Depression

When I was a teenager, I experienced what I now recognize as “depression.” I have vivid memories of the professionals with whom i came into contact who ranged  from traumatizingly unhelpful to life-savingly helpful. Ever since, I have been drawn to insider accounts of depression and recovery from depression.

My experiences as a therapist continue to deepen/thicken my understandings. The people who consult with me teach me so much – some of which I share in the book, Reauthoring Teaching such as:

• Public Practices (Chapter 9) about working with Nicole in her struggles with  suicidal depression, bodily harm and anorexia.
• Teaching Stories (Chapter 8) about Kate’s experience of psychotic depression

Chava has taught me a great deal about the tyranny of suicidal thoughts and the choice to abandon one’s life.

“Letter to Nina’s loved ones” has been circulated to many people throughout the world.

I just posted a bunch of links to articles and recordings by Andrew Solomon  – his accounts of his own experiences of depression and what contributed to his recovery, and foray into cross-cultural possibilities.  Here is one of his talks on The Moth:

More form Andrew Solomon on the Moth.

That is just a glimpse. And I’m sure many of you have some of your own experiences, knowledge and resources.

I am starting this interest group to see who else out there shares a particular interest in/against depression. For example, Andrew Solomon’s writing can be rather provocative in his belief that drugs saved his life (it’s especially provocative since his father is apparently the CEO of the drug company that brought Celexa to the USA). I have witnessed many times how the right mix of anti-depressants can save lives. And yet, there is also reason for cynicism toward the profit motive in the pharmaceutical industry. I’d love for more conversation that allows for the complexity..Anyone else?

Peggy

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Mohammad: February 13, 2011

The depression has been an old friend of mine. Far into my childhood it was there with me and like you in my teenage years revealed how strong of a hold it had on my life and the important role that it played in shaping its direction. I recall tearful nights in early teens filled with a sense of longing that what I wished out of my life was not in grasp and the possibilities of ever reaching it seemed so dismal. Like a lover who could not join the beloved I mourned the loss of a lover I had never had and never known.   Poetic in one hand and joyless in another.
Obviously hormones were at work wrecking havoc and so was the desire to eek out more out of a life that was permeated with limitations and oppression. I wished for Freedom.
I lived in Iran then, then a society much similar to what Egyptians are emerging from. Those around me seemed beaten and unable to live their dreams.  The governing system had failed to live up to its promise to provide opportunities for all. Only a very small, select portion seemed to have available to them that which they needed from the external world to build upon and pursue their dreams. Education, career opportunities, a measure of financial safety, reasonable health care, freedom to associate with others, express opinions and form relationships as one wished were only available to, in those days, the members of the elite, the top “one thousand families”.
Those were some of the societal forces that gave credence to the depression and power to capture and hold firm. And yet there were much that were unique to my family and within my own skin.
My relationship with that old friend has evolved. I have at times been subservient to it and at times been able to make friends with it and even get around it. It is through much effort to not heed to its instructions to stay “in” and “alone” as if I were contagious and needed to be quarantined. Like a predator that would want to have its prey away from the pack, the depression corners its prey by convincing it to be ill and contagious. Conversely it is being with others out in the light where its grip loosens.
My work now helps me watch the struggles of others in transforming their relationship with the depression. Situated in a psychiatry program, I have observed the advantage that medication provides. The explanation that I provide is that being in the clutches of the depression is akin to being in a bowl wishing to climb up and out and medication being the boost to push part way up but the rest has of the way would need to be through personal effort through cultivating connections with like minded others and engaging in activities that promote a sense of realistic joy.
The promise of medication has to be examined in the light of all its economical imperatives and understood that over time it wears off!
Human connection however does not!

Mohammad: January, 2012

Hi All,
Sitting through the weekly meeting for “Mood Disorders Clinic” I learned that in the past when a psychiatrist would hospitalize one of his/her patients s/he would have been the one to attend to the patient in the hospital also. Today we have “Hospitalists” who care for patients not the psychiatrist who has decided that hospitalization was necessary. This shift is more for “insurance purposes and pertains to financial structure of the hospital rather than the needs of the patient and the psychiatrist.” I wonder how else financial imparatives may be influencing the way in which we percieve “Disorders” and how to “treat” them.
Below is a brief commentary about Depression. I wonder what you think?
Mohammad

Depression Defies the Rush to Find an Evolutionary Upside
New York Times
January 16, 2012

By RICHARD A. FRIEDMAN, M.D.

