In case you missed my psych meds 101 series, here’s the post on antidepressants.
In case you missed my psych meds 101 series, here’s the post on antidepressants.
I Am the Architect of My Own Destruction is Juansen Dizon’s second book of poetry. The book opens with a letter to the reader, which begins “It’s hard to write when you want to kill yourself. It’s harder when you don’t really know the reason as to why.” Throughout the book I felt like I as a reader was being directly spoken to.
The poems capture the darkness and depth of mental illness, and often I was left thinking wow, that’s exactly how I have felt. Thoughts of suicide are shared in a way that feels very genuine and non-triggering. The book touches on a range of topics including body image and the difficulty of self-love. Along with the difficult part of mental illness, Juansen also writes about healing and happiness. This provides a good balance to some of the darker poems.
Many of the poems were quite short, which I really appreciated because as I was reading the book depression was doing a number on my concentration. Some are only one line, but carry profound meaning in those few words, like Numb and Casket. I was impressed by the emotional depth that could be captured in just a few words.
The book explores love and navigating relationships, and how challenging this can be when in the depths of mental illness. Juansen clearly bares his soul as he writes about this. The book also includes touching letters to his girlfriend and his brother.
I particularly liked the one-line poem Seraphim: “Melancholy is an angel that fell in love with a demon.” Another favourite was Warriors, which talks about the strength it can take to stay alive.
This book carries the reader on a poetic journey into the author’s mind and heart, giving an intimate look at the experience of mental illness. The poems are very accessible, in the sense that even people who don’t normally read much poetry would likely find it easy to engage with this book. It’s well worth checking out.
You can find Juansen on his blog Lonely Blue Boy.
Note: I was provided with a free copy of this book in exchange for an honest review.
Image credit: Amazon.com
I have never had a problem with medications in general, and in my work as a nurse I’ve seen how much good they can do. Despite that, I’ve gone off the meds I take for depression a few times, and that’s what this post is about.
My first episode of depression was in 2007. I ended up hospitalized following a suicide attempt, and spent 2 months in hospital. I continued taking my meds for a few months and I then I had another suicide attempt, this time by overdosing on my psych meds. I didn’t do any significant damage, so I chose not to tell anybody at the time. I decided that to hell with it, if I was on meds and still feeling shitty, what was the point of continuing meds? Continuing on my deceptive theme, I didn’t want my treatment team to know I wasn’t taking meds, so I continued to pick them up regularly from the pharmacy. I ended up getting into full remission without meds, and I remained well for almost 4 years.
My plan all along was that if I started to have signs of getting worse, I would restart meds. When the depression started to hit me in 2011, I quickly recognized the red flags of poor sleep and low mood, and made an appointment to see my GP. I had to practically beg for meds, and he begrudgingly gave me 10mg of citalopram, although his preference was that I attend group therapy. 2 weeks later I ended up in hospital.
It took a year and a half to get fully well again, and I ended up on multiple weight gain-inducing meds (lithium, quetiapine, and mirtazapine). The weight gain was hard to adjust to, although I recognized it was probably a fair price to pay for being well. After 2 years in full remission, I decided I wanted to try going off the quetiapine, and my psychiatrist was agreeable. We tapered down the dose gradually, and at first it seemed like I was going ok, until suddenly it wasn’t. I got really slowed down, and ended up having to go back on the quetiapine as well as up my dose of lithium. Clearly I needed my full med cocktail.
It wasn’t too long afterwards that my workplace bullying debacle began. This culminated in me deciding to quit my job, and I became quite depressed again. My psychiatrist ‘s reaction was tremendously invalidating, so I stopped seeing him. I had recently begun seeing a new GP, and when I told her why I wasn’t seeing the psychiatrist any more, she came out with the same invalidating comments he did. I refused to see her again, so she booked me in to see another GP at the same clinic, who ended up being even worse. I couldn’t bear the thought of going to see another doctor, so I decided that with the meds I still had at home I would do a gradual taper and then stope them. It wasn’t that I wanted to stop taking meds, I just wasn’t willing to see another doctor. Not surprisingly, that strategy didn’t work out very well for me. I was barely sleeping despite taking everything over-the-counter I could think of.
