treatment

Having a close friend or two to talk to---someone on whom you can depend for emotional support---can be great when little things accumulate or you temporarily feel down in the dumps. But can a friend talk you out of depression or lessen its pernicious effects? A study recently published in the British Journal of Psychiatry examined the viability of "befriending" as a tool in the treatment of emotional distress and depressive symptoms. The findings suggest that friendships, even therapeutic ones, aren't necessarily substitutes for good treatment.

Keep in mind the researchers weren't talking either about the garden variety of befriending (a term that has become common parlance among Facebook or Twitter users) or about a mild case of the blues. For the purposes of their study, the team of primary care researchers at the University of Manchester, Manchester, UK defined "befriending" as social support that was "initiated, supported and monitored by an agency" expressly for one or more parties to benefit. It was, by definition, a treatment for depression or emotional distress that was "non-judgmental, mutual and purposeful."

The meta-analysis (a systematic statistical analysis) looked at more than 24 studies that covered a wide range of depressed populations, including caregivers of individuals with dementia, adolescents, lonely widows, men with prostate cancer, and pregnant women. The frequency of befriending varied among the studies as well as the ways in which the befriending took place. Some contacts were made face-to-face, others were by telephone, and some were a combination of both. Befriending was delivered both by trained and untrained volunteers.

The researchers found that the befriending intervention was less effective than cognitive behavioral therapy (CBT) in adolescents with depression and in medication-resistant individuals with schizophrenia. It was also less effective than nurse cognitive-behavioral problem solving in caregivers of people with dementia. It was similar in effectiveness to a nurse education and self-efficacy intervention in older adults recovering from myocardial infarction, to local community support groups for new inner-city mothers, and to systemic family therapy in depressed adolescents.

Based on their data, the researchers were unable to conclude that "befriending" is an effective, evidence-based treatment. Instead, they suggested that more rigorous study was needed to compare "befriending" head-to-head with standard treatments (such as CBT and medication), and that individual preferences should be considered in determining what works, for whom, and under what circumstances. This study relied on meta-analytic techniques to look at the friendship question but it would be worthwhile for researchers to design more large studies that look closely at whether and how friendships can alter the course and outcomes of various types of depression.

The conventional wisdom is that the presence of social supports can serve as a buffer against depression. Sounds logical enough: Friendships offer an outlet for people to express their emotions, to put things into perspective, to feel less alone, to reduce stress, and to encourage someone who's feeling distressed to seek out professional help when needed. But people with severe depression often have a hard time reaching out to anyone and it is often equally difficult for friends, even very good ones, to know what to do to help them recover. There's a lot more to learn.

Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis

Nicola Mead, PhD, Helen Lester, MB, ChB, MD, FRCGP, Carolyn Chew-Graham, MB, ChB, MD, FRCGP and Linda Gask, PhD, FRCPsych, NIHR School for Primary Care Research, University of Manchester
Peter Bower, PhD, National Primary Care Research and Development Centre, University of Manchester, Manchester, UK

The British Journal of Psychiatry (2010) 196: 96-101. doi: 10.1192/bjp.bp.109.064089

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How to Help a Friend or Relative Who is Depressed (From the NIMH)

If you know someone who is depressed, it affects you too. The first and most important thing you can do to help a friend or relative who has depression is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with him or her to see the doctor. Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

To help a friend or relative:

• Offer emotional support, understanding, patience and encouragement.
• Engage your friend or relative in conversation, and listen carefully.
• Never disparage feelings your friend or relative expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend's or relative's therapist or doctor.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if he or she declines, but don't push him or her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind your friend or relative that with time and treatment, the depression will lift.

Facts about Major Depression

According to the National Institute of Mental Health (NIMH), major depression is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. An episode may occur only once in a person's lifetime, but more often, it recurs throughout a person's life. , It is estimated to affect 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.

QUESTION

Dear Irene,

I've gone through multiple friend break-ups and it seems to be a recurring theme for me. I never want these friendships to end but they always fall apart because I ask too much of them.

I always have a feeling of insecurity with friends to the point where I need so much reassurance that the friend becomes exhausted. I think this tendency may spring from my ongoing depression---but how can I overcome this extreme friendship anxiety?

And how can I go about repairing friendships that have been weakened or cut off because of this? Too frequently I've had friendships that have started well, escalated towards very intense then petered out for the reason above. I don't want this to happen anymore, what can I do?

Signed,
Anonymous

ANSWER

Dear Anonymous,

If you feel depressed and it is complicating your friendships, you need to get to the root cause of your problem: depression. When someone is depressed, it can take a lot of energy to focus on other people.

The good news: You seem to have a knack for making friends and you've recognized that you eventually ask too much of them. Try to keep this in mind and see your friends in small doses so it isn't overwhelming for them or for you. At the same time, speak to a mental health professional (perhaps, you're already seeing one) and ask for help. Depression is a treatable illness.

Thanks so much for posting and I hope this was helpful.