In certain quarters of academia, it’s all the rage these days to view human behavior through the lens of evolutionary biology. What survival advantages, researchers ask, may lie hidden in our actions, even in our pathologies?

Depression has come in for particular scrutiny. Some evolutionary psychologists think this painful and often disabling disease conceals something positive. Most of us who treat patients vehemently disagree.

Consider a patient I saw not long ago, a 30-year-old woman whose husband had had an affair and left her. Within several weeks, she became despondent and socially isolated. She developed insomnia and started to ruminate constantly about what she might have done wrong.

An evolutionary psychologist might posit that my patient’s response has a certain logic. After all, she broke off her normal routine, isolated herself and tried to understand her abandonment and plan for the future. You might see a survival advantage in the ability of depressed people like her to rigidly and obsessively fix their attention on one problem, tuning out just about everything and everyone else around them.

Certain studies might seem to support this perspective. Paul W. Andrews, a psychologist at Virginia Commonwealth University, reported that normal subjects get sadder while trying to solve a demanding spatial pattern recognition test, suggesting that something about sadness might improve analytical reasoning.

In a similar vein, Joseph P. Forgas, a psychologist at the University of New South Wales in Australia, found that sad subjects were better judges of deception than happy ones. After subjects were shown a video intended to induce a happy or a sad mood, Dr. Forgas had them view deceptive or truthful interviews with people who denied committing a theft. Subjects in a sad mood were more skeptical and more accurate in detecting deceptive communication, while subjects in a positive mood were far more trusting and gullible.

Findings like these may suggest some benefits to sadness, but lately they have been generalized to patients with full-blown depression. For example, Dr. Andrews and Dr. J. Anderson Thomson Jr., a psychiatrist at the University of Virginia, have proposed that the rumination of depressives is an adaptive strategy to solve a painful problem. Clinicians, on the other hand, continue to maintain that the grim outlook of depressives is evidence that their thought process is distorted and erroneous. It must be fixed, not embraced.

There is strong evidence from neuropsychological and brain imaging studies that clinical depression is linked with various types of memory impairments in all age groups and at all levels of depressive severity. Challenging and changing the dysfunctional thoughts of depression are the exact aims of cognitive-behavioral therapy, one of the most empirically validated and popular forms of psychotherapy.

So who’s right about depression, the evolutionary biologists or the clinicians?

To start, the subjects in the above studies were normal controls whose moods were manipulated to be transiently sad. They do not really resemble people with clinical depression, whose condition can last months or even years.

Indeed, as Dr. Forgas said by e-mail, “I never worked with depressives, and I do not think that the experiments we have done looking at mood effects on cognitive processes in normal populations experiencing minor, everyday mood differences can be readily generalized to depressive cognition.”

Under close scrutiny, the case for depression’s adaptive benefits has problems — big ones. For one thing, the ruminative thinking of depression is often not particularly effective in solving problems. As another patient of mine once said: “I would think the same things over and over and could never decide what to do. It’s not a creative way of thinking.”

More critically, depression can arise without any psychosocial stressor at all, which makes it hard to argue that depression is a response to a difficult situation or problem. Dr. David J. Kupfer, a psychiatrist at the University of Pittsburgh, has found that a major life stressor almost always precedes a first episode of depression, but that episodes recur with milder stressors, or even none at all.

If depression conferred a problem-solving benefit, it should not become a chronic or autonomous condition — which it is for about half the patients.

According to the World Health Organization, depression is the leading cause of disability and the fourth leading contributor to the global burden of disease, projected to reach second place by 2020. There is also strong evidence that it is an independent risk factor for heart disease, and several studies show that prolonged depression is associated with selective and possibly permanent damage to the hippocampus, a region of the brain critical to memory and learning.

Add the fact that 2 percent to 12 percent of depressed people eventually commit suicide, and the “advantages” of depression suddenly don’t look so good.

Why, then, does the notion persist that depression confers special insights and benefits?

