I know there is SOME research evidence for these two herbs. However, it is not that conclusive or even impressive. But it is some and they have the following going for them: in the cultures they come from, they are traditionally used for anxiety. That's encouraging. The first is Black Cohosh, the root of which was used by Indians in our country. The second is Kava, sometimes called Kava Kava, which is from the Pacific Islands. Again, these herbal recommendations are secondary to the medication treatment unless medications show they are not working.

Diet: cut out coffee, sugar, white flour. That may be tough. But you will see results as some of the newer research shows. And lean meats only. No fast food restaurants, no fatty foods.

Vitamins can be useful for moods. A good quality daily vitamin, for example. One of the most important supplements is Omega 3 fatty acids, either in fish oil or capsules or in flax seed oil. Buy good quality. The clinical dosage is 2-3,000 mg daily. Omega 3 is the main supplement. The research on it and depression is conclusive. All these things you should get at the biggest and most frequented health food store and ask them for the best brands they trust in terms of quality. Omegas are the best "natural" thing to add to your diet.

Exercise: 5 days a week moderate exercise, to include 3 days of strength training as you get more used to it. Your doctor will verify the research results showing the benefit.

Psychotherapy: this requires to have you reorient your thinking about depression and meds and remedies. Medications and remedies only treat the symptoms of depression and that it is important to treat your depression as a HUMAN symptom.

As I said above this would need you to reorient your view of what's happening to you so that your emotions, which ARE after all, what is being talked about here with depression are treated with human respect and value and given a chance to help you grow and gain as a human being. This would mean changing your focus from the medications being your main "work" on your depression to exploring your emotional reactions of being in such a depressed dark place as being your MAIN work and the meds and remedies as being the boost to help not be so anxious and in a dark hole so that you CAN work on what's going on inside. Do you see this reorientation? We have emotions because they are part of how we grow and learn and become more fulfilled.

Here is the web address for Psychology Today's therapist directory. You can sort by zip codes and when you see someone who seems like they might be helpful (they show you a photo of the therapist!) look at the listing and see if they list psychodynamic therapy in their orientations and depression and anxiety disorders as one of the areas they work with.

The idea here isn't that these types of therapy are magic. It's that you want to find a therapist who will form a strong therapeutic alliance with you and will help you look at the sources of your emotions. So interview the person first to make sure you feel confident and comfortable.

I wish you the very best!

Now for the technique: here are instructions on a therapeutic protocol called Progressive Muscle Relaxation (PMR). It's really quite easy to do almost anywhere. My patients, when I teach them PMR at first are amazed how simple it is and that it is a psychological protocol. It was first used in the 1920s! Since then, of course, it has been refined and many studies have been done showing its effectiveness. I want you to practice the PMR at least 5-6 times before an attack or feeling acute anxiety. Why? Because when you're in the throes of anxiety, you will only remember to do something you are very familiar with it. So practicing 5-6 times is really a minimum.

I want to stress the importance of breathing as well. Part of the physiology of what is happening to you when the anxiety of depression is present is that your breathing is getting shallower. This reduces the oxygen in your blood to your brain. That increases the anxiety and depression, which strengthens the emotion and you are in a vicious cycle! Not good. So breathing is the primary tool. I have found in my practice that learning breathing techniques can be helpful. But some of my patients are not interested in learning more than one thing at the beginning, so I have found that just reminding you to BREATHE deeply at the same time you are doing PMR is almost as good. If you are willing to take a yoga class and learn breathing techniques, that's the best. But, breathing deeply with your PMR will help.

So, we're ready for learning PMR. I want you to print my instructions below my signature and have a copy in each of the rooms of your home where you may be when you have an attack. And again, you need to practice this easy technique at least 5-6 times as soon as you can. It needs to become as natural to you as breathing. Ah, remember breathing?


  1. After finding a quiet place and several free minutes to practice progressive muscle relaxation, sit or lie down and make yourself comfortable.
  2. Begin by tensing all the muscles in your face. Make a tight grimace, close your eyes as tightly as possible, clench your teeth, even move your ears up if you can. Hold this for the count of eight as you inhale.
  3. Now exhale and relax completely. Let your face go completely lax, as though you were sleeping. Feel the tension seep from your facial muscles, and enjoy the feeling.
  4. Next, completely tense your neck and shoulders, again inhaling and counting to eight. Then exhale and relax.
  5. Continue down your body, repeating the procedure with the following muscle groups:
    • chest
    • abdomen
    • entire right arm
    • right forearm and hand (making a fist)
    • right hand
    • entire left arm
    • left forearm and hand (again, making a fist)
    • left hand
    • buttocks
    • entire right leg
    • lower right leg and foot
    • right foot
    • entire left leg
    • lower left leg and foot
    • left foot
  6. for the shortened version, which includes just four main muscle groups:
    • face
    • neck, shoulders and arms
    • abdomen and chest
    • buttocks, legs and feet

Quickly focusing on each group one after the other, with practice you can relax your body like ‘liquid relaxation’ poured on your head and it flowed down and completely covered you. You can use progressive muscle relaxation to quickly de-stress any time.

What You Need:

  • A comfortable place.
  • Some privacy.
  • A few minutes.


Dr. Mark and other Mental Health Specialists are ready to help you
Customer: replied 5 years ago.
Thank you so much. You are a kind thoughtful professional.
Expert:  Dr. Mark replied 5 years ago.
You are so welcome. And all the best to you, Dr. Mark