A person with longer-term depression has often lost interest in many of his usual
activities.
He may have stopped pursuing avocations such as sports or hobbies and has perhaps even stopped working. He may go out less often with
friends, who eventually stop extending invitations.
Shopping can be chore, so, especially if the individual lives alone, the
refrigerator is empty and diet becomes unhealthy. This, together with lack
of exercise, results in lower energy level and less restful sleep.
Perhaps he’s
stopped attending church or synagogue, dropped out of clubs, stopped gardening or volunteering, or going to sports or cultural events.
He gradually
loses touch with the people, places, and things that had been sources of pleasure and satisfaction and kept him involved in the world.
Eventually, the
structure of his life becomes dilapidated, even bleak.
A vicious cycle has been set up: the symptoms of depression have resulted in an environment that makes the depression worse.
One day is just
like the next; with nothing much to look forward to, day blends into night
into the next day.
It’s important to talk about this issue because this lifestyle trap makes
getting better from depression more diffi cult.
Patients who get into treatment after the depressive lifestyle has become established and experience
improvement in their mood will still be hampered by this environment from
making progress as quickly as they would otherwise.
I once had a patient who had taken early retirement in the midst of a
severe depression. After he stopped working, he’d basically retreated to the
home because he was so crippled by anxiety and depression.
His depression
was very resistant to treatment, and it was over a year before he got the defi nitive treatment that improved his condition signifi cantly.
When his mood
fi nally started to get better, he was suddenly faced with all the complicated
issues that retiring persons face: the change in self-concept that comes with
the end of working life, for example.
It was as if after breaking through one
brick wall—severe depression—he had run into another. Because his social
life had largely revolved around work friends, friends he now had much less
in common with, he felt isolated.
He didn’t know what to do with all the time
he now had on his hands because he’d never had many interests outside of
work and family.
At one point when he was nearly better, he told me he felt a
little like Rip Van Winkle: “It’s as if I went into a long, dark tunnel and now
that I’ve come out the other end, I don’t know where I am!”
Because of the
depressive lifestyle he’d been living for a year (not willingly, of course), the
work of getting better was much harder—there was simply a lot more to do
than if he’d just been out of work for a week or two.
He no longer had the
support system he’d once had—the structure of the regular work schedule,
the support system of coworkers and friends—not to mention that he hadn’t
been able to prepare for retirement the way he otherwise would have.
Theree are two main points to note here.
One is that it is very important
not to let the depressive lifestyle take over. This means aggressive treatment
and not giving up—neither the patient nor the doctor—as long as the patient is still impaired from usual activities.
If the depression threatens to
make a major impact, if going on long-term disability is being considered,
for example, it’s time to visit a major medical center for a consultation and
consider hospitalization or ECT.
The other point is that the person who has been depressed for a long period of time will need more than medication to get back to their usual level
of functioning.
Psychotherapy is especially important for these patients to
help them deal with all the complicated issues that emerging from the depressive lifestyle brings them face to face with and to give them the support
and encouragement that their depleted environment no longer gives them.
The term rehabilitation can be applied to this aspect of treatment. Just as a
person needs help readjusting to the environment after a lengthy illness such
as surgery and chemotherapy for cancer, the person who’s recovering from
a long and severe bout of depression (or mania for that matter) needs extra
psychological support.
I’ll be discussing occupational therapy and support
groups later in this chapter, interventions that can be extremely valuable
for these patients and can signifi cantly expedite their recovery in a way that
medication alone cannot.
- Suicide
Mood disorders are potentially fatal illnesses. Self-destructive thoughts
and impulses and even suicide attempts are not uncommon in persons suffering from these illnesses.
The intensely sad and oppressive feelings mood
disorders cause can make life itself seem a diffi cult, even overwhelming, burden.
Minimizing the risk of self-destructive behavior is a necessary part of
living with a mood disorder and needs to be discussed in detail.
Perhaps the most effective means of minimizing the risk for suicide is the
prevention of episodes of illness.
This may seem so obvious as to not bear
discussion, yet, as with many ideas that may seem obvious, it is a rather profound truth. Relapse prevention is really suicide prevention, and I invite you
to reread the preceding sections dealing with relapse with this idea in mind.