I got a clue recently from one depressed patient. He was an educated and articulate young man, unhappy because the world was such an awful place, he said. Because he had so many other symptoms of depression — insomnia, fatigue, low libido and poor self-esteem — I told him that he was clinically depressed and that his Hobbesian worldview was probably a result of depression, not its cause.

He scoffed, but he was willing to try a course of cognitive-behavioral therapy and antidepressant medication, if only to feel better. Months later, when he had recovered, I asked him again about his worldview.

The world was just as dire, he said, but he felt better. Still, he speculated wistfully that his newfound cheerfulness was not his authentic self, which he described as brooding and creative.

This cuts to the heart of why depression is increasingly romanticized. What is natural, the thinking goes, is best. If we are designed to suffer depression in response to life’s ills, there must be a good reason for it, and we should allow it to take its painful and natural course.

But unlike ordinary sadness, the natural course of depression can be devastating and lethal. And while sadness is useful, clinical depression signals a failure to adapt to stress or loss, because it impairs a person’s ability to solve the very dilemmas that triggered it.

Even if depression is “natural” and evolved from an emotional state that might once have given us some advantage, that doesn’t make it any more desirable than other maladies. Nature offers us cancer, infections and heart disease, which we happily avoid and do our best to treat. Depression is no different.

Peggy: January 18, 2012
Thanks for opening the conversation about depression. I somehow missed seeing the article in Monday’s NYT. I like the article very much. In both contexts – envisioning you at your “Mood Disorders Clinic” meeting at Hopkins, and the discussion of depression through the lens of biological evolution – I am struck by the current medicalization of human behavior including Depression. Having seen close-up the life-saving benefits of anti-depressants in the face of debilitating depression, I deeply value the contribution of western medicine. Yet I also get really uncomfortable when I hear people talk about “depressives” being “treated” by hospitalists.

I immediately think of several people with whom I have worked intensely through life-threatening depressions. After their recovery, they have each told me in their own way that what mattered most (combined with finding the right medication) was my “there-ness” in accompanying them along the way. It was that checking-in phone call,  making the effort to visit during a hospitalization after taking action to end one’s life, someone remembering when I said earnestly “I don’t want to lose you” – in all of these situations, they knew a human being on the other side was not forgetting the person, knowing that I was still there, and not giving up. I fear this might be seen as “poor boundaries” in therapy school, yet I am committed to these ways of working and being. So putting that “Hospitalist” in charge feels like a cop-out to me, and not particularly cost effective in the long run.

Over the years, I have witnessed how depression can take many different forms. It’s an umbrella term, isn’t it, used to convey a range of experiences? Everyone knows sadness and loss. Yet real “depression” is in a category of it’s own,  like a cyclone that can wreak havoc on the life of an otherwise very competent wise person. Sometimes the manifestation is more is the form of acute anxiety and disorienting confusion than “sadness.”

Mohammad, what is it like for you to participate in the “Mood Disorder Clinic” at one of the most esteemed hospitals in the USA? How do you cope with this medicalization and expert model of treatment? (I just got notice that my battery is running out).

What about people living in other countries/cultures? How is Depression manifested and treated where you live?

Peggy

Sarah: January 21, 2012

Thanks for this discussion Mohammad and Peggy
There is a blizzard here in my town today and I am sitting by my hire feeling content and warm.  But I have been holding some of the people I work with in my hear today as I look out the window.  People really struggling with despair and hopelessness and living in situations that require them to get up and chop firewood or they will freeze.  I imagine the blizzard does not seem so cosy to them.
I appreciate your thoughts as they capture some do the complexity of depression but also remind me of the importance of there-ness.  I want to be there and i am going to send out some letters/emails today to capture some of the little glimpses of light I saw in the conversations I had with people this week. I know when I am feeling down and out – and I have been a lot over the last year or so – a letter reminding me of myself and my connections can make a world of difference to my day.
Sarah

Peggy: January 22, 2012

Sarah! It’s so good to feel your presence here again. Every post. I have continued to think about the complexity of depression. It’s true that I have seen up close how medication can save lives –  anti-depressants and anti-psychotics in particular. And yet, the reverse is also true. Last week, I met with a woman whose husband abandoned his life (suicide) 4 years ago, after many years of struggle with depression. Looking back, she remembers many crises along the way, and believes each time the psychiatrist (there were many along the way) would add another medication to the mix. She says she thinks all the medication made his depression worse, and lamented “If only there could have been a place where he could detox totally from all the meds, and then step-by-step explore options from scratch again.” I really understand this. Do only the very rich have the time or money for such a restorative convalescence? If Jo and her group in South Africa can offer a program for people detoxing from heroin or alcohol, why can there be a similar program for recovering from many years of added on medication? I think  tinkering with meds used to be a legitimate reason for hospitalization, yet everyone knows a hospital is often not a healing place and certainly no place to linger. It’s simply not possible to adequately taper off of drugs and then explore possible other options in the short hospital stays that insurance will cover here in the USA. What about in other countries?

