What is… Self-esteem

psychology word graphic in the shape of a brain

In this series, I dig a little deeper into the meaning of psychological terms.

This week’s term: self-esteem

Wikipedia defines self-esteem as “reflects an individual’s overall subjective emotional evaluation of his or her own worth”.  It reflects a person’s beliefs about the self and emotional states.  Self-esteem is seen as a predictor of outcomes such as academic achievement, happiness, and interpersonal relationships.  While there may be short-term variations, self-esteem is thought to be an enduring trait.  Self-esteem is heavily influenced by life experience, particularly childhood experiences.

People with high self-esteem firmly stick to their values/principles, trust their own judgment and problem-solving abilities, and are sensitive to the needs and feelings of others.  People with low self-esteem tend to be self-critical and hypersensitive to criticism from others, are indecisive and fear making mistakes, tend to be perfectionistic, tend to feel guilty, and have a negative general outlook.

The last time I was in hospital, one of my doctors was a quacky psychoanalytic type.  He was telling me I needed to do this psychodynamic therapy-based group after discharge, and the part of the group he thought I needed most was the module on improving self-esteem.  I told him that when I’m well my self-esteem is actually quite good, and he condescendingly explained that no, it was not, because if I had good self-esteem I wouldn’t have attempted suicide.  I would’ve slapped him upside the head except that’s generally not the best approach with someone who has the final say in your discharge.

It’s true, though.  When I’m well I have good self-esteem.  I know myself well, am comfortable in my own skin, know what I’m good at and not good at, and I’m fiercely independent, which makes it easier not to spend much time worrying about what other people think of me.  I suspect a lot of that comes from a very well-adjusted childhood.  Affection was never lacking.  School was easy for me and I did well at it, and this was very positively reinforced by my parents.  By the time high school rolled around I felt pretty far removed from the world of the “in crowd”, but I was comfortable in my little niche.  From a young age I wanted to do things my own way, whatever that might be, and again, this was something that was encouraged by my parents.

Being stuck in a prolonged depressive episode, my self-esteem has suffered.  I don’t know this depressed self as well because she’s an unpredictable, fluctuating self.  The things I used to know I was good at are now so much harder and are not predictably reliable.  Some of the things that used to make me me feel hidden away somewhere.  I’m not always self-critical, but I’ve become ultra-sensitive to criticism from others.  Strangely, though, while I’m sensitive to the criticism that is wielded outwardly as a weapon, I don’t care that much about what people might think about me.  As long as it stays inside their heads, I don’t place a lot of value on what others think, in large part because in general I hate people (thanks to the depression).  It doesn’t make a lot of sense, but that’s the best explanation I can come up with.

Has your self-esteem been influenced by your illness?

 

Source: https://en.wikipedia.org/wiki/Self-esteem

Image credit: GDJ on Pixabay

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What the STAR*D study means for depression treatment

brain shining like a star

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial studied 2876 people with major depressive disorder to evaluate their response to depression treatment in a real-world setting.  Unlike the randomized controlled trials that are often used to evaluate a drug’s efficacy, there were few exclusion criteria, the patient and their physician knew which drug they were taking, and patient choice was incorporated.  Four sequential levels of treatment were established, and if a patient failed to achieve remission after 12-14 weeks, they would be moved to the next level.  The target was full remission, unlike many other studies which measure response (i.e. a ≥50% reduction in symptom rating scale scores).  Remission rates can be substantially lower than response rates, but are useful because there are better long-term outcomes for people who do achieve full remission.

Level 1 treatment consisted of citalopram, and 28% of patients achieved remission based on the Hamilton Rating Scale for Depression (HAM-D).  Certain factors were identified, such as other comorbid mental illnesses, that were associated with lower or higher remission rates.

In level 2, patients were offered cognitive psychotherapy, a switch to another antidepressant (randomly selected), or the addition of another medication to augment the treatment.  Among level 2 patients who switched to another medication, remission rates were 21.3% for bupropion, 17.6% for sertraline, 24.8% for venlafaxine.  Rates were similar among those patients who switched to cognitive psychotherapy.  Among the patients who received augmentation treatment, the remission rates were approximately 30% for both bupropion and buspirone.  Augmentation with medication produced more rapid remission than augmentation with cognitive psychotherapy.

In level 3, patients who switched medication were randomly assigned to mirtazapine or nortriptyline, and patients who received an medication for augmentation were randomly assigned to lithium or the T3 form of thyroid hormone (liothyronine).  Remission rates were 12.3% for mirtazapine, 19.8% for nortriptyline, 15.9% for lithium, and 24.7% for thyroid hormone.

In level 4, patients were randomly assigned to switch to either tranylcypromine (an MAOI antidepressant) or venlafaxine plus mirtazapine.  Remission rates were 6.9% for tranylcypromine and 13.7% for venlafaxine plus mirtazapine.

Altogether, 67% of patients were able to achieve remission.  The study found that people may still remit by 12 weeks even if there’s only a modest symptom reduction at 6 weeks.  However, the more treatment steps that are required, the lower the chance of a patient achieving remission and the higher the chance of intolerable side effects and relapse.

Personally I found the take-home message from this study rather discouraging.  During my last hospitalization I argued that my suicide attempt was supported by the STAR*D’s not so subtle hint that I was shit outta luck.  I think it’s crucial that we find new kinds of treatment that will help that 33% of people who just aren’t achieving remission with many currently available antidepressant medications.  This study doesn’t consider all potential treatments; for example, atypical antipsychotics, ketamine, and ECT aren’ included, and psychotherapy plays a limited part.  Still, we deserve better.  A lot better.

 

For more info on the research terminology I’ve used in this post, see my post on research literacy.

Image credit: geralt on Pixabay

Suicide and barriers to help-seeking

brick castle walls

There’s lots of information out there about crisis resources for people thinking about suicide, but resources accomplish very little if we don’t reach out to access them.  There are many reasons people don’t seek help, and I wanted to talk about a few of them here based on my own experience with major depressive disorder and suicide attempts.

Fear of being a burden

No matter how much anyone might say “you’re not a burden”, I wouldn’t believe them.  The suicidal thoughts were such a heavy burden for me to carry, so why would I want to place some of that burden on anyone else?  And it doesn’t feel like it is with pack animals where I can shift my rocks to someone else’s donkey and make it lighter for my donkey.  It feels more like extra rocks would be getting dumped on both donkeys, so I’ve got extra weight weight that I have to carry as well.

Fear of others’ responses

There’s a lot of stigma out there in the world, about mental illness in general and suicide in particular.  When the word “selfish” gets tossed around in relation to suicide, that’s certainly not going to make it more likely that people will speak up.  Being judged is the last thing someone needs when they’re feeling desperate.

For those of us who have been open with others about our illness, even if we’re not necessarily worried about stigma there’s still uncertainty about how others might respond.  People say well-meaning but just plain stupid things about depression all the time, so what kind of supportive idiocy is likely to come out of their mouths when faced with the topic of suicide?  That I should be grateful for what I have, even though none of it matters?  Or maybe something along the lines of oh, you should go out for a walk in nature?  #SickNotWeak #FuckTheWalk

Hopelessness

My illness makes me feel like there is no hope for the future, and it’s when that hopelessness gets particularly intense that I want to end my life.  I’m not thinking oh, if only I could get help things would be so much better.  At that point, I have given up and don’t want anyone trying and failing to help and in the end just making things more difficult.

Over the entire course of my illness it has proven to be very hard to treat.  In the past I was able to achieve full remission eventually, but now it seems like that may be a thing of the past.  Because of my professional background I know what my options are, and I know there aren’t a lot of them, which tends to really reinforce those feelings of hopelessness.

Worthlessness

When mental illness steals away your whole sense of worth as a human being, it can start to feel like people would barely notice, much less care, if you weren’t around any more.

Crisis lines/services

The only time I’ve ever used a crisis line myself was in the first few weeks after my first hospitalization.  I had discharged myself against medical advice after they decided not to renew my involuntary committal.  I’d been in hospital for 2 months, and out I went, with no discharge plan in place.  I was cutting as a strategy to cope with suicidal thoughts, and mostly when I called the crisis line I talked about the cutting rather than what was underlying it.  I guess it was nice to have someone to talk to, but I remember feeling like their responses were kind of formulaic, as if they’d been told these are the things you should say in these situations.

A lot of crisis lines have volunteers providing support.  I’m sure they’re great, they care, they want to listen, but they don’t have the level of expertise of mental health professionals.  Part of that is that they don’t have training in assessing mental status, which makes me inclined to think they have a lower threshold of concern to call the police.  I may be overestimating the risk of this, but if I’m thinking about ending my life the last thing I want is the police banging on my door.

In some ways it works against me that I’m a mental health professional, because it means I know a lot of people working in local emergency and non-emergency mental health services.  I have no desire to call the emergency mental health service or go into the hospital emergency department and have to deal with some asshole that I’ve worked with before and know is useless at their job.

Fear of hospitalization

This is the single biggest reason I keep my mouth shut when I’m thinking about suicide.  I’ve been hospitalized four times, and these experiences were extremely difficult.  When I’m at my lowest, given the choice between death and hospitalization, realistically death is going to win out.  This reflects fundamental flaws in a system that disempowers and traumatizes patients, but there’s also a sense of personal failure that I connect with hospitalization.  This isn’t a judgment I pass on others, but probably part of why I apply it to myself is that three out of four of my hospitalizations were involuntary, so it’s kind of a failure to maintain the ability to make choices for myself.  This fear of hospitalization is deeply ingrained in me, and over the years it has made me tell lies and keep secrets.  I realize that this is something that puts me at risk, but I don’t see that just spontaneously changing.

 

I know that reaching out for help dealing with thoughts of suicide is the right thing to do, and it’s certainly what I would urge to anyone reading.  But realistically it’s just not alwawys that simple, and I think it deserves some thought when we’re not in the midst of our deepest lows.

What has been your experience of accessing help in crisis?

Click here for info on crisis support resources.