It was when I decided that I needed to go back on meds that I found my current GP, who’s very reasonable and pragmatic. Even so, there have been a couple of times that I’ve thought screw it, there’s no point going in to get my meds reordered because I just feel like crap anyway.
My logical mind is very adamant that I need meds. Unfortunately, sometimes depression sneaks in and twists things around, and for me I don’t think that’s something that will ever go away no matter how pro-meds I am most of the time.
Have you gone off meds before? What was the experience like?
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Faith Trent explains that she wrote Be There For Me: An Insight Into My Journey With Depression to “1. Show sufferers they are not alone. 2. Provide advice and guidance for those trying to support a sufferer. 3. Try to remove some stigma around depression.” At the time of writing she was in the midst of a depressive episode and was off work, and she thought writing would be a good way to make something positive out of something horribly difficult.
The author’s depression journey captures common elements shared by many of us living with depression. When she first became depressed, she had no idea what was happening, especially since there was no identifiable trigger or reason for her to be depressed. She was initially reluctant to try medication, a view that she’d picked up from her mother. There are chapters devoted to various different features of her illness, including anxiety and self-harm. For her, self-harm was a way to somehow legitimize the way she was feeling.
She describes what it feels like to live with depressive symptoms such as fatigue, apathy, poor concentration, and the pervasive shadow of guilt. She also explains common thought patterns in depression, including self-doubting, feeling like a burden, and drowning in shoulds. These are not textbook definitions, but rather descriptions of the subjective experience.
She writes about the challenges of parenting young children with depression, and how the illness makes the daily parenting tasks feel like a mountain that must be climbed. She finds it hard to be fully present with her children, and she regrets the distance from them that has created. She also crying in front of them. I’ve always wondered, though, if there isn’t benefit in children seeing what mental illness actually looks like, and perhaps this helps to prevent the propagation of stigma.
She identifies the essential elements she has found for managing her illness: becoming aware of her triggers and early red flags of worsening illness, maintaining work-life balance, getting enough rest, talking to a close circle of friends, exercising, and doing things that make her happy. When her illness hits hard, she says “it cripples my whole life… It causes me to question every part of my life, doubt my value, and make me feel like I am a burden to all I encounter.” This struck me as such classic depressive thinking.
As is far too often the case for those of us living with mental illness, the author has experienced stigma directly. Some people made her feel “truly inadequate and small for suffering from something that I feel they didn’t believe was real. I was patronised and made to feel like I was making it up at times.” It was disturbing to read that a teaching colleague of hers questioned whether she should be allowed to be at work because she might pose a danger to her students. As a nurse I have faced questions about my safety to my patients, but somehow no one realizes (or cares?) that with depression most often the real risk is to ourselves.
The main focus of the book is breaking down stigma. She concludes that the only way to do this is for people with depression to share their stories to counter the misconceptions others may have. I wholeheartedly agree.
You can find the author on her blog Shatter the Stigma.
You can find my other book reviews on my blog index.
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Content warning: This post openly discusses suicide and suicide attempts
You can find info here on where to reach out for help if you’re in crisis.
It’s suicide prevention week, so it seems like an appropriate time to talk about suicide in all its ugliness. I have attempted suicide multiple times; most were associated with my first episode of depression just over 10 years ago. Suicidal thinking is a symptom of my illness, and one that will most likely continue to pop up when things get really dark. It’s something abnormal that unfortunately has come to be all too familiar.