Peggy

Mohammad: January 22, 2012

Dear Peggy,
Dear Sarah,
Dear All,
I am a psychotherapist, a clinical social worker- or even better description: a psychiatric social worker- in an outpatient clinic for adults, part of a community psychiatry program, located on the campus of a hospital. Most of the people who come to us are either looking for the best care possible which they hope to receive from one of the best hospitals in this country, as Hopkins deservedly has the reputation for providing in many areas. Or that they want mostly psychiatric care, which we are well equipped to provide; our program employs plenty of psychiatrists who can see “patients” in a relatively short time, often within a week if not days. The rest of the folks who turn to us for care are from the surrounding neighborhoods- as the program in essence is a community mental health center- and are on medicare or medicaid (it is called Medical Assistance in Maryland and offers rather generous mental health benefit, up to 150 psychotherapy sessions per six months-can do psychoanalysis if desired!) and are basically poor or have a disability status. Most also would rather take a pill and make the problem go away and who wouldn’t if the pill actually could do so.
My focus lately is more on trauma. I am more and  noticing how traumatic events set off reactions that can manifest as “the depression” or other “diagnosis”.  Medications can help some folks tremendously with the depression but need not to be viewed as the final fix that requires tweaking every now and again.
The legacy of the traumatic events continue to impact the survivors’ lives adversely and medications may indeed hinder the process of re-learning and re-positioning oneself in relation to the trauma.
At the moment for anyone requiring hospital care- due to experiencing a psychotic episode, feeling suicidal/homicidal and feeling grossly unsafe- usually due to having experienced a traumatic event such as a loved one’s suicide or having taken some form of action against his/her own life- the number of days they can stay in a psychiatric unit are rather limited. The care itself consists primarily of medication management and occupational therapy groups, and in most settings absolutely no psychotherapy, no “restorative convalescence” period, no one to feel connected with who can guide toward a way out while a person in crisis weathers the storm. That is left to very much over stretched, under resourced and under paid outpatient psychotherapists working within corporate structures that view and refer to traumatized folks as customers and hence the care provided subject to productivity and efficiency standards of a widget manufacturing plant. The role of the social workers in the psychiatric unit, even if they have any training in psychotherapy which is probably not the case, is to prepare the discharge summary and locate the after care, as the care in the psychiatric unit is just about trying out a few medications, or changing the ones that people are already on to “stabilize” them, patch them up and send them back out.
There are places, as you mentioned Peggy, that cost a lot of money-$1900 per night in one setting- that provide the old fashioned care (individual, groups, etc. and the new models including yoga, meditation, EMDR, DBT, the whole works, as well as psychiatric medication management and even psychotherapy provided and led by psychiatrists as it was the case long ago!) for as long as you can pay which the very wealthy can only access. So, yes we do have a two teared system here in this country.
But, I am not here to despair.
It is amazing how people are resilient and can even make use of the placebo effect effectively. Just the fact that someone is there to listen, daring to collaboratively create the “there-ness” together, people do feel safe to let go of the safety of the pill.
The psychiatrist who leads the “Mood Disorders Clinic” is amongst those who think less medication is best. He is a leading author on Bipolar disorder though he can be heard saying “that person is bipolar.” When that person comes into my office, however, the first thing I do is to externalize the bipolar or the depression by pointing out that if they had been diagnosed with cancer no one would say “that person is cancer.”
So, to answer your question about how it is for me to be sitting there in that “clinic”: I see myself as a subversive!
My role is, once back in the safety of my tiny office, to bring the attention back to personal agency, to the fact that surely the medication did not do all that, influencing folks to acknowledge their own role in bringing about the changes that they notice, be it even in the form of diligently taking the medication, to acknowledging the implicit hope that life could be better and how is it that they know that, when did they experience “the better”, and asking for a rich description of the hardly ever told stories that have been squelched and over shadowed by the dominant problem saturated stories about the pathology and how they have been convinced that they are the pathology and somehow have agreed to view themselves as that, and the process of self- subjugation, how did that come about, what is its use and what are its pitfalls for them, what is the price and what they gain, and what others gain, the psychiatrists, the pharmaceuticals, the insurance companies, and even I the therapist in the position of power, undermining that power differential as much as possible hopefully down to two human beings in the room, charting unknown territories, uncertain, with hearts intent to beat a new more life fulfilling rhythm!
Mohammad