 

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Crisis resources for suicide prevention

cartoon face shushing surrounded by the word suicide

Sadly, we hear all too often of people who have lost their lives to suicide.  Many among us in the mental health blogging community have either attempted suicide or had thoughts of doing so.  There are resources available to support us; it’s just a matter of knowing what they are and being willing to reach out (I must admit that’s something I’ve been reluctant to do in the past, and I’ll talk more about this in tomorrow’s post).  Here are some of the many resources that are out there.

International:

  • The International Association for Suicide Prevention has listings of crisis centres organized by continent and other resources worldwide.
  • Unsuicide has listings of IM, chat, and text services in Australia, Canada, the USA, and the UK
  • Wikipedia has a list of suicide crisis lines for 48 different countries
  • Suicide.org has a list of local crisis lines for multiple different countries

 

Australia

 

Canada

 

India

 

UK:

  • Samaritans crisis line 116 123
  • CALM webchat for men
  • Papyrus HopeLineUK for adults under 35, call 0800 068 41 41 or text 07786209697

 

USA:

 

Safety planning apps

 

 

 

Image credit: geralt on Pixabay

My relationship with death

mourning candle

Content warning: This post talks about suicide, but not in the present tense.


I’ve always thought my reaction to death was a bit weird, in that I’ve never had a strong reaction to death.  Part of it is that I view death less as a loss and more as a natural transition, and part of it is probably how I think about people who are aren’t physically present.  I’ve always tended to have an out of sight out of mind sort of view of people I don’t have regular physical contact with.  This has popped up in various ways, and is probably a big part of why I’ve never been good at maintaining long-distance friendships.  In a way death feels like the same thing taken to an extreme, a twisted form of object impermanence.

My dispassionate view of death has become even more firmly entrenched since my first episode of depression.  Sometimes when my depression has really bad I’ve had thoughts of suicide.  I’ve attempted suicide four times outside of hospital plus several times in hospital.  It seems unrealistic to me that I would live until a natural death (which, given my genes, probably would happen until well over 90).  I just can’t imagine living another 50+ years, and I’m ok with the idea that my life might end prematurely due to suicide.  It’s not necessarily an outcome I actively desire, but it seems the most likely.  While I do reach out for help with my depression, I don’t disclose to health care providers when I have active thoughts of suicide.  It’s not an issue right now, but most likely it will come into play at some nebulous point in the future.

As my depressive illness has progressed, the future seems very indistinct.  I have a hard time imagining what my life might be like at 50, 60, or beyond.  I’ve got no partner, no kids, a small family, and only one friend.  Life is something I just keep doing out of momentum, not because there’s anything to look forward to.  I sort of feel like that should disturb me, but I’m pretty indifferent.

My grandma, who I’ve always been very close to, is 101 years old, so clearly she doesn’t have long to live.  And I wonder sometimes how I’ll react when she dies.  Will I grieve?  Or will I just shrug and move on, all the while hating myself for feeling that way?  I don’t know, but I’m inclined to think the latter.

Death and I have a weird relationship.  Please don’t worry about me; I’m fine, this is just something I think about sometimes.

What is your relationship with death like?

 

Image credit: geralt on Pixabay

My mental illness is a member of the family

family of elephants

It’s easy for me to focus on how my mental illness has affected me, but it has also profoundly affected my family, and that’s something that perhaps I should give a bit more thought to.

When I first became ill in 2007, I didn’t say anything to my parents or brother, although my mom thought something seemed off.  I’m told that I called my parents after I’d been in hospital several days since my 2nd suicide attempt, but I told them that I didn’t want them to come to visit me.  My mom ended up taking a couple months off work and stayed in my condo while I was in hospital (they live 4 hours away).  She didn’t approve when I became romantically involved with another patient, and as a result I stopped talking to my parents for several months.

When I got sick again in 2011 I realized that I needed to go into hospital, but I wanted to do it in the city where my parents live rather than the city where I live and work as a nurse.  Apparently my dad drove down and picked me up, and then took me to the hospital, where I would spend the next 2 months.  My parents really noticed the memory loss I had from the ECT, as I would ask them the same questions over and over.

The next summer I completely fell apart just before leaving on a trip to Russia.  I called my parents from my hostel in Moscow sobbing uncontrollably.  I can only imagine what that must have felt like for them.  Several months later I decided to return to hospital in the city where my parents lived.  I was really unhappy with how I was treated during that hospitalization and fought the treatment team every step of the way.  I was discharged still very unwell, and my parents were extremely concerned.

A couple of months later I attempted suicide and ended up back in hospital.  I called my brother to let him know.  He came over to my place to take care of my guinea pigs, and while he was here he cleaned up the mess I’d made when I urinated on the floor.  When he came to visit me in hospital, I asked him to get rid of my suicide note so our parents wouldn’t see it (I didn’t realize at that point that the police had already taken it).  That was the only time I’ve ever seen him cry.

When I got sick in 2016, I broke off all contact with my family for over a year, thinking that they would judge me and I couldn’t deal with that.  I resumed contact last fall, but it’s been tough.  I still don’t feel comfortable sharing much with them.  My parents are judgmental; not in a malicious way, but more that they think things should be done in a particular way and doing them differently is just plain wrong.  It’s how they are and how they’ve always been, but what I used to roll my eyes over and joke about with my brother and grandma is now something I’m very wary of.  I also find that with my family I have a very hard time putting on the superficial act of normalcy that I would use with strangers.  So I have nothing superficial and casual to say, and I don’t feel comfortable sharing anything deeper about myself, which makes for pretty scanty conversation.

I don’t think my grandma every really did understand much about my illness, but now she has started dementing and doesn’t even remember that I have a mental illness.  She occasionally makes stigmatizing jokes about crazy people, and I know I need to just let that go.

This mental illness journey is never one we truly walk alone, no matter how alone it may make us feel.  It’s the kind of illness that leaves its mark not only on us but on those that love us, and I almost feel like I owe my family an apology, even though the depression isn’t my fault.  I feel very far away from my family, and I don’t know when/how/if that’s going to change.  But right now the only way to bring about any kind of change is by continuing to work on myself.  The future will be what it is.

How has your family been affected by your own illness journey?

 

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Mental illness and the dreaded job interview

woman preparing for a job interview

Job interviews are unpleasant at the best of times, and to me have always felt very fake.  But throw mental illness into the mix, and they can be a huge obstacle.  There are a number of aspects of job interviews that particularly worry me.

Answering unexpected questions

My cognitive symptoms of depression aren’t as bad now as they have been, but my brain is still pretty slow to react to anything unexpected.  Even in low-pressure situations I may be asked a question and I just can’t generate an answer.  I may make light of it and brush it off as oh, brain fart, I lost my train of thought.  In a high-pressure interview, my mind would go blank, and that would make me anxious, which would further ensure that my mind would stay blank, and I would be left staring stupidly at the interviewer.

Having to identify positive examples

I can identify some positive things in my past and present, but put me on the spot and the only things that my mind can find are negatives.  Throw in that my memory is not that great, and I would be waiting/begging for the ground to open up and swallow me.

Having to sell myself

I’ve always thought it felt rather fake trying to convince interviewers that you’re amazing and wonderful and all that crap, because it always seems like there’s things you’re expected to say and not say.  It’s tough even when I believe that I actually am pretty wonderful.  Now?  Well, I know that I have my strengths, but the idea of trying to self myself to someone makes me want to barf.  I have to work hard at trying to shift focus to genuine positives, and trying to portray a prettily wrapped fake package of trite expected positives sounds pretty close to impossible.

Questions about interpersonal things like dealing with conflict

I hate people.  I like my fellow bloggers, and I like my patients, but otherwise I pretty much hate people in general these days.  That hasn’t always been the case, but the combination of depression and having experienced workplace bullying have pretty much soured me on humanity.  So there’s that.  Then there’s avoidance, the coping mechanism I’ve had to rely on far too often to extricate myself from situations I don’t have the resources available to cope with.  So when faced with the inevitable interview question about how I handle conflict, I can hardly say I run as far away as I can as fast as I can to hide out in my cave away from people, who, by the way, I hate.  Can’t talk about being bullied, either, because that’s not considered acceptable.  Obviously I would need to lie.  Depression makes me very good at lies like “I’m fine” or “I’m okay”, but makes me very bad at crafting (and remembering) more elaborate lies.

Having to answer questions about gaps in my resumé

I quit a job because I was bullied.  I was unemployed for 9 months due to lasting effects of the bullying.  One of my current jobs, the one in mental health, I think I’m going to leave off my resumé entirely.  So there’s holes, and in my experience interviewers tend to be nosy buggers, so they want those holes filled in or the application goes straight in the recycle bin.  Except neither bullying nor mental illness are “acceptable” excuses for resumé holes.  So what, more lies that I’d have to pull out of my ass that is getting sorer by the minute?

Managing anxiety

Interviews are anxiety-provoking for anyone.  Anxiety isn’t a huge part of my depression,  but not surprisingly it gets amplified in high-stress situations, and my brain runs in circles but doesn’t move forward.  So then it’s a matter of figuring out a pre-medicating strategy; enough Ativan and/or Seroquel to tone it down without turning me into a drooling zombie.

Managing triggers without either crying or completely shutting down

There was one interview I did while I was depressed, and I don’t remember if it was something the interviews said or the way they said it that triggered me, and I started crying.  I couldn’t stop, so I just got up and walked out.  Not surprisingly I never heard from them again.

 

Mental illness is hard enough without having to concoct BS stories to appease potential employers who are bursting at the seams with stigma.  Even employers who are more progressive are likely to have an easy time coming up with excuses not to hire someone who has a hard time explaining away the effects of their illness on their work history.

Has your illness impacted your search for work?

 

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Book review/rant: Lost Connections

Book cover: Lost Connections by Johann Hari

In Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions, Johann Hari takes a stand against the idea of biological causation of depression and anxiety.  I expected going in that this book would annoy me, but at times it was just plain ridiculousness.