In 2007 I had three suicide attempts outside of hospital, plus multiple attempts while in hospital that resulted in me being sent to psych ICU. At the time of the first attempt. I hadn’t been diagnosed with depression yet, but I was fairly certain that’s what was going on. The suicidal thinking had been building, and then it got to the point where I had a plan. The next step was getting pills, and finally I ended up taking those pills. Each of these steps was well thought out and took some time; there was nothing impulsive about any of it. I tried to hold off as long as I could out of a sense of responsibility to my family and other people in my life, but things were just so bleak and hopeless that the idea of remaining alive seemed totally untolerable. The suicidal thinking was something new to me at that point in my life, so it was hard to figure out ways to cope with it. I went through a brief phase of cutting in an attempt to find an alternate way to deal with the pain.
When I became depressed in 2010, initially suicidality wasn’t among the symptoms I was experiencing. However, as the episode extended over the next year I began having ever-increasing thoughts of suicide. I took myself to hospital voluntarily, but had a very negative experience and ended up being discharged without feeling any better. I developed a suicide plan involving my psych meds. At the time, I was working Monday to Friday with every other Friday off, and my plan was to take the pills on one of my Fridays off so no one would notice anything out of the ordinary until Monday. Each Friday off, I would evaluate whether or not I thought I could make it through until the next Friday off. Eventually one Friday I decided I just couldn’t take the pain anymore, and I took the pills. Over the next few days I alternated between sleeping and wandering around delirious, and then when I didn’t show up for work on Monday they called the police. When the police showed up at my door I was totally loopy, and they hauled me off to hospital.
I haven’t attempted suicide since then, but there have been a few occasions when I have taken steps towards enacting a plan to kill myself. What has stopped me has been fear – not fear of dying, but fear of “failing” to kill myself. I generally don’t tell people when I feel suicidal, partly because I don’t feel like talking will help, and partly because I have a strong aversion to going to hospital. I’ve come to the conclusion that given the history of my illness, chances are fairly good that I will eventually, at some nebulous point in the future, end up dying by suicide. I don’t say this because I desire this outcome or because I’m suicidal right now, but in terms of simple probability it seems the most likely.
That brings me back to what I said in my post yesterday. To really decrease the risk of suicide in those of us living with mental illness, we need better treatment. We need more than just an ear to listen to us; we need something tangible that will truly make a difference and create a bright light of hope. And that can’t come soon enough.
Image credit: American Foundation for Suicide Prevention
Wouldn’t it be nice if the treatment of depression was simple? Unfortunately, there’s nothing simple about depression treatment in the real world Treatment resistant depression (TRD) refers to illness that hasn’t respond to trials of adequate duration and dosage of at least two antidepressants. The STAR*D research study found that only about 1/3 of people get well with one anti-depressant trial, a further 1/4 get well with a second trial, and only 67% get well after a fourth medication trail. That’s a whole lot of people not getting well. So if you fall into that category of TRD, what are your options?
If depression isn’t responding to treatment, it’s important that the diagnosis be re-evaluated. Could this be bipolar depression? In that case, the treatment strategy may need to be quite different, and antidepressants alone are seldom effective for bipolar depression. Is there a medication, medical condition (e.g. hypothyroidism), or substance use that could be contributing to the problem that needs to be addressed in order to properly treat the depression? Is there unaddressed trauma that needs to be targeted?
Let’s say the diagnosis is major depressive disorder and no complicating factors can be identified. Has psychotherapy been tried? If not, that’s always a great place to start. Other first steps might be to increase dose, switch antidepressants, or try antidepressant combos. Another strategy is augmentation, which refers to medications that are added onto an antidepressant regimen to achieve a greater therapeutic effect. Options include lithium, thyroid hormone, antipsychotics, and stimulants.
Ok, so what if you’ve tried, maxed out, and failed on these various treatment strategies? Ketamine, a dissociative anaesthetic, has a novel mechanism of action, affecting the glutamate system in the brain. It is a relatively new treatment and availability can be limited, but there is some good research supporting its effectiveness.