Sarah: January 24, 2012

Good morning
Really great for me to read this before I head off into a day of 15 consults with the psychiatrist.  I will hold onto some of your words and loving ways of caring to keep on track with being the kind of consultant I want to be today.Thank you.
Sarah

Mohammad: January 24, 2012

Hi Sarah,
Hi Peggy,
Hi All,
The article bellow about the possibility of expansion of the diagnosis of “depression to include grieving” speaks for itself!
Mohammad

 

 

The New York Times

January 24, 2012

Depression’s Criteria Might Include Grieving
By BENEDICT CAREY

When does a broken heart become a diagnosis?
In a bitter skirmish over the definition of depression, a new report contends that a proposed change to the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it.

The criteria for depression are being reviewed by the American Psychiatric Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come.

In coming months, as the manual is finalized, outside experts will intensify scrutiny of its finer points, many of which are deeply contentious in the field. A controversy erupted last week over the proposed tightening of the definition of autism, possibly sharply reducing the number of people who receive the diagnosis. Psychiatrists say current efforts to revise the manual are shaping up as the most contentious ever.

The new report, by psychiatric researchers from Columbia and New York Universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems.

But experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego.

In blogs, letters, and editorials, experts and advocates have been busy dissecting the implications of this and scores of other proposed revisions, now available online, including new diagnoses that include “binge eating disorder,” “premenstrual dysphoric disorder” and “attenuated psychosis syndrome.” The clashes typically revolve around subtle distinctions that are often not readily apparent to those unfamiliar with the revision process. If a person does not meet precise criteria, then the diagnosis does not apply and treatment is not covered, so the stakes are high.

“The world has changed” since the last revision, in 1993, said Dr. James H. Scully Jr., chief executive of the psychiatric association. “We’ve got electronic media around the clock, and we’ve made drafts of the proposed changes public online, for one thing. So anybody and everybody can comment on them, at any time, without any editors.”

Many doctors and therapists approve of efforts to eliminate vague, catch-all diagnostic labels like “eating disorder-not otherwise specified” and “pervasive development disorder-not otherwise specified,” which is related to autism. But a swarm of critics, including two psychiatrists who oversaw revisions of earlier editions, has descended on many other proposals.

“What I worry about most is that the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily,” said Dr. Allen Frances, who was chairman of the task force that revised the last edition.

Dr. Frances, now an emeritus professor at Duke University, has been criticizing the current process relentlessly in blog posts and e-mails. Dr. Robert L. Spitzer, who oversaw revision of the third manual in 1980, has also voiced concerns, as have the American Counseling Association, the British Psychological Society and a division of the American Psychological Association. Some of the concerns have to do with important technical matters, like the statistical reliability of diagnostic questionnaires. Others are focused on proposed changes to the most familiar diagnoses.

Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression.

But the proposed diagnosis of depression has no such exclusion, and in the new study, Jerome C. Wakefield of New York University and Dr. Michael First of Columbia concluded that the evidence was not strong enough to support the change. “An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”

But Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and the chairman of the task force making revisions, disagreed, saying, “If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression — well, that is not being clinically proactive. That person may then not get the treatment they need.”

Another point of growing contention is a proposed new diagnosis, “attenuated psychosis syndrome,” which would be given to people who experience delusional thinking and hallucinations and sometimes say things that do not make sense. Psychosis is the signature symptom of schizophrenia, typically a lifelong, disabling mental disorder. Psychiatrists have long hoped for a way to catch it early, before it turns into full-blown schizophrenia.