Best,
Irene

QUESTION

Dear Irene,

My friend started on anti-depressants about 6 months ago, and has been drinking a lot lately. Drinking while on medication is usually not a good idea. It's gotten to the point where she goes out every weekend, gets so drunk she pukes, and makes a total fool of herself. She 'blacks out' and forgets nearly half the night. She'll be all over guys, some of them complete strangers, spilling her drink, and losing her phone, too. It used to be fun going out with her, but now she gets drunk so early in the night that I feel like I have to babysit her.

A few weeks ago, she got into a car with some guys that we knew. She wanted me to go with them but I declined. I had work the next day, and had a feeling that I wasn't going to get to where I needed to be by noon. I insisted that she come with me, but she didn't want to get out of their car.

The next day, I found out from her roommate that my friend had said something wrong to the driver of the car, and he kicked her out, 3 miles from her house, at 3AM, in the country. She lost her phone, and had to walk to find a phone to call a friend.

I felt badly for her, but I thought it served her right for being so ridiculous. I thought that it would get her to tone it down, but she's just getting worse. This weekend, she puked in the street. It really makes me upset, because she's such a strong independent woman. I've never seen her act like this before. It's like she's trying to destroy herself, and I don't want to see my best friend get arrested, raped, or worse.

I just don't know what to do in this situation. I've told her to stop, but she won't. I've talked to another one of our close friends, who has known her longer than I have, and she doesn't know what to do either. We tried getting her to do other things, but she just isn't interested. Her roommate started being rude to her just so she would leave. She was tired of my friend coming home at 4am all the time, and waking her up.

Is there something I could tell her? Or should I just leave it alone, and wait for her to wise up on her own?

Signed,
Kayla

ANSWER

Kayla,

You are right to be concerned about your friend’s well-being. It sounds like she is engaging in a number of very risky behaviors.

It’s always a problem when someone needs but doesn’t want help. At this point, it sounds like your friend’s behavior is out of her control and she should be diagnosed and treated by a professional. A few thoughts:

•    Can you talk to her when she’s sober and see if she is willing to call or go back to the person who prescribed her anti-depressants?

•    Can you contact one of her family members and let them know what’s going on?

•    Can you provide her with contact information for Alcoholics Anonymous in your area and see if she is willing to attend a meeting?

If none of these are possible, you may want to assemble her friends as a group to let her know how concerned you all are. You didn’t mention whether she is able to work and has a source of income.

She is fortunate to have a friend like you. Encourage her to talk to you and gain her trust. Continue to express your concerns for her well-being and maybe you’ll be able to catch her at a moment when she’ll respond. Of course, if she seems to be in danger or she is homeless, you should consider calling 911.

My best,

Irene

In a recent article in the UK Telegraph entitled, Could friendships be ruining your life? journalist Tim Shipman reports that the American self-help industry is booming as we are becoming increasingly aware of toxic friendships. He points to the pervasive use of the term in our culture---noting the growing number of popular books and TV shows on the topic (As further evidence, he adds that the subject has even been covered on Oprah Winfrey).

“The realization that friends can be the cause of unhappiness is fueling a rapid rise in the number of people consulting therapists,” writes Shipman. He reports that 10,000 psychologists and counselors are providing sessions focused on friendships. Whether or not the number is correct (and I’m not sure whether it is high or low) it raises the question of whether and when a history of fractured friendships should drive a woman into therapy.

How can you avoid the couch?

WHEN YOU ARE HANGING ON TO A TOXIC FRIENDSHIP

To extricate yourself from an unhealthy friendship, you need to overcome the guilt of leaving. Whatever the reason, if you are feeling uncomfortable in a relationship, you have the right and responsibility to put yourself first. Remember that good friendships are good for your health and happiness, but toxic ones are exactly that: toxic.

WHEN YOU ARE JILTED

All breakups are painful but particularly when they are one-sided. When that happens, it’s easy to feel rejected and take it very personally. Yet even these heal with the tincture of time. If your pain persists, talk out the problem with a sibling or spouse, or other uninvolved friend who can help you gain perspective.

WHEN A FRIENDSHIP FALLS APART

Just because you have a rift or a friendship drifts apart, it isn’t necessarily a sign of pathology. Friendships, even strong ones, come and go. If you can get over the “myth of best friends forever,” these breakups will be less painful when they occur.

When should you consider the couch?

Look for patterns. If you find that you REPEATEDLY make bad choices in friends---particularly those who are abusive, untrustworthy, and belittling---you may benefit from talking to a mental health professional. Also, if you find yourself jilted over and over and have no insight into why it is happening, you might benefit from therapy or counseling. Most professionals would agree that therapy is indicated when an individual’s thoughts, feelings or behaviors interfere with their ability to successfully carry out their roles---as friends, students, parents, partners, workers, or so forth..

The large majority of friendships tend to be dynamic, changing as individuals and their life circumstances change. While there shouldn’t be stigma or guilt associated with a broken friendship, there also shouldn’t be any stigma associated with seeking professional help when needed.