To start off, let me tell you the perspective I’m coming from.  I support a biopsychosocial model that recognizes mental illness as complex and often multifactorial.  Every individual’s illness stems from a unique combination of factors, and for a treatment plan to work best it needs to effectively target whatever contributing factors can be identified.  Sometimes that’s meds, sometimes that’s psychotherapy, and more often than not it’s a combination of multiple different strategies.  Meds aren’t a miracle cure but can get you well enough to do whatever it is you need to do to find true wellness.  Ok, now that we’ve got that out of the way, let’s jump headfirst into the book.

Red flags were set off for me early on in the book when the author wrote that at age 18 he had an epiphany that he had the medical condition called depression, and from information in the media he knew that antidepressants were just what he needed to quickly make him all better.  Initially he was convinced paroxetine made him feel even better than simply not depressed, and he spread the word to others that depression was solely about serotonin and antidepressants were the best thing since sliced bread.  Years later, his therapist pointed out to him that it seemed like he was still depressed; the author responded that no, he couldn’t possibly be depressed because paroxetine was keeping his serotonin levels up; but then changed his mind and decided to stop meds.  “It was only when I stopped taking the [SSRI] and I started having more pleasurable sex again that I remembered regular sex is one of the best natural antidepressants in the world.”  I guess I’m just a little (or a lot) judgmental, but this dude seemed like he was energetically leaping onto the train to out-there-ville.

toy train

Next stop on that train is with researcher Irving Kirsch.  Kirsch criticized the typical design of drug trials, i.e. randomized placebo-controlled trials (you can find more about that in my post on research literacy).  He argued that to truly understand the effect of a drug there should be 3 arms to these kinds of studies: drug, placebo, and no-intervention, with the third arm capturing the number of people who get better with no treatment or placebo at all.  This sounds all well and good except that it gives you zero new information about what the drug does.  The people who would respond to no intervention are already captured in the placebo responders, so adding a do-nothing arm only gives you information about how much of the placebo effect is due to that sugar pill the researchers are giving the patients.  Now that information may be useful in examining the placebo effect, but it doesn’t in any way change what a study shows about the effect of drug response over placebo.

Next stop on the train is holding up the old serotonin deficiency hypothesis for depression as evidence that the illness doesn’t have a biological basis.  That hypothesis was originally developed to try to explain why drugs that blocked serotonin reuptake had an antidepressant effect, and at the time they didn’t have the scientific techniques available to test whether this was really accurate.  It has since become clear that depression is not related to a deficit in the absolute amount of serotonin, but that doesn’t mean we should throw the baby out with the bathwater.  Just because the overly simplistic early explanation was wrong doesn’t mean that neurotransmitters have nothing to do with depression period, and it doesn’t mean that antidepressants that affect neurotransmission won’t work.  It’s like saying that because the flat earth hypothesis was wrong there must be no earth at all.

The author talked about bereavement being mislabelled as depression.  A woman he interviewed said “So now if your baby dies and you go to the doctor the next day and you’re in extreme distress, you can be diagnosed immediately.”  People have the right to be ignorant, but that doesn’t mean their ignorant comments should be thrown into a book as evidence.  This idea that the DSM diagnostic criteria are a checklist and if you tick enough boxes you must be labelled with the disorder, well, it’s just not correct, which is why only highly trained clinicians are qualified to diagnose.  Admittedly, some clinicians are too quick to jump to a diagnosis, but that’s very much a separate problem.

In the DSM-IV, bereavement was listed as an exclusion criteria for diagnosing a major depressive episode; this was done in an attempt to avoid bereavement from being mistaken as depressiom.  The author raised concerns that maybe depression wasn’t so sound an entity if a normal experience mimicked the symptoms.  But then he does a 180 and questions the removal of that bereavement exclusion in the DSM-5 and the addition of only a “vague footnote”.  That “vague footnote” is actually part of diagnostic criterion C for a depressive episode, and says: “Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.”  So yeah, no day-after-death diagnosis.

toy train

The author announced that based on his information gathering (and no training whatsoever in psychiatry/psychology) he has identified 9 causes of depression.  He adds that depression is a form of grief over these various forms of disconnection.  The identified causes are:

  1. Disconnection from meaningful work
  2. Disconnection from other people
  3. Disconnection from meaningful values:  The author talked about “junk values”, and particularly materialism, as being problematic and something he had struggled with.  It was around this point that it really started to sound like the author was referring to depression and anxiety as negative emotional states and existential malaise and not necessarily appreciating the difference between these emotion states and mood/anxiety disorders.
  4. Disconnection from childhood trauma
  5. Disconnection from status and respect
  6. Disconnection from the natural world
  7. Disconnection from a hopeful or secure future
  8. The real role of genes and brain changes: The author saw 2 potential roles for biology: circumstances can cause brain changes that accelerate the problem, OR
  9. genetic variations may contribute to depression but only in specific environmental circumstances; they can’t cause depression without an environmental trigger

Part II of the book, “Reconnection: A new kind of antidepressant”, looks at ways in which people can reestablish those needed connections.  This starts off with what to me seemed to be a rather rambling story about an apartment block in Berlin slated for demolition.  An older woman had posted a note saying she was going to kill herself because she’d be losing her housing and she had no other options (there’s no indication that this was a woman with any history of mental illness).  This sparked community activism that positively impacted all of those involved.  And lo and behold, the woman’s suicidal thinking disappeared – so that’s what I must have been missing those times I tried to kill myself!  It made me think of a line from a medical historian interviewed in the documentary The Age of Anxiety: “If your problem can be corrected by a new boyfriend or a cheque for $5000, you probably don’t have a psychiatric disorder.”

The author came to the conclusion from this and other examples that “if you want to stop being depressed, don’t be you. Don’t be yourself.  Don’t fixate on how you’re worth it. It’s thinking about you, you, you that’s helped to make you feel so lousy. Don’t be you. Be us. Be we. Be part of the group. Make the group worth it…  So part of overcoming our depression and anxiety—the first step, and one of the most crucial—is coming together.”

The author says that “work is essential”, which made me wonder why he has his head up his privileged ass.  He talked to a woman who was anxious because of her negative work situation, then she joined with her husband and others in creating a cooperative bike repair business and things were hunky dory.  The author describes this “recipe for mental health” as “Elect Your Boss”.  So that’s what we’re all doing wrong…

toy train

Hari wrote that if he could speak to his younger self, he would say: “You are not suffering from a chemical imbalance in your brain. You are suffering from a social and spiritual imbalance in how we live. Much more than you’ve been told up to now, it’s not serotonin; it’s society. It’s not your brain; it’s your pain… Because you are being told depression and anxiety are misfirings of brain chemicals, you will stop looking for answers in your life and your psyche and your environment and how you might change them. You will become sealed off in a serotonin story.”  I suspect there may be some funky paint fumes going on up in that serotonin story.

If this had been a book about general dissatisfaction and unhappiness in society at large, I would be writing a very different review right now.  I suspect that Hillary Clinton and some of the other well known people who have commented positively on the book may have been looking at it from that perspective.  If the book had talked about some people having mental illness that is heavily influenced by social/environmental factors, or the need to take social/environmental factors into account in approaching the treatment for mental illness, then I would have far more positive things to say.  But that’s not the case.  He is saying that mental illness is not biologically caused and medication is not a valid treatment for depression.  Full stop.  I think that’s just as bad as the purely biomedical stance that he criticizes.  Such a reductionistic approach really isn’t useful to anybody, and is insulting to those of us living with the complexity of mental illness.

So what can I conclude personally from this book?  Apparently to get better I’m supposed to engage in local activism, participate in a community garden, start a co-op, hang out in nature, and get laid.  Forget meds, give me a little penis therapy instead.  Why would anyone be suicidal when they could bond over community activism?  Of the various disconnects that he believes cause depression, I had a whopping none of them for my first two depressive episodes.  Screw pain, I was generally happy and optimistic, and had no childhood trauma, a supportive social circle, a job I liked, a strong preference for the value of travelling the world rather than accumulating possessions, a home in an urban oasis right with a forest just steps away… and yet there I was, depressed, psychotic, suicidal.  Meds are certainly not the only tool in my toolbox, but without them, I probably wouldn’t be alive today.  So rather than go postal on the author’s ass for presuming to tell me what’s going on with my illness, I’ll just wave as he goes by on the train to out-there-villle.  Enjoy the ride!

 

You can find my other book reviews in my blog index.

Image credit: Amazon, OpenClipart-Vectors on Pixabay

Living in the present… or just avoidance?

hiding-cushions

This post is sort of a follow-up to my post yesterday on goal-setting, in which I talked about the difficulty I have in setting goals for the future.

The past includes good stuff in the more distant past and a lot of not so good stuff in the more recent past.  I used to be someone who was generally pretty optimistic about the future, but depression has robbed me of that.  It’s been two years since I was last in full remission, and I’m not sure if that’s something I’ll ever be able to get back to.  Maybe the future will hold good things and maybe it won’t, but there’s no positive that I anticipate with any sort of certainty.  It’s hard to set goals for the future when I’m not certain what I’ll be capable of, and it’s hard to set career goals when there are some major factors outside of my control that are keeping me stuck where I am now.

All this means I’ve been in a holding pattern of living in the present.  From a mindfulness perspective I suppose that’s a good thing, but what if I’m using it as an avoidance strategy?  Avoidance has become a very close friend of mine.  The past holds a lot of pain, but even if I try to focus further back to a more positive past, I’m reminded of how much I have lost.  Looking to the future is terrifying, and something that I actively avoid doing.  Even though I’m not feeling suicidal, I don’t have a particularly strong wish to carry on living.  I carry on because my body keeps on living, but if I knew I was going to be killed by lightning strike tomorrow I’d be fine with that.

So I live for today because it’s the most bearable place to be.  Perhaps that’s a good thing, perhaps it’s not, but it keeps me moving forward one today after another.

What kind of relationship do you have with the past, present, and future?

 

Image credit: ambermb on Pixabay

A heart of ice

ice formation

A few nights ago, there was an accident in the Canadian province of Saskatchewan involving a bus carrying members of a junior hockey team and their coaches.  Fifteen people died, the majority of them ages 18-20.  This tragedy has dominated the news since then.