There are a number of other drugs that have been studied that are potential options although there isn’t a large body of research evidence to support them. D-cycloserine is an antibiotic that at high doses acts on the same NDMA receptors that ketamine works on. Minocycline is another antibiotic that has shows some benefit, as it calms inflammatory microglia in the brain. I wouldn’t be all that keen to use an antibiotic for a prolonged period, particularly when there’s not much evidence to back it up. Infliximab, which is used for autoimmune diseases, has shown some antidepressant effect in depressed people with elevated levels of inflammation. As a biological agent, it is quite expensive. Botox has also been shown to be helpful, and I feel like I’ve had some positive results from it.
Scopolamine, which is used for nausea, appears to have an antidepressant effect via its action on muscarinic receptors in the brain. Studies have primarily involved 3 doses via IV infusion, with a rapid but not sustained effect. This is something I’ve considered trying in the form of an intramuscular injection, as the oral version of scopolamine that’s available in Canada can’t cross the blood-brain barrier to enter the brain.
Blocking kappa-type opioid receptors has been associated with an antidepressant effect. This is different from the µ-type opioid receptors which are associated with effects like analgesia and respiratory depression. Buprenorphine, which is found in Suboxone, is a kappa antagonist but also has effects on µ receptors, and research is being done to develop drugs that are selective for kappa receptors with no activity at µ receptors.
There are a number of over-the-counter supplements which have shown some effectiveness in depression. These include L-methylfolate, which may be most useful in those with elevated inflammation or impaired methylation cycles, S-adenosyl methionine (SAMe), omega-3 fatty acids, creatine, and n-acetyl cysteine, which decreases oxidative stress. I take L-methylfolate along with vitamin B12 by injection every 2 weeks, and have noticed that if I go longer than 2 weeks my thinking and my energy start to slow down. I also take omega-3’s, although I’m nor sure if it’s actually helping me or not.
Other options involve the application of energy to the brain. Probably the best known is electroconvulsive therapy (ECT). ECT has been helpful for me in the past, but it’s difficult to manage on an outpatient basis, both because of the effects on memory and because you’re required to essentially have a babysitter on ECT days. Another option is transcranial magnetic stimulation (TMS), which stimulates the brain through the creation of a magnetic field.. It has demonstrated good results in research studies, and because there’s no anaesthesia involved that decreases the pain-in-the-butt factor compared to ECT. It brings about its own pain-in-the-butt factor, though, as it’s more frequent, and at least where I live it’s not covered by insurance. Deep brain stimulation (DBS) is another option that I have very limited familiarity with. This involves the surgical implantation of a neurostimulator device that sends electrical impulses to target areas in the brain. DBS is also used for other conditions including Parkinson’s disease. The potential complications sound a bit frightening, but a quick google search shows it’s the most common operation performed for Parkinson’s Disease at the major local hospital in my area.
How is your treatment working for you? If it’s not working, what other options have you considered?
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I was browsing the web for interesting therapy materials, when I came across the worksheets for Acceptance & Commitment Therapy for Anxiety Disorders on the website of one of the authors, Dr. John Forsyth. I’ve never done ACT, but I’ve done a lot of reading about it, and it makes a lot of sense to me.
One thing that I found particularly interesting is the White Bear Suppression Inventory, which I’ve copied verbatim from the linked site; the material is copyright (1994) by Blackwell Publishing Company. All questions are rated from 1=strongly disagree to 5=strongly agree:
1) There are things I prefer not to think about.
2) Sometimes I wonder why I have the thoughts I do.
3) I have thoughts that I cannot stop.
4) There are images that come to mind that I cannot erase.
5) My thoughts frequently return to one idea.
6) I wish I could stop thinking of certain things.
7) Sometimes my mind races so fast I wish I could stop it.
8) I always try to put problems out of mind.
9) There are thoughts that keep jumping into my head.
10) Sometimes I stay busy just to keep thoughts from intruding on my mind.
11) There are things that I try not to think about.
12) Sometimes I really wish I could stop thinking.
13) I often do things to distract myself from my thoughts.
14) I often have thoughts that I try to avoid.
15) There are many thoughts that I have that I don’t tell anyone.