Persons with mood disorders should know well all the signs and symptoms
of relapse and not hesitate to get in touch with their doctor should they notice these changes.
. The best preventative action of all in dealing with suicide
is to prevent relapse.
Nevertheless, despite the best efforts of all involved, relapses do occur,
and the symptoms of a recurrent depression may include suicidal thoughts.
The appearance of self-destructive thoughts and impulses is in itself very
frightening, both to the patient and to those around him.
For many centuries, tremendous stigma and disgrace has been associated with suicide, and
this sense of shamefulness still makes some people reluctant to discuss these
thoughts when they occur.
These ideas, similar to the common misconception that “only crazy people kill themselves,” only complicate what is really
a simple clinical issue: suicidal thoughts and behavior are a complication of
a medical illness, a serious complication that warrants immediate medical
attention.
For this reason, involvement of a mental health professional to
assess the situation and make recommendations is a necessary and very appropriate fi rst step.
Another common misconception about suicide is that asking a person if
they are thinking of harming themselves will “plant the idea” and may thus
increase the chances of suicide.
There is no scientific evidence to support this
idea; indeed, many persons who are having suicidal feelings are relieved to
be able to talk about them.
Prediction of suicide is very diffi cult, but one feeling that seems to be
associated with suicide attempts is hopelessness.
Depressed people who express hopelessness, believe there is “no way out,” or feel trapped may be at
high risk of self-injurious behavior.
Those close to the patient with depression need to become familiar and comfortable with words they can use to
ask about suicide: “Are you bothered by feelings that life isn’t worth living?”
“Are you having thoughts about hurting yourself?” If there is even a hint that the answer may be yes, professional assessment of the situation is necessary.
Avoiding the subject may cause the affl icted person to conceal self-destructive thoughts and feelings until they feel overwhelmed and then act on them
suddenly.
To reiterate, mental health professionals know how to assess the risk and
what steps to take.
Change of medication, dosage increase, more frequent
therapy visits, hospitalization—there are many options.
As I said earlier, discussing these thoughts with a professional trained in the assessment of the
potentially self-destructive person can be very encouraging and reassuring
for everyone involved and may in itself resolve the situation.
II want to emphasize that professionals can help best in making treatment
decisions.
If a member of the family with a history of heart problems suddenly developed chest pain, the family wouldn’t try to decide whether or not
to change medication or hospitalize—the doctor would be called immediately!
The appearance of suicidal thoughts should be treated in the same way.
It is a serious symptom; its appearance calls for cool heads and a contingency
plan. Everyone should know who to call and not hesitate to do so.
Everyy year or so I will see a patient in my offi ce who is depressed and, after reassuring myself during the interview that the risk of suicide is low, will
send them home only to get a panicked phone call from a spouse or parent,
“Why didn’t you put her in the hospital?
Didn’t she tell you she had asked
me where she could buy a gun?”
Contrary to popular belief, psychiatrists
cannot read minds! Suicidal thoughts may be accompanied by feelings of
shame, or felt by the patient to indicate weakness or being “really far gone,”
and so might be concealed.
It’s important to remember that just as there are
things a person will tell their therapist and not their family, the converse is
true as well.
Also, suicidal thoughts, like the mood itself in depression, can
change throughout the day or be present on some days and not on others,
or at some times of day and not others. All these factors may contribute to
the patient not revealing these thoughts to the doctor.
The family should not
assume that the doctor will fi gure out in a brief interview everything that
they have been observing for weeks or even months.
Another key in suicide
prevention is free communication—patient, family, and psychiatrist all need
to be talking to each other.
Ironically, when people are getting better from their depression they are
often more vulnerable to suicide. Sometimes severely depressed persons are
so lethargic that any action is too much of an effort.
When they are getting a
bit better and begin to have more energy, it can be a dangerous time.
In the
next section I will discuss involuntary treatment. When someone is suicidal
or even possibly suicidal, one should not hesitate to invoke the legal procedures available to get them the help they need.
Here are a few very simple and practical recommendations that will reduce the risk of suicide and that need to be in place not just during a crisis, but
every day in a household in which a person with a mood disorder resides.
I have