And I can’t seem to make myself care.  I watch the news, because that’s part of my routine, and I think move on, you’ve talked about this enough already.  This evening, the news anchor’s voice broke as she read out the names of the deceased, and she was clearly fighting back tears.  Her job is to be cool as a cucumber and she struggles to maintain her composure, while I feel like an ice queen.

This isn’t new.  Depression does this.  It hardens my heart to anyone’s pain but my own.  I recognize that this isn’t who I am, but right now it’s how I experience the world.  I don’t blame myself per se, but I’m the only one accountable for my emotions.

Jumping off on a bit of a tangent, my brother’s wedding is coming up this summer.  And I don’t care.  I have no interest in going to the wedding, although I will go because that’s what’s expected of me.  I won’t feel happy for him, because my ice heart doesn’t do that.

Maybe global warming will melt my heart of ice.  Or maybe I will sink the Titanic all over again.  But now I’m just rambling.

 

As

 

Image credit: Ezra Jeffrey on Unsplash

TED Talks on depression and suicide

TED Talks logo

Somehow, the folks at TED manage to gather amazing individuals with powerful voices to speak up about difficult topics.  Here are some talks related to depression that grabbed me.

 

Nikki Webber Allen: Don’t Suffer Your Depression in Silence

When  Nikki Webber Allen was first diagnosed with depression, she didn’t tell anyone, because “I didn’t think I had the right to be depressed.”  She attempted to self-medicate through high achievement.  It wasn’t until her nephew, who she hadn’t known was depressed, died by suicide that she decided to share her story.

 

Andrew Solomon: Depression, The Secret We Share

Andrew Solomon described depression as something “braided so deep into us there was no separating it from our character or personality”.  He observed that depression makes it seem like a veil of happiness has been removed from the world so that the depressing truth is made visible.  He described the current state of treatment as “appalling”.

 

Kevin Breel: Confessions of a Depressed Comic

Kevin Breel points out that depression often happens to people who don’t seem like they should be depressed.  He spoke passionately about the silencing effect of stigma, and the need to shatter that silence.  He described depression as society’s deep cut that we simply slap a bandaid on.

 

Sherwin Nuland: How Electroshock Therapy Changed My Life

Sherwin Nuland shared how his life was saved by ECT in the 1970’s.  At that time, most of his doctors had identified a lobotomy as the only option, and it was a medical resident that actually pushed for ECT.  After 20 treatments he’d experienced a significant response and finally was able to feel hope.  He came up with safe words to manage obsessive thoughts, and I think they’re just perfect: “Ah, fuck it”.

 

Kevin Briggs: The Bridge Between Suicide and Life

Kevin Briggs worked for many years for California Highway Patrol, and was often called to suicide attempters on the Golden Gate Bridge.  He was struck by how well people responded to being listened to.  He sends a strong message that there is hope, and suicide is preventable.

 

JD Schramm: Break the Silence For Suicide Attempt Survivors

In this short talk, JD Schramm addresses the taboos around suicide that silence and isolate people.  He brings up some disturbing statistics, and issues a call to speak up about suicide and provide resources to those who have survived suicide attempts.

 

Have you seen any TED Talks that you would consider must-see?

Botox update

Forehead frown lines

Around 5 weeks ago, I blogged about deciding to get Botox injections in my forehead to hopefully help in the management of my depression.  I got the first injections at that time, and then got round two a couple of weeks later, for a total dose of 29 units, which was the amount used in the research studies that shown that Botox can have a beneficial effect on depressive symptoms.  The Botox was injected into the frown line areas, and the idea is to block the feedback loop of frowning reinforcing negative mood.  For anyone who’s curious, botulinum toxin comes from the Clostridium botulinum bacteria and acts at the neuromuscular junction to cause muscle paralysis.  Besides cosmetic use, it’s used for a number of different muscular disorders, hyperhidrosis (excessive sweating), and the in the prevention of migraine headaches.  Effects are expected to last 3-4 months, although in the studies for depression the beneficial effect was found to last even longer.

It takes about 2 days to start noticing the effects of Botox injections, and 2 weeks to get the full effect.  I would describe the feeling as numb but not numb.  It feels numb much the same way as if your mouth was numb after going to the dentist and you couldn’t move the area.  When I try to move the muscles in my forehead, I get that same sort of numb feeling.  It’s not numb to sensory input, though, so I still feel touch, pressure, temperature, and other sensations.

What I’ve really noticed is how often I was frowning before.  Because I get that numb sort of feeling when I try to move my forehead, I notice when my face is trying to frown. And it happens often, far more often than I would have guessed.  In terms of outward appearance, when I try frown there are some little crinkles visible above the outer half of each eyebrow, but that’s it.  When I raise my eyebrows in a surprised sort of expression, there’s limited movement, but one eyebrow raises more than the other one, a fun little quirk that my naturopathic doctors said she could fix but I actually kind of like.

So, is it helping with my mood?  I’ll say a cautious maybe.  I’m still having bad days and I have no resilience when it comes to situational stressors, but looking at my mood tracking app there has been a bit of an improvement over the last couple of weeks.  It’s always hard to know what’s causing what, and there are probably other things that are helping, like the approach of spring probably and some more positive interpersonal interactions.

I’ll probably never really know for sure what effect if any the Botox is having, but I do like the idea that it’s getting in the way all the frowning I was apparently doing before.  And at this point I’m willing to do pretty much anything, even if it’s only having a small impact.

 

Images from Botox Cosmetic

Book review: Mindfulness For Bipolar Disorder

MindfulnessForBipolar

Mindfulness for Bipolar Disorder: How Mindfulness and Neuroscience Can Help You Manage Your Bipolar Symptoms by Dr. William R. Marchand lays out specific areas for mindfulness practices that be useful in managing bipolar disorder symptoms (and most if the book is also applicable to other mood disorders).  I believe mindfulness can be a really helpful thing to incorporate into one’s life, so I had originally intended to write this as a summary of the book’s suggestions rather than as a review of the book.  However, along with the good stuff I found a fair bit in the book that bugged me as well, so I didn’t think I should leave that out.

A note on language:  The author talks about things like “your everyday bipolar life”, “your bipolar self”, and “being bipolar”.  If people who have bipolar disorder want to talk about “being bipolar” because that’s how they conceptualize their self and their illness, that’s totally fine, but when people who don’t have a mental illness start talking about “being” bipolar/depressive/schizophrenic/anxious/personality disordered, it grates on me.  It bugs me because it sounds like they’re telling us that we are our illnesses, even though it’s not up to them to define us, our identities, and where our illnesses fit in.

Ok, time to delve into the practices the book suggests.

Daily meditation practice:

This meditation is focused on breathing, and bringing the focus back to the breath any time the mind wanders.  This noticing and refocusing is an important part of the practice.  The breath serves as an anchor for all of the other meditations described in the book.

Targeting bipolar depression:

This chapter looks at recognizing and moving out of autopilot thinking patterns, which often serve the purpose of trying to avoid emotional discomfort.  Instead, the aim is to accept the reality of the moment, unobscured by our own beliefs.  By mindfully accepting depressive symptoms rather than fighting them, they are more likely to fade away on their own.

The mindful minute meditation is suggested as a regular practice three times a day plus more often as needed.  It involves taking an inventory of the body, autopilot scripts that are playing, and mood, and then finding acknowledgement, acceptance, and presence.

Calming bipolar anxiety

The book talks about confronting one’s fears of impermanence.  “Being present with impermanence is the toll-free expressway to freedom from suffering.  This path leads to the solution to the bipolar puzzle and the solution to the puzzle of all our lives.”  In my own experience, when I’m depressed, I’m not experiencing fear about impermanence.  Quite the opposite, actually; ideas of permanence get me bogged down in hopelessness.  Maybe there’s a freight train blocking my toll-free expressway.

Avoidance is described as a cause of suffering, and the suggested meditation practice involves sitting with an anxiety-provoking idea.  This sounds similar to imaginal exposure work.  The steps in the meditation are:

  1. Focus on breath as an anchor for around 5 minutes.
  2. Bring into awareness a moderately anxiety-provoking situation.
  3. Observe what happens, including thoughts and bodily sensations.  Notice when shifts to autopilot occur and then refocus.
  4. Watch anxiety begin to fade.  However, don’t hold onto a preference for it to go away.

Observing your thinking pattern

This chapter focuses on autopilot, an idea that’s similar to negative automatic thoughts in cognitive behavioural therapy.  Autopilot learns from our past experiences, and one of its jobs is to protect us from getting hurt.  While this can be useful at times, it can prevent us from taking risks and lead to us getting stuck.  It’s useful to recognize how much we’re driven by autopilot, and see autopilots as just thoughts that are neither good nor bad.  Rather than suppressing them, we should try to be fully present.

The steps of the recommended meditation are:

  1. Focus on the breath.
  2. Expand awareness to physical sensations and then sensory input.
  3. Watch your thoughts like clouds in the sky.
  4. Relax in mindful awareness.

Working with mania and desire

While desire is a major source of motivation, it can also underlie discontent and dissatisfaction.  Autopilot scripts are often aimed at wanting to be different, and satisfaction doesn’t last long after desires are fulfilled.  Mindfulness allows desire to be seen as empty of substance; satisfying it doesn’t lead to true happiness.

The recommended meditation involves the same first 2 steps as in the previous chapter.  Then you bring a desire-provoking situation to mind, imagine an open space in your awareness where it can be present, and notice what arises in you.

Managing irritability and anger

In this chapter, thoughts and emotions related to desire and aversion are identified as causing the most problems in bipolar disorder.  It’s important to learn to be present with these emotions rather than try to suppress them, and recognize that thoughts and emotions don’t define who we are as people.

Mindfulness is presented as a way to find freedom from fearing your symptoms; it is this fear that tends to trigger autopilot.  The author goes so far as to suggest welcoming your symptoms, since they’re present anyway, and this will make it more likely that they will move along.  I’m uncomfortable with this choice of words, as I see a considerable difference between accepting what is and actively welcoming it to come and join the party.