But critics say these symptoms are poor predictors of the disorder. In studies, 70 percent to 80 percent of young people who report these strange experiences do not ever qualify for a full-blown schizophrenia diagnosis, yet the label increases the risk of being “treated” with powerful anti-psychosis drugs.

“There’s already overuse of these drugs in children and adolescents, and having this vague diagnosis, regardless of its intent, will only increase misuse in this vulnerable population,” said Dr. Peter J. Weiden, director of the psychosis treatment program at the University of Illinois at Chicago.

Some outside experts say the same is true of other proposed additions, like premenstrual dysphoric disorder (lethargy and other depressive symptoms in the week before menses, among other things) and binge-eating disorder (out-of-control bingeing, complete with self-loathing). Getting the diagnosis increases the likelihood of being treated for what is normal behavior, or close enough.

Task force members argue differently: if a person is in distress and seeking help, then treatment ought to be offered — and covered by insurance.

For now, these revisions are still in play; the completed manuscript is due to the printer in December. In the longer term, the politicking is likely to have a corrosive effect on the process, some experts said. Recent findings in genetics show that nature does not respect psychiatric categories — many different disorders seem linked to some of the same genetic glitches.

Already a federal agency, the National Institute of Mental Health, has set up its own independent effort to classify mental disorders, called Research Domain Criteria, which will not be based on existing categories.

In time, said Dr. Steven E. Hyman, a resident scholar at the Broad Institute of M.I.T. and Harvard, this kind of approach should ground the field more in nature and less in expert opinion. Until then, there is and will be the diagnostic manual.

Mohammad: January 25, 2012

Hi Sarah,
It just darned on me! Fifteen Consults in one day!? Oh, my!
I think four or five with three or four different psychiatrists I have ever been able to manage.
In our clinic we, the therapists, essentially do the work of physician’s assistants without the privileges- writing scripts, etc.
We make the appointments for the “patients” with the psychiatrists and facilitate that appointment. That is we sit through the session and often even record in the chart the prescriptions written, the changes to medications, etc. and make sure the required signatures and documentation is done. The psychiatrists most of the times don’t know the patient. We help them remember and update them about how the patient is doing, etc. Every medication review session lasts 30 minutes or more. Depending on the style of the particular psychiatrist we may participate in the “interview” during this session or just sit back and listen. We are often handed the prescriptions to pass on to the patient and are responsible for obtaining refill prescriptions for patients and even the lab results go through us.
It is a rather unique arrangement. I am told that almost no other clinic takes as much responsibility away from psychiatrists and hands it over to therapists and yet maintains the traditional hierarchy of the medical establishments.
It has been great learning process for me. After four years and some months in the clinic I know a great deal about medications, the side effects, dosages, etc. that I some of the psychiatrists often do want to know my opinion on the suitability of the medication they have in mind for the patient. I am often talking with patients about their medications, calling pharmacies about medications, and advising patients on how to manage their medications.

This morning I had a very interesting conversation with a patient who has been in the clutches of the depression for over 20 years and has been coming to me for consult for nearly three years. He helped me understand how the medication has been immensely helpful to him and how after all these years with the help of medications and psychotherapy together he has been able to shift his position from a passive “fix me” relationship with both therapist and medications to an alternate stance of he being in charge, claiming his personal agency and directing the process. He explained that he had seen himself at war with the depression for much of those years but at last he has “invited the depression in for negotiations, realizing that there are times that the depression has been his ally.”
Good Night!
Mohammad

Sarah: January 26, 2012

Hello,
I like that story.  And the article was interesting.  So much to think about. I just have a minute here as I have to walk my dog but I wanted to say that I work in a small rural town so the psychiastrist only comes out once every six weeks. So we do one crazy long day.  We do give longer to the new consults and then just 15 or twenty minutes for people she saw the last time.  So I was tired at end of that day!
It is a huge problem here the lack of resources.  I am the only mental health person in the town and I only have 22 hours to work.
Anyway I will take the dog out and ponder that article and my thoughts about grief and depression.  I am so invested to know what others think too?
Sarah

Bonnie: February 1, 2012

It’s very nice to have you back Mohammed

I’ve been so fortunate to work in a Family Health team practice for the last 18 months- it’s in a hospital setting, but it’s not hospital social work- it is entirely therapeutic conversation.