I was already aware that I tend to use avoidance as a fall-back strategy, but this inventory reminded me just how much I end up doing this. I would rate myself a 5 (strongly agree) for questions 1, 2, 3, 5, 6, 8, 10, 11, and 14. Yikes. Yet with the current state of my treatment-resistant depression, I wonder if this suppression is the only way that I can manage to keep it together most of the time. That sounds avoidant in and of itself, but I think it’s a legitimate question; with an illness that’s only partially responsive to treatment, are there limits to how much my conscious mind can handle? And from a mindfulness perspective, is it useful to think about things related to past and future that I have limited control over, or is it better to just keep on chugging in the present moment? I really don’t know, and to be honest, I don’t know that I’m prepared to trust anyone enough to dig into that further.
Did this suppression inventory tell you anything new about yourself, or did it confirm anything you already knew?
Image credit: https://www.drjohnforsyth.com/free-resources.html
I was raised in a household where alcohol consumption consisted of one or two beer or glass of wine the occasional evening. I was offered small sips of both, and didn’t like the taste of either. In my early university days, I drank, often heavily, on or two nights a week. It was part of a package of having fun with my friends. It wasn’t something I used as a coping strategy, I never drank alone, and I never craved alcohol on nights we weren’t going out. I always planned ahead to make sure I’d be safe, so as far as binge drinking goes I’d say I was fairly responsible.
As I moved a little further into my 20’s, with the odd party night as an exception, I became a social drinker, having a drink or two when out with friends doing non-alcohol-focused things. As I moved into my 30’s and became more asocial in general, I drank alone more of the time, but the general pattern of consumption stayed the same.
But then depression got in the way. When depressed, alcohol became an escape tool. It would allow me to forget some of what I was feeling and thinking about. That worked (sort of) until it started making things worse. Because the temporary escapes meant more and more pain was getting bottled up inside, ready to explode. That’s where alcohol, instead of lifting me off the ground, dropped me hard on my ass.
The most spectacular alcohol-triggered meltdown happened when I was 33. Unfortunately, it happened to be at a work team-building retreat. The team I was working on at the time was pretty laid back, and some alcohol consumption was considered normal at the annual retreats. I had brought a 4-pack of cider, and I figured that spaced out over the course of the day, accompanied by plenty of food, that would be manageable. Except it wasn’t. Somehow, by the end of the afternoon, that 4 cider had got me totally drunk. I remember standing around with a group of people and I started crying. I went to the washroom and had a huge sob-fest. And then I, someone who has never driven drunk ever, started insisting that I was leaving and I was going to drive myself home. Unsurprisingly, others intervened, but it got ugly. I was yelling at people, and they had to physically wrestle me outside and into the passenger seat of my car. Someone drove me home in my car, and I sobbed the whole way. Things continued to get worse from there. A couple of months later, I ended up in hospital, and then a couple of months after that I was back in hospital again after a suicide attempt.
You would think it would have been lesson learned. Perhaps I have, in the sense that I recognize that depression-related escapist drinking is destructive. I still do it, but manage to put the kibosh on it before it gets out of hand. Yet when the depression is relatively manageable, alcohol and I have an easy non-problematic relationship.
Does mental illness interfere with your relationship with alcohol or other substances?
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Not too long ago I wrote a post on how not to be supportive of someone with depression, and had a comment from Meg that I should do a post on how to be supportive. So here it is. I freely admit that this is a post that’s been done many times before by many different people, so I doubt I’m coming up with anything particularly original, but here’s my two cents.
What are some of the things you would like people to do when you’re not feeling well?
I feel trapped in several areas of my life. Trapped in a few different ways, and really not sure how to get myself out.
The most obvious is that I feel trapped in my depression. I’m feeling at a loss as to what to do. I’m managing ok for the most part, but I want to be able to do more than just managing. Yet I have a reluctance to mess with the treatment regimen that’s keeping me reasonably contained a fair bit of the time, so I’m coasting along and getting knocked off the rails whenever anything mildly distressing comes up.