Rethinking your bipolar self

Mindfulness gives distance from thoughts about self, which can fluctuate and often become more frequent with depression and mania; instead, these thoughts are allowed to just run in the background.  Mindfulness can allow you to be less attached to your own viewpoint, moving from an egocentric to a wider perspective.

The author explains that, “The answer to suffering is to move into mindful awareness, where you can be fully present with reality without needing to fix or change it.”  I think this is overly simplistic, and based on some of the other books I’ve read recently (A Fearless Heart and The Book of Joy), compassion is a major piece that’s missing here.

Furthermore, mindfulness “means experiencing at a deep level that, in each moment, the universe and everything in it – including you – is perfect as it is.”  From where I stand this is a load of crap.  It’s quite a large leap from acceptance to perfection.  If you consider the Buddhist idea that compassion is a wish for others and the self to be free from suffering, to see everything as perfect in the moment appears to deny the suffering of others and thus is an uncompassionate stance.

Being bipolar and happy

In this chapter, Dr. Marchand writes that ,“Mindfulness can teach you to view your illness as a gift.”  While it seems that what he’s trying to say is that there are things we gain from our illness experience, in my mind calling it a gift makes light of the very real pain and suffering people with mental illness and their loved ones experience.  Acceptance of the illness can be a powerful thing, and can allow us to see that there are things we gain from our illness, but that is very different from framing it as a gift.

Happiness is presented as something that “is always available to you right here and now…  From the viewpoint of mindful awareness you can be happy and joyful in this very moment…  That is the gift of mindfulness.”  I’ve ranted before about the idea that happiness is a choice.  I’m not saying that mindfulness can’t make it easier to find happiness, but I strongly disagree with the assertion that happiness is always available to everyone at any given moment if you only think in the right way.  According to Dr. Marchand, this is as simple as doing a meditation that begins with the breath, then expands the awareness, and “now allow happiness and joy to arise”.  The ad slogan “thanks, Captain Obvious” jumps to mind.  How remarkably unhelpful.

So in the end, for me the irksome in this book tended to drown out the good, but I still believe in the benefits of mindfulness, and I’m going to continue to work on incorporating it into my life.

 

You can find my other book reviews in my blog index.

 

 

Is oversimplification of mental illness useful?

brain depicted as puzzle pieces

We’ve all heard of the “chemical imbalance” explanation for mental illness.  This terminology has served a purpose in making the argument that mental illness is actually an illness.  However, it is a gross simplification of what’s actually going on in the brain.  Lately I’ve read criticism of the chemical imbalance idea as being inaccurate, which makes me wonder if it’s terminology that’s no longer serving us.  I’m going to focus on depression, as it’s probably the condition for which I’ve seen  the chemical imbalance idea challenged the most.

This chemical imbalance theory arose in the 1960’s, when it was hypothesized that a deficit in serotonin caused depression.  According to Wikipedia, it began with observations with the drugs reserpine and isoniazid, and the way they affected monoamine neurotransmitters (the monoamines include serotonin, norepinephrine, and dopamine).  The serotonin hypothesis fuelled further research and the development of new serotonergic drugs.  These drugs proved to be effective, which reinforced the hypothesis. “Chemical imbalance” certainly captures the state of scientific understanding 50 years ago, but we’ve come a long way since then.

Now it’s generally recognized that the etiology of depression is complex and multi-factorial, and the idea of a simple serotonin deficit is inaccurate.  In many ways, the more the science has progressed the more we realize just how much we don’t know.  A few of the biological factors that have been implicated are:

  • Signalling between neurons via monoamine neurotransmitters (serotonin, norepinephrine, and dopamine): This is much more complex than absolute amounts of these neurotransmitters.  Regulation of neurotransmitter receptors and transporters on nerve cell membranes has a major impact on signal conduction.  It’s been suggested that the delayed onset of action of antidepressants may be related to the time it takes to adapt the regulation of these receptors via changes in the expression of genes encoding for them.
  • Glutamate:  It is thought that the neurotransmitter glutamate can cause what’s referred to as “excitotoxicity”.  Inflammation is one of the factors suspected to play a role in promoting glutamate excitotoxicity, mediated by various factors including microglial cells.   Ketamine affects the glutamate signalling system via its effect on NMDA receptors.
  • Genetic factors: Genetic variants affecting such things as serotonin transporters and methylation processes are thought to potentially play a role.  Variants in the SERT (serotonin transporter) gene are associated with different patterns of response to treatment than those with the “normal” SERT gene.  Significantly more research is needed in this area to gain a greater understanding of the role of genetics.
  • Epigenetic changes:  Epigenetics refers to when and how often our genes are translated into the proteins that they code for.  A wide variety of environmental factors are thought to affect this, and this is where adverse childhood experiences can have a huge impact.  There is still much, much more to be learned in this area.

Sometimes people will argue that depression is not biologically caused, but instead is caused by psychosocial factors including trauma.  I guess the problem I have with this is that it strikes me as another oversimplification.  David Karp is a remarkable author and sociologist who has written about his own experiences with depression.  He argues that purely social determinism is just as problematic as biological determinism when it comes to depression.

I’m inclined to think that at this stage of the game “chemical imbalance” has outlived its usefulness.  In a time when it’s so easy for people to look things up, if we’re using terminology that oversimplifies to the point that it’s not really accurate, we may just be shooting ourselves in the foot by hanging onto this kind of language.  I’m not sure what would work better.  I could suggest “complex, multifactorial, biopsychosocial illness” but that’s rather long-winded.

What do you think is the best way to characterize mental illness?

 

Note: There are a couple of good papers by Albert and Benkelfat looking at where things stand now in relation to the serotonin deficit hypothesis; these are available from the National Institutes of Health here and here.

Image credit: GDJ / 2536 images on Pixabay

Falling down the rabbit hole

whirlpool fractal image

Sometimes I think that I’m making progress and the shit from the past has settled down and resumed its rightful place in the past.  Maybe I am making progress or maybe I’m not, but every once in a while some of that shit makes an explosive reemergence.  It only takes one little nudge in that direction to make things fall apart.  There are many metaphors I could use.  What originally popped into my head as a title for this post was scratching the surface and breaking the ice.  But the straw that broke the camel’s back also seems appropriate, as does getting nudged and falling down the rabbit hole into a depressive whirlpool.  I feel like I’m rambling and not making a lot of sense.

I’m in this place of not making sense in my head after something someone said that was not in any way meant to be hurtful.  But that slight nudge pointed me in the direction of this particular rabbit hole, and in I plunged headfirst.  I had a freeze response, and remember focusing my gaze on my hand suspended in the air.  Then the tears began as emotional memories swirled around my head.  Those memories had to do with having my fragile self torn to shreds by my manager at one of my jobs, a psychological shit-kicking that is the reason I now refuse to work any shift other than graveyard.

This whole mess happened while I was working a night shift at said job, and I hate when I lose my composure at work.  The clients were all asleep, so it was just my coworker around.  He was the one that unknowingly triggered my journey down the rabbit hole and then probably wondered what the hell was wrong with me.  This particular individual has been subjected to my own personal brand of crazy more than once now, and I would imagine he’s a bit tired of it at this point.

I’m writing this maybe 3 hours after the incident happened.  I’ve finally got my composure back, but I feel mentally exhausted.  Physically, I’m feeling dizzy and I’m freezing cold.  I feel somewhat embarrassed in the sense that I wish my coworker didn’t have to see that, but I recognize it’s not as thought I deliberately chose my reaction.  Clearly there’s stuff that hasn’t been dealt with, even though I haven’t thought about it for a while.

I could come back and edit this later before I publish it, but I think I’ll leave it as is.  My brain feels like a scrambled mess.  Down the rabbit hole and shit out the other end.  I think I need to keep my stupid mouth shut at work.

 

Image credit: Alpac1t on Pixabay

Stigma and the pathologization of normal

Health spelled out in tablets

Mental illness stigma comes from many places and in many forms.  Stigma often invalidates the experience of those of us with mental illness, and one of the ways this can happen is through pathologizing normalcy.  By this I mean inflating the significance of “normal” emotions and minimizing the significance of mental illness to make it seems as though they’re on par with each other.  Some of this comes from the language we use.  “Anxiety” and “depression” are often used to describe “normal” human emotions, but the same words are also used to describe psychiatric disorders.  This distinction is not always apparent to people with limited knowledge about mental illness, which is where misinterpretations come in.  People may think that because they feel “anxious” or “depressed” emotionally and those feelings are uncomfortable, then they likely have a mental health disorder.  Conversely, people with an anxiety disorder or a depressive disorder may be dismissed as just overinflating “normal” emotions.

I got thinking about this issue after watching  a documentary called The Age of Anxiety, which was aired on Doc Zone on CBC, Canada’s public broadcaster (it can be viewed online here, but only in Canada unfortunately).  According to the producer, “The medical definition of what constitutes an anxiety disorder is expanding to include so many aspects of normal human behaviour that we’re in danger of turning half the population into psychiatric patients.”

One woman featured in the documentary appeared to have high levels of neuroticism (I use that in a psychological rather than a pejorative sense).  She was shown hosting some friends for what was essentially a DSM self-diagnosis dinner party.  At the end of their discussion, they concluded that all of them, and probably most people in general, “meet the threshold” for an anxiety disorder.

The DSM, the “bible” of psychiatry, was never intended to be a paint-by-numbers self-diagnosis tool.  Someone might think check, check, check, I meet all the criteria for this disorder, but there’s an important piece that’s very easy to overlook.  In the DSM-5, criterion D for diagnosing generalized anxiety disorder is: “The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”  That “clinically significant distress” is where clinical judgment is called on to distinguish between “normal” and “disorder” when it comes to things like anxiety and depression.

That boundary between normal and disorder can appear murky or even non-existant if people don’t have good information and haven’t seen the devastation that mental illness can cause.  Without a frame of reference, it’s easy to start making uneducated guesses about what constitutes a disorder.  A medical historian interviewed for the documentary suggested that if your problem can be corrected by a new boyfriend or a cheque for $5000, you probably don’t have a psychiatric disorder.  Simplistic, yes, but still a good point.  What is not helpful is when medical professionals contribute to the blurring of boundaries.  A psychiatrist interviewed for the film speculated that “by age 32, 50% of the population might qualify for an anxiety disorder”.  If it’s uninformed people doing the diagnosing, perhaps, but not if it’s a skilled clinician.