However, we have electronic records, and I am able to work closely with the physicians, in general practice.

One thing that I have been doing regarding medication for depression is making use of some of the interesting ideas from neuroscience.

I tell people a bit about the plasticity of the brain, and talk about the ‘neurons that fire together, wire together’ and how depression and anxiety work to create habits of mind/body- paving a very fast pathway in the brain.

I use the metaphor of a roadblock, to explain that medication can slow the ‘traffic’ on this pathway, giving them time to develop other practices to ‘pave other pathways’ in the brain, other habits of life that reduce Depressions influence.

I use Walter Bera’s question ‘what are you doing to help the medication help you?’ (He asks this when people give all the credit for change to medication- he wants to shine a light on their own actions)

The people I have shared this information with tell me that it is very useful. Not everyone choses to use medication- some begin to ‘rewire their brain’ by focusing on alternative stories and practices; for those that do chose to use medication, they seem to be much more active in their partnership with it (like the fellow you mention Mohammed)- they are taking up ways of thinking and acting that develop those other pathways, and access to those other stories. The medication just helps us clear some space to do that…

Bonnie

Mohammad

Hi Bonnie,
Hi All,
Yes! It feels very nice for me to be back here and talk with you again!
I have been for some time eying the land up north where there seems to be a more sensible approach taken to provision of health care. From where I see it the Canadian approach is more comprehensive with less of a focus on the profit and more of a focus on people!
The Hopkins system is working right now on electronic record keeping system that would allow physicians to write prescriptions that will be directly sent to the pharmacy and everyone will have access to pertinent information such as us for instance having that ability to access the primary care physician’s notes. Right now for some patients who have a primary care physician within the system here at Hopkins I can access their notes and medication charts but for the most part the system at large is still very fragmented. Hopkins is going to have a system called “Epic” up and running soon. The definition of soon though is very flexible within such a massive system. This has been talked about for a couple of years and probably will take another couple of years or even more before epic is in full use. One thing that most don’t know about is the scale of the system that is being talked about. Hopkins employes a quarter of a million people here in Maryland. It is in fact the state’s largest private employer- the largest employer in the state is the Federal government. It will take a while but once is up and running and all the bugs are out it may help speed things.
I have been already using variations of of Walter’s statement but today I used it very much close to what you had written here. It was in front of our chief psychiatrist while we were trying to decide with a patient if she still needed the antidepressant she has been on for a couple of years. She chose to continue to take it but did give herself plenty of credit for the actions she has taken in her life to loosen the hold of the depression.
Mohammad

Mohammad: February 20, 2012

Hi All!

Just a quick note and an article that poses questions that for me are worth thinking about.
I have some thoughts about our relationship with the depression. The way in which we often refer to it as “my depression” almost speaks of, in one sense, an endearment for a friend and ally and in the other as if once in its clutches for a long time, such as it is with all other problems, we may become convinced that we are the depression. I will post later more about what I am thinking. Once in the clutches of the depression it is hard to notice that the problem is the problem not the person.
Mohammad

Psychiatry debates whether the pain of loss is really depression

Amy Vaughn: February 20, 2012

Thanks Mohammed, for getting me back into the loop on the progression of the new DSM, although I have to say I’m angered and saddened by the thought that grief could be added to the list of pathologies in the DSM. I have also struggled with something labelled as ‘depression’ off and on throughout my life, but when my mother died the feelings I had were quite different from those previous episodes. To take grief from the ‘normal’ category and place it into the realm of pathology takes away its power to heal and help people make sense of their loss. Grief does sometimes look like ‘depression’ if it’s prolonged but usually it doesn’t.

Peggy, I appreciate you bringing up the topic. I have struggled with a way to interpret my experiences, not content to think that brain miswiring is responsible for the prolonged helplessness I’ve felt, yet tempted to use the word depression because it conveys a seriousness that most people understand. A narrative practitioner I know substitutes the word depression with oppression, asking what it’s affects are on the person, what supports it, what makes it weaker. The substitution isn’t wholly satisfying either though, because it doesn’t explain why some people have the experience of being oppressed without suffering discrimination by race, class or poverty, and some people do not have the experience of being oppressed when they are on the disadvantaged side of all these things. So really, depression is quite a mystery, to be solved on a case by case basis. It’s also my experience, personally and professionally, that building personal agency is anathema to depression’s hold on a person.

