I am a 55-year-old woman. I was diagnosed with major clinical depression in March 1997 after a suicide attempt. I am currently on Effexor and under the care of a psychiatrist. I have made many strides, but I still don't feel satisfied with my progress. I still have a lot of anxiety and angry outbursts. Many times the anger and anxiety are there with no stimulus and seem to be cyclical. It is very frustrating to feel better for a few days or weeks and then be hit with a down spell. Any advice would be appreciated.

ù Margaret

The first thing I recommend is for you to tell your psychiatrist of this cyclical pattern, if you haven't already. He or she may want to adjust your medication, or even add mood-stabilizing medication if that seems appropriate.

The second -- and perhaps most important -- thing I recommend is that you see a psychologist or other licensed mental health professional for psychotherapy. You don't mention psychotherapy in your treatment by the psychiatrist, and that's common today. Most psychiatrists today are trained primarily in medical and biological interventions rather than in psychological treatments such as psychotherapy.

One thing I wonder is if you have yet to resolve all of the problems that led you to attempt suicide. What contributed to, caused or exacerbated the pain and despair that fueled your suicide attempt?
As a psychologist, I take a holistic view of depression (as well as other conditions), seeing it as caused by a combination of psychological, biological/chemical, behavioral, environmental and even spiritual or existential factors. The way in which these factors interact and manifest will depend on each individual's personal makeup and circumstances. Even a biological predisposition to depression must be triggered or "set off" by some events or circumstances and can be alleviated by psychological and behavioral interventions.

So even if your anxiety and your angry outbursts have strong biological roots, psychotherapy can help. I'd give it a try.