The documentary described the ethically questionable marketing campaign run by the pharmaceutical giant GlaxoSmithKline promoting social anxiety disorder as a common problem that could be managed with Paxil.  This led the filmmakers to conclude that social anxiety is essentially a made-up condition for the purpose of selling drugs.  Just because a drug company is pathologizing “normal” levels of “anxiety” in social situations does not in any way mean there aren’t people who truly have crippling social anxiety disorder, and I think it’s irresponsible when people suggest that this is the case.

The DSM has been a frequent target for criticism when it comes to pathologizing normalcy.  In some cases this has very much been warranted, with homosexuality being a prime example of this.  But that’s not always as much of an issue as it might appear.  One of the concerns often expressed when the DSM-5 came out was the removal of grief as an exclusion criteria for diagnosing a major depressive episode, as some thought that this would end up pathologizing “normal” grieving.  Yet the DSM-5 specifically addresses and cautions against this, stating that the purpose of the change was not to diagnose grief as depression, but rather to recognize that for some people grief may precipitate a major depressive episode.  Again we run into the problem that if depression is thought to be a sham diagnosis for grieving, this is likely to contribute to stigma that invalidates the experience of people who genuinely have a mood disorder.

If people are in fact being overdiagnosed with anxiety and depression, I suspect a major contributing factor is how doctors get paid for their time.  Billing is typically done using diagnostic codes.  General practitioners don’t get paid to do a lengthy psychiatric assessment, so they’re often not getting the history needed to make a solid diagnosis.

The documentary observed that more and more people are turning to medications to manage “anxiety” over everyday issues, and general practitioners are handing them out like candy.  I think insurance coverage has something to do with this; many people are more likely to have coverage for medications than psychotherapy.  I find it really interesting that within the mental illness community there are a fair number of people who are really uncomfortable with medication, but among the “worried well” it seems that medications may be seen as a quick and easy fix.

A pharmacy technician who was interviewed speculated that “about 3/4 of what we have [in the pharmacy] is for anxiety”, and the pharmacist working with her added “these things are all for situational anxiety, situational depression”.  I’m glad I don’t go to that pharmacy!  If society gets the idea that anti-anxiety and antidepressant medications are doled out like candy, how likely are they to take it seriously when some of us truly need medication to manage our illnesses?

There’s a lot of work still to be done in the fight against stigma, and education is a huge part of that, which means that it’s important for us to keep writing, raising our voices, and sharing our stories.

 

Image credit:

Padrinan on Pixabay

Profiles in Tremendousness

screen shot - the Daily Show with Trevor Noah

Profiles in Tremendousness is a segment on the Daily Show with Trevor Noah that pokes fun at the competency (and lack thereof) of various characters in the Trump White House.  I’m going to borrow that idea to take a look at the less than stellar characters I’ve come across in my mental health journey.

My first hospitalization was a sh*tstorm of incompetence all around as far as I was concerned, and years later I found out a little tidbit that gave at least some objective confirmation of that.  One of my discharge diagnoses was borderline personality traits.  There’s nothing wrong with that diagnosis if it’s accurate, but unfortunately sometimes it says more about a practitioner’s stigmatized views than anything else, and is applied as a euphemism for “difficult patient”.  Any competent psychiatrist would know that a diagnosis of personality traits/disorder can’t be made cross-sectionally (i.e. just looking at a specific point in time), particularly when someone is acutely ill; it needs to be made based on patterns that are relatively consistent throughout the person’s life.  The hospital psychiatrist seemed to  have skipped this lecture in med school, and instead decided to ignore taking any sort of social history or gathering any collateral information and instead just slap a label on because I fought the treatment team tooth and nail while I was in hospital.  Not only does this leave me with a diagnosis that doesn’t accurately reflect my experience, but it minimizes the significance of the challenges that people with BPD often face every single day.

I used to go to a medical clinic associated with the local university’s medical school, and I would get seen by whatever medical resident happened to be on for that day.  The discharge summary and who knows what else from my first hospitalization were in my chart at the clinic, and I think a lot of the residents were scared because I was the crazy girl who had tried to kill herself and they didn’t know how to deal with that.  When I went in for pap tests, they would always insist on doing a PHQ-9 (a depression screening test).  One day I went in asking for a lab requisition to get routine blood sugar and cholesterol  checks.  I was stuck there for an hour because, even though my illness was in full remission at the time and I had a psychiatrist who I was seeing regularly, the resident had a very hard time believing I wasn’t going to jump in front of a bus the moment I left the clinic.

The first time I tried therapy was okay but not particularly productive.  I decided to try again when I became depressed a few years later, and made an appointment through my Employee Assistance Program.  I wasn’t thrilled with the therapist’s interviewing style, but the real treat came as we were wrapping up the session.  Her advice was that I would feel better if I started dating.  Seriously?  That was the end of that.  And to top it off, when I emailed her to say that I wouldn’t be seeing her again and explained the reason, she thought it was peculiar that I would have chosen to fixate on that particular statement.  Um, perhaps because it represents incompetence?

That theme came up again more than once.  I clearly remember a nurse in hospital who observed that I must be depressed because I was single, and that must have been why I attempted suicide.  Between her and the nurse who was convinced that I must have attempted suicide because I was angry about something, it was a sad state of affairs.  But the stellar lack of competence didn’t end there.

freudThe hospital psychiatrist who initially treated me on the inpatient unit knew I didn’t like him (I guess the screaming and swearing was a pretty strong hint), so he decided to transfer my care to a different doctor.  This character was very much of the psychoanalytic/psychodynamic therapy persuasion, and as far as I could tell he was even more of a nutbar than I was.  My first meeting with him was all very Freudian, with a focus on sex and early childhood.  How old was I when I lost my virginity?  Did I like sex?  Did I remember how I felt when my brother was born when I was 3 years old?  He told me that the ONLY way for me to get better was to get psychoanalytic therapy, and I should only be on meds for a couple of months and then come off them.  Wowza.  But I wanted to get discharged, so I said the things he wanted to hear.  Later, my community psychiatrist commented that he wasn’t sure who that discharge summary was written about, but it definitely didn’t sound like me.

A couple of years ago, things started falling apart.  A very close friend died unexpectedly. I was bullied at work and ended up quitting because of it.  I was worried about getting sick, but I held it together.  And then I found out that my ex-manager was doing his best to destroy my career (in very much a reality-based sense, not a cognitive distortion sense), and the sh*t really hit the fan.  When I went in to see my psychiatrist, I was so slowed down that I moved from the waiting room to his office at a snail’s pace, and had a hard time even stringing a sentence together.  He knew about all the other stuff I’d made it through, but the best he could come up with was that I needed therapy to learn better coping skills so I wouldn’t get depressed when things like this happened.  I’m not sure why he thought that was the appropriate response and the appropriate time, but that was the last time I ever saw him.  Once trust is broken, I’m done.  So I decided to go see my new GP, who didn’t know me from a hole in the ground.  And what did she have to say after I told her the reason I’d decided to stop seeing my psychiatrist?  “Don’t you think you do need better coping  skills?”  Are we passing around stupid pills?

Don’t get me wrong, there are some great mental health professionals out there; I know because I’ve worked with some of them.  Unfortunately there are also some real duds, and in the next edition of Profiles in Tremendousness I’ll cover some of the specimens that I’ve worked with.  It would be nice if this wasn’t an issue we faced when trying to access mental health care, but sadly it’s far too often the reality.

What have been some of your worst experiences?

 

Image credits:

The Daily Show with Trevor Noah

Skeeze on Pixabay

Allowing vulnerability

woman in bath surrounded by flowers

I had a tough weekend.  It started off badly with a friend contacting my brother to check up on me, which rocked the walls of the little cave I’ve built for myself.  And then something happened with my safe person that made me feel very unsafe.  The dark voice inside my head kept repeating “He’s using me.  He’s using me, and now he’s trying to pay me.  I’m not a f***ing prostitute”.  Some of the same thoughts I’ve had to rein in before, but taken to a new  level.  I chose to withdraw rather than unleash a tantrum, and spent much of yesterday crying and just generally feeling awful.  I felt angry at myself for trusting someone and allowing myself to feel safe, because I should have realized that everyone really is out to hurt me.  Why did I let down my barriers, why this, why that.

I woke up this morning feeling somewhat more human.  In a brief moment of wanting to be mature I emailed him to apologize for going MIA, saying that I was feeling upset but needed to figure it out in my own head.  He responded and said I could should go ahead and tell him whenever I felt ready, so I let er rip.  My ugly, messy, depressive thoughts coalesced in email form, and I hit send.  The response I got surprised me, although it probably shouldn’t have.  Totally supportive.  Glad that I’d opened up.  Wanted me to tell him right away if those kinds of thought distortions come up in the future so we can work through them together.  As I was reading this I was crying and my head was spinning.  Was this what it feels like for vulnerability to be okay?

I recently watched an amazing TED Talk by Brene Brown about vulnerability.  She said a willingness to be vulnerable underpins our ability to feel worthy and experience love and belonging.  She encouraged us to allow ourselves to be vulnerably seen.  And maybe I did that, at least a little bit.  It was scary as hell, but maybe that doesn’t have to be a bad thing.

Cave-dwelling

cave

I live in a figurative cave that is of my own making (although I suppose of my depression’s making would be more accurate).  I have pushed nearly everyone out of my life, and while that is occasionally lonely, it feels much easier.

My oldest friend keeps trying to remain in my life, even though I don’t allow her in.  It’s been over a year since I last saw her, and almost as long since I last responded to any of her messages.  Yet she stubbornly continues texting me every few months.