I feel trapped in my career. I’ve kvetched about this before, but there are factors outside of my control that seriously limit my options (mostly related to a former bully‘s somewhat successful attempts to destroy my career). Plus I worry that trying and failing to push back against those external factors could further destabilize my mental health. So I look for the path of least resistance, which is typically to stay bogged down in the status quo.
Then there’s interpersonal relationships. I shut people out of my life. I’ve pushed my family away, yet at the same time the maintenance of this distant but still kind of there relationship doesn’t feel very good. Yet I have no idea how to let myself open up and move in closer, because it just doesn’t feel safe.
In a sense I feel trapped in my city. I like where I live, and I’m very comfortable in the condo where I’ve lived for the past 13 years. But I’m so settled in that even if moving seemed like a good thing to do for my career or other purposes, the very idea is terrifying. The thought of having to go through the process of selling my place and trying to find a new home is completely overwhelming, to the point that I don’t even think of it as a feasible option, at least for the time being.
While some of this trapped-ness is related to external factors, a large part of it is firmly rooted in my thinking. Yet recognizing it doesn’t necessarily make it easier to move out of my rut. When even my rut feels scary and unsafe a lot of the time, and when past experience has clearly shown that the world often in unsafe, it’s hard to contemplate what positive change could actually look like.
Are there areas of your life where you feel trapped?
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I love Canada, but sometimes we’re a little behind. Drugs are slower to get approved by Health Canada compared to the US, and we have fewer clinical trials going on here. I would be really interested in trying out ketamine, but it doesn’t have Health Canada approval for use in depression, there are no clinical trials in my neck of the woods accepting new patients, and going to a private clinic in the US would be extremely expensive. So for now, all I can do is dream of ketamine. But in the meantime, what is ketamine and how does it work?
Ketamine has been in use for some time as an anaesthetic drug, and it has been abused as the club drug Special K. In the last several years multiple research trials have shown that it has a rapid onset antidepressant effect (within about 24 hours). It increases rates of remission in major disorder, but the effect is not as pronounced for bipolar depression. It appears to have a protective effect against suicide, and unlike many antidepressants it doesn’t appear to trigger mania.
It has a different mechanism of action than other antidepressant medications. It acts on NMDA and AMPA receptors, affecting the balance between the calming neurotransmitter GABA and the excitatory/stress neurotransmitter glutamate. It also boosts production of BDNF (brain-derived neurotropic factor), which in turn promotes the formation of new synaptic connections in the brain. It has been suggested that people with depression may have abnormalities related to their NMDA receptors and experience what’s referred to “excitotoxicity” from glutamate overactivity.
Ketamine is typically given at a dose of 0.4-0.5 mg per kg of body weight, which is a lower dose than would be used for anaesthesia, with 1-2 doses per week. The effect from each dose typically lasts 3-7 days, but can last up to 15 days. It can be given as an intravenous infusion, or the esketamine version of the drug is available as a nasal spray.
Apparently side effects are generally mild and wear off within 2 hours. While harmful effects to the bladder can occur at high doses, this hasn’t been demonstrated at the doses used for depression treatment. It can have dissociative effects while the drug is being infused and in that 2 hours window after the dose, which could potentially limit the tolerability for some people. It can trigger spikes in heart rate and blood pressure, as well as headaches, dizziness, blurred vision, drowsiness, abnormal sensations, and perceptual disturbances. Patients remain in the clinic for a period of time following the dose so that they can be monitored.
What are your thoughts? Have you had any experience with ketamine?
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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?
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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 are treatment-resistant and 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.
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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.
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.
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
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.
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.
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.
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?
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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.
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Content warning: This post talks about suicide, but not in the present tense. You can find info here on crisis lines.
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?
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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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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.
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.
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.
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.
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.
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?
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.
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?
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.
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.
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:
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…
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-ville. Enjoy the ride!
You can find my other book reviews in my blog index.
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?
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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.
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.
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 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 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 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 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.
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?
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
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:
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:
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.
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:
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.