Mohammad: February 24, 2012

Hi Amy,
Hi All,
Thank you for your heart felt thoughts. I like how you word that experiencing grief is the process of healing: “To take grief from the ‘normal’ category and place it into the realm of pathology takes away its power to heal and help people make sense of their loss.”
A friend just recently was put on an anti depressant by her primary care physician who diagnosed her with the depression. She is unhappy with some of the turns that her marriage has taken and rightfully is sad, disappointed and angry about how things have turned out for her. Some of the behaviors of her husband have been oppressive and I wonder too that anger and depression are simply natural reactions to oppression.
I have been thinking about how we take ownership of depression and call it “my depression” or “her depression”. Were it a disease would we say “my heart disease or my high blood pressure”? And if cancer is referred to as “my cancer” is it with the same sense of endearment or ownership?
The depression that I see wrecking havoc in lives of those who for instance have survived through a very traumatic event is an unrelenting tyrant, dishing out oppression in every aspect of their lives and those around them. How did an ally that provided for the process of making sense out of loss become such an exacting adversary? What does really happen in the brain, or does it happen in the brain? How come the heart aches?
I helps me continue hoping that you say: ” building personal agency is anathema to depression’s hold on a person.” There is a way out of the clutches of the depression. They can be loosened. Collectively in the sun light,perhaps dancing, a stance can be taken against the oppression of the depression!
Mohammad

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Los Angeles Times
February 16, 2012

By Melissa Healy

The pain of losing a loved one can be a searing, gut-wrenching hurt and a long-lasting blow to a person’s mood, concentration and ability to function. But is grief the same as depression?

That’s a lively debate right now, as the psychiatric profession considers a key change in the forthcoming rewrite of its diagnostic “Bible.” That proposed modification — one of many — would allow mental health providers to label the psychic pain of bereavement a mood disorder and act quickly to treat it, in some cases, with medication. With the Diagnostic and Statistical Manual’s fifth edition set for completion by the end of this year, the editors of the British journal The Lancet have come out in strong opposition to the new language, calling grief a natural and healthy response to loss, not a pathological state.

“Grief is not an illness. It is more usefully thought of as part of being human, and a normal response to the death of a loved one,” writes the editor of The Lancet. “Most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.”

The change under consideration would expunge any reference to the passage of time since a loved one’s death before a diagnosis of depression could be considered. The current edition of the diagnostic manual states that if a patient’s low mood and energy, sleep difficulties and appetite changes persist for more than two months following bereavement, a diagnosis of depression might be considered. An earlier edition of the manual had established a year as the period during which mourning should not be confused with depression.

“Putting a time frame on grief is inappropriate,” The Lancet’s lead editorial states simply. And in a “Perspectives” essay also published Thursday in Lancet, Harvard University medical anthropologist Dr. Arthur Kleinman agrees, eloquently exploring what’s at stake.

“Is grief something we can or should no longer tolerate?” asks Kleinman, who describes his own grief after his wife of 46 years died last March from Alzheimer’s Disease. “Is this existential source of suffering like any dental or back pain unwanted and unneeded?”

Kleinman calls the current two-month time period allowed for grief a “shockingly short expectation” that no religion or society would support. To allow grief to be redefined as depression with no allowance at all for the passage of time not only spells “the loss of grief”: it risks redefining vast numbers of Americans who are taking their time to adjust to the loss of a loved one as sick, he writes. And it powerfully rewrites cultural values about how we understand and mark the loss of a fellow human being.

Proponents of the change have argued that it would allow the bereaved to seek help for their suffering. And they add that it would not define all who grieve as depressed. They argue there is often no difference, but for the recent death of a loved one, between the behaviors that define depression and those that define grief.

The Lancet’s editors note there is no evidence that antidepressant medications improve the moods of people who are healthy to begin with. Citing fellow critics of the proposed move, Kleinman suggests that it might have been inevitable once the financial interests of pharmaceutical manufacturers collided with psychiatry’s loose definitions of mental illness and the profession’s tendency to expand its patient base.

“Its ubiquity makes grief a potential profit centre for the business of psychiatry,” writes Kleinman.

Copyright © 2012, Los Angeles Times