She texted again a few days ago to ask how I’m doing.  I thought about whether I should respond or not, but then realized I wasn’t there yet.  Even if I wanted to respond, what on earth would I say?  This is someone who has a normal life and does normal things, and I just feel so far removed from that.  I feel like we live in totally different worlds.  It’s not that I don’t think she cares; I know she does.  Maybe what scares me is that I would be reminded of what I’ve lost, and what I can’t do any more.  There’s probably more to it than that, but I feel a strong sense of revulsion at the thought of interacting with her.  And it’s not anything about her; she knows about my illness and has always been supportive and nonjudgmental.  It’s 100% about me.

I got an email from my brother yesterday.  He said this friend had contacted him to ask if he’d talked to me recently.  The idea of them talking about me was disturbing.  It’s not that they would say anything “bad” about me, but it just doesn’t sit well with me.  Part of me feels annoyed with my brother, although logically I know there’s nothing to be legitimately annoyed about.

I thought writing this post might help me figure out in my own head why I’m feeling a messy jumble of emotions about this, but I’m still feeling just as jumbled.  I hate what I’ve become, and I know that’s not fair and I don’t hate the self that’s at the core, but this has caused a bit of a stumble.  I’ve stumbled before, though, and like before I will pick myself back up and carry on.

 

Image credit: Glavo on Pixabay

Do antidepressants work? What a new meta-analysis says.

meds

A recent paper published in the Lancet looked at how effective antidepressants are, and this has been reported on in the media.  Since media outlets don’t necessarily have strong research literacy, let’s take a look at what the paper itself has to say.  My earlier post on research literacy explains some of the terms I’ll be using here.

Full reference details for the paper:

  • Cipriani, A., et. al. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet. doi:10.1016/S0140-6736(17)32802-7

A systematic review involves collecting a body of relevant literature on a topic using academic databases and search terms that are clearly specified, and then narrowing that down by applying certain criteria to find studies that are academically rigorous and fit with the research parameters being considered.  Typically, different investigators go through this process independently and then come to a consensus on which studies to include in the review.  The results are then evaluated to get a picture of the current state of the evidence.  A meta-analysis goes a step further by pooling the data from the various studies and then performing statistical analysis.

Inclusion criteria for this paper were:

  • randomized, double-blinded, controlled trials (either placebo-controlled or head-to-head trials of different antidepressants)
  • study participants were adults 18+
  • diagnosis of major depressive disorder
  • no more than 20% of participants in a study had bipolar disorder, treatment resistant depression, psychotic depression, or serious concurrent medical condition (while this might sound like a bad thing, when pooling numbers for a meta-analysis you want to make sure you’re comparing apples to apples)
  • evaluation of quality of evidence and risk of bias met specified academic standards

The outcome measures were response rate and acceptability (as measured by number of discontinuations due to side effects).  While ideally patients should be treated to full remission of symptoms, response rate is often used in research studies.  Response rate is defined as a 50% reduction in score on a standardized depression rating scale such as the Hamilton Depression Rating Scale (HAM-D).  For this meta-analysis they chose to evaluate outcomes at the 8-week point, and for the included studies that didn’t take ratings at 8 weeks this was imputed using statistical methods.

Findings:

  • All 21 antidepressants considered were more effective than placebo in adults with major depressive disorder.
  • In head-to-head studies, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants.
  • Fluoxetine, fluuvoxamine, reboxetine, and trazodone were the least efficacious drugs.
  • For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were the most tolerable.
  • The most discontinuations occurred with amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine.
  • Agomelatine was the only antidepressant with a lower dropout rate than placebo.

So, what does this paper not give information about, i.e. what conclusions are we not able to draw from it?

  • How effective these antidepressants are in terms of achieving full remission
  • Efficacy measures are only based on a 50% reduction in rating scale scores; there is no information about which particular clusters of symptoms are more or less likely to respond
  • What outcomes are beyond the 8-week point
  • Whether a specific antidepressant is or is not likely to be a) effective in a specific individual or b) more or less effective than any other antidepressant in that same individual
  • Whether a specific antidepressant is or is not likely to be tolerable for a specific individual
  • How often people experience side effects due to any of the antidepressants (it only looks at discontinuations due to side effects)
  • Whether any specific individual would or would not benefit from antidepressants at all
  • How well antidepressants work outside of the population considered in the review (i.e. under 18 years old or with treatment resistant depression, psychotic depression, or bipolar depression)

And what does all of this mean?  It’s important to keep in mind that a systematic review/meta-analysis such as this is only aiming to tell us very specific things.  The authors are deliberately comparing apples to apples so they can pool large groups of numbers and draw conclusions from that.  There’s a lot of real-world information that it doesn’t give us, but it’s worth keeping in mind that it makes no claims that it is.  The authors do not suggest that their findings can be extrapolated to answer any of the questions I’ve mentioned that the paper doesn’t give us information about.  What it does tell us is that antidepressants belong in our arsenal of available treatment strategies.  Anything more specific than that always needs to be a collaborative decision between the individual and their treatment team.

 

Image credit: matvevna on Pixabay

Aromatherapy and mental health

field of lavender

There are various sources that can be found online that talk about the mental health benefits of aromatherapy with certain essential oils.  I started using aromatherapy daily almost a year ago.  Mostly I use a diffuser but I also have a few topical roll-ons.  It’s hard to say if there’s a benefit aside from the very real benefit of a regular practice of engaging in self-care, but if nothing else it smells really nice.

An article by Dr. Axe lists a top 4 of essential oils for depression:

  • Bergamot: calming, works well in combination with lavender
  • Lavender: useful for stress, anxiety, depression, and PTSD
  • Chamomile: soothing, calming
  • Ylang ylang: boosts mood, mild sedative

Other essential oils that may be helpful are rose, geranium, clary sage, jasmine, sandalwood, sweet marjoram, frankincense, wild orange, lemon, patchouli, grapefruit, and neroli.

I get most of my essential oil blends from Saje Natural Wellness.  I specifically pick blends that contain mental health-boosting oils.  My favourites are Embrace (which includes ylang ylang, patchouli, and geranium, among others), Stress Release (with lavender, clary sage, geranium, and roman chamomile), Tranquility (with lavender, ylang ylang, and roman chamomile), and Unwind (with lavender, bergamot, and geranium).

I subscribe to a sort of the more the merrier holistic approach to mental health.  My treatment-resistant depression doesn’t seem to be inclined to budge, so I throw at it whatever I can come up with in the hope that any little bit helps.  And if what I’m throwing at it happens to smell nice, so much the better, meaning I will keep taking care of myself with aromatherapy.

Why did I get sick?

strands of DNA

There is so much that we don’t know about what causes mental illness, and very little that we do know.  This means that asking why is rather futile at this point, but it’s hard not to.  It feels like maybe if I had some idea where my depression was coming from I’d have a better idea how to manage it.

We know that there is often a genetic element to mental illness, but we know very little about how that actually works.  One way of examining this is twin studies.  Monozygotic twins come from a single egg and sperm, and so have identical DNA.  Dizygotic twins come from 2 separate egg/sperm pairs, so they do not share the same DNA.  The concordance rate (probability of sharing a specific trait) for major depressive disorder in monozygotic twins is almost double that for dizygotic twins.  For schizophrenia, the concordance rate is even higher, suggesting an even stronger genetic link.  In my own family, there was one great-uncle (possibly two) on my dad’s side with schizophrenia.  That’s it  There is no other known mental illness in the family.

Childhood trauma may be a contributing factor, and there’s some really interesting data from the Adverse Childhood Experiences research on this.  Stress and trauma, particularly in childhood, can cause “epigenetic” changes.  We have the genes we’re born with, but it’s more complicated that that.  Sections of genes code for various proteins, but when and how our bodies decide to actually make protein based on that code is studied in the field of epigenetics.  Interactions with our environment are a major factor, but there is still so much more to learn in this field.  There is even some research suggesting that epigenetic changes can even be passed down to offspring.  It’s a really interesting area that I suspect is going to be the source of some major discoveries as the science moves forward.

Yet I didn’t have any childhood trauma.  Yes, I had the “normal” challenging experiences that people are likely to have, but I was not abused, neglected, or bullied.  I was lucky enough to have parents that were caring, affectionate, and supportive.  We were financially secure enough that I had opportunities that might not have been available to others.  I did well in school, and although I was kind of geeky and unpopular, I was generally quite comfortable in my small circle of close friends.  The really challenging stuff that’s happened in my life, including bullying, came after I got sick, not before.

Substance use was never an issue.  Yes, I drank a lot of alcohol in my late teens and early 20’s, but there were no apparent negative consequences other than the odd hangover, and I had no problems stopping drinking when I moved on to the next stage of my life.

I was not someone who was prone to low moods.  I’ve always been emotionally sensitive, but overall I was a happy, optimistic person with good self-esteem.  I didn’t have my first episode of depression until age 27, although looking back there may have been an earlier hint of things to come.  When I was around 15 I had a period of 2-3 months with unexplained physical symptoms, including weakness and fatigue severe enough that I could barely get in and out of bed.  Various tests were done, but no physical cause was identified.  From what I can recall, I was terrified by what I was experiencing, but my mood at the time was numb more than anything.  Still, physically there is a definitely a resemblance to what I experience when my depression causes psychomotor retardation (significant slowing of movement and thoughts).

When I had my first episode at 27, it came on over the space of maybe 4 months, triggered by situational stress.  My ex-boyfriend and I had remained very close friends after I’d broken up with him, but then he started dating someone and all of a sudden my best friend didn’t want to be in my life anymore.  It was difficult, but something that I had sufficient coping skills that I would’ve expected to be able to handle it.  I had two suicide attempts in the space of a couple months, then ended up in hospital for 2 months, psychotic and continuing to try to take my own life.  Later that year I went off meds because I felt they weren’t working, but I ended up achieving full remission despite that.  I stayed well for 4 years, and then got very sick again very quickly, with no apparent trigger.  I noticed symptoms coming on and got started back on meds quickly, but within four weeks I ended up in hospital.  It took a year and a half, 3 hospitalizations, and many different treatment trials to get into remission.  It wasn’t a stable remission, though; there were a lot of bumps that were mostly manageable with increases in my medication dosages.  That is, until I had another relapse almost 2 years ago.  My illness is now more treatment-resistant than ever.

So where the heck did this come from?  I doubt I’ll ever know the answer.  In the end I suppose it doesn’t really matter all that much, but I wish I knew more about this beast that has intruded into my life.  How did it sneak up out of nowhere, and why did it pick me?  Is it the ghost of that distant great-uncle’s genes swooping in to haunt me but sparing everyone else in the family?  There can be no answers, only more questions.  I hope that some day science is able to start to answer these questions for others, even if it comes too late for me.

 

Image credit: Qimono on Pixabay

Anti-inflammatory brain food

 

It was spring of 2017, and my depression had gotten worse despite being on plenty of meds.  I decided that I needed to add in other elements to my treatment plan.  I’d had some labwork done that showed I had elevated levels of inflammation as measured by something called C-reactive protein.  I decided the perfect person to talk to was the naturopath who I’d first started seeing the year before to help get my gut back on track after a parasitic infection.  She recommended that I adopt an anti-inflammatory diet and supplement with omega-3 fatty acids and a combined vitamin/mineral/antioxidant supplement called Ultra-Preventive.

I’ve never been interested in doing any sort of diet, but I started doing some reading and was interested by what I found.  Inflammation is involved in a variety of physical health problems, and recent research has also suggested a link to mental illness.  Depressed people with elevated levels of inflammation (as indicated by C-reactive protein and a few other markers) actually have differences in how well they respond to different types of treatment, and some studies have shown that anti-inflammatory medications can have a beneficial effect in depression.  Some types of food are thought to promote inflammation while others reduce it, and the goal of an anti-inflammatory nutritional approach is to improve health by reducing inflammation.  It’s quite similar to a Mediterranean way of eating.  Weight loss is not the goal, so I prefer not to call it a diet.

Pro-inflammatory foods to limit:

  • Sugar and refined carbs: Simple sugars (including high fructose corn syrup) and highly refined carbs (e.g. flour, white rice) cause spikes in blood sugar, leading to a cascade of reaction in the body that can increase inflammation.  My naturopath wanted me to cut out bread entirely and as well as sugar-containing drinks.  I managed to stop sweetening my tea and coffee by first switching from sugar to stevia (a plant-based zero-calorie sweetener) and then steadily decreasing the stevia.
  • Grain-fed red meat:  What the cow eats actually makes a difference in how your body reacts to the resulting food product.  Grass would naturally be a staple food for cows, but in modern farming cows are sent to feedlots where they’re given corn or soy-based feed.  There are a number of adverse health effects that appear to be linked to high consumption of grain-fed red meat (i.e. the beef typically found in grocery stores), and it’s something that’s recommended to avoid in an anti-inflammatory diet.  Grass-fed beef is considered a better choice, and butter from grass-fed cows contains significantly higher levels of healthy fats.
  • Highly processed foods:  As a general rule of thumb, the less a food product resembles simple, natural ingredients, the less likely it is to do good things in your body.
  • Trans fats

vegetables

Foods to look for:  

Fibre, plant-based nutrients, and healthy fats are your best friends with this nutritional approach.  Dr. Andrew Weil’s anti-inflammatory food pyramid is a useful place to start from.

  • Veggies (especially dark leafy greens and crucifers like broccoli and cauliflower): These are full of fibre, phytochemicals (i.e. nutrients found in plants), and antioxidants, which scavenge harmful free radicals.  I tried to make myself like broccoli to no avail, but I did find a yummy way to cook cauliflower.
  • Fruit: Berries in particular are packed with antioxidants.  The fibre in fruit helps slow down absorption of naturally occurring sugar to minimize spikes in blood sugar.
  • Whole grains (eg brown rice, quinoa, steel cut oats):  The whole grain contains the nutritious parts that get stripped away during refining, and these nutritious bits, including fibre, also slow carbohydrate absorption, reducing spikes in blood sugar.
  • Beans and legumes:  These are protein- and fibre-packed nutritional powerhouses.  Chick peas are a favourite of mine.
  • Pasta: Dr. Weil suggests 2-3 servings per week.  When I first started my plan I cut out pasta altogether, but I’ve since added whole wheat pasta back into the mix.
  • Healthy fats: Yes, fat can be good for you!  Fats found in extra virgin olive oil, nuts (especially walnuts, cashews, and almonds), seeds (including hemp seeds and flaxseeds), and avocados help to decrease inflammation.
  • Wild-caught fish and shellfish:  Fish like salmon and sardines have lots of healthy omega-3 fatty acids.  Wild-caught is preferable to farmed.  Shellfish contains choline, which is a precursor in the production of neurotransmitters.
  • Whole-soy foods: Tofu is a very versatile food with great nutritional value, but personally I’ve just never been a fan.  It’s worth noting that processed soy-based products do not have the same benefits as whole soy.
  • Cooked Asian mushrooms (eg shiitake and oyster)
  • Other protein sources: The food pyramid includes occasional consumption of foods like dairy, eggs, poultry, and lean meat.  I’ve never had any problems with lactose intolerance and had no interest in cutting out milk, but I did cut back somewhat on cheese.  I’ve gone from being an ardent carnivore to eating very little meat.  Eggs I like to include because they’re rich in choline.
  • Herbs and spices: Turmeric is an anti-inflammatory superpower.  Cinnamon, ginger, garlic, basil, rosemary, and thyme are also good choices.
  • Tea (preferably white, green, or oolong)
  • Treats: Red wine and dark chocolate with at least 70% cacao are yummy goodies with the benefit of antioxidants.  70% cacao chocolate isn’t very sweet, but gradually I’ve built all the way up to a preference for 85% cacao so I can get yumminess factor as well as antioxidants with minimal sugar.

 

After a few months of sticking pretty closely to my anti-inflammatory plan, my bloodwork showed that my level of C-reactive protein had come back down to normal range.  Despite not trying to lose weight, I did lose some of my medication-induced weight gain.  Since then, I’ve eased up and don’t follow my nutrition plan as closely, but I’m still far more conscious than I used to be about what I’m choosing to put into my body, and I’ve cut way down on my intake of processed food.  I use the app My Fitness Pal to keep track of what I’m eating, and that was particularly useful when I was starting out as it helped me to understand what exactly I was putting into my body, including a breakdown of fat, protein, and sugar.

So, has this actually helped with my mental health?  It’s hard to say, because there are so many different factors that influence my depression.  Still, this approach to eating can’t hurt, and at least in theory bringing down inflammation is a good thing, so any little bit helps.

Who woulda thought I’d get Botox

Botox_before

Botox

I’m not a cosmetic procedures kind of gal.  Power to others if that’s what works for them, but given that I can’t even be bothered putting on makeup most of the time, all things physical appearance-related don’t rank very high on my priority list.

But that’s not why I’ve just gotten Botox.  To keep my knowledge base up to date in the field of psychiatry I try to watch webinars on a somewhat regular basis.  The other day I was watching a webinar on novel treatments for depression, and one of the things mentioned was Botox.  There have been a few small research studies (one from 2014, one from 2012, and another from 2006) that found that injecting Botox into the frown line areas on the forehead actually led to an improvement in depressive symptoms, even in people with treatment resistant illness.  The thinking behind it is that not only does facial musculature express mood states, but it gives feedback that in turn regulates mood states.  By preventing frowning, Botox may disrupt that harmful feedback loop.

Will it work?  Who knows.  At this point, I’m willing to try just about anything.  I’m doing this with my naturopath, who does cosmetic procedures as part of her practice.  I trust her, and she thinks it’s a good idea, so what the heck, might as well give it a go.  Fingers crossed!

 

Images from Botox Cosmetic

In times of life or death

shadow_face

As some of you are likely already aware. one of our fellow members of the mental health blogging community attempted suicide earlier today, and posted a suicide note on her blog.  I choose not to link to her blog here because for those of you who aren’t already familiar with her amazing work, I don’t want to introduce you to her at her most desperate moment.

I saw it about an hour after it was posted, and my heart started pounding as I wondered what the hell I was going to do.  I flailed around feeling powerless for a bit before realizing that her Twitter page stated where she lived.  I called the police there, and they said they’d already made contact with her.  I then saw that I’d gotten a message from one of her Twitter followers, who had made the initial contact with police that resulted to them getting to her in time (thankfully; who knows, this may not have been the case if mine had been the first contact).  The police were able to get to her and get her much needed help because there was sufficient identifying information in her online accounts for them to figure out who and where she was.

That got me thinking.  Many of us value our anonymity, and very deliberately choose not to put identifying details about ourselves online  And at the same time, many of us do experience thoughts of suicide at times due to our illnesses.  If we, in moments of desperation and hopelessness, were to publish our intentions or actions with respect to suicide, would fellow bloggers who wanted to help us be able to figure out how?

WordPress doesn’t have a lot to say about the matter.  In their page on “Self-harm and online safety“, they suggest calling the authorities if you know the person, and posting suicide resource information for them if you don’t.  You can “report content“, but it doesn’t sound like this is likely to accomplish much, if anything.

Thinking about myself, the city where I live is displayed on my Twitter account.  I don’t use my full name, but I’ve done some guest posts under my full name, and that probably wouldn’t be too hard to find.  They would mean my first, middle, and last names woild be available, , plus I’m already in the local police system as an “emotionally disturbed person” (police jargon for contacts they have with someone with mental health problems), so they’d probably track me down fairly quickly.  I’m not sure how comfortable I feel with that, to be honest.

Being on the other end, as a fellow blogger wanting to help, the feeling of powerlessness is terrifying.  The desperate desire to help crashes headfirst into having no idea where to even start.  In this particular instance, enough pieces were there, but what if that wasn’t the case?

I’m not sure what the answer is, or if there even is an answer.  We can hope this is an issue that won’t come up very often, but I think the reality is that it’s inevitable that sometimes it will arise.  It’s probably better that we start to think about it when we’re not trapped in the darkest depths, and consider how many crumbs of information we’/re prepared to dole out, and much power we are willing to offer to our fellow bloggers to help us if things get really bad.

 

Image credit: Ian Espinosa on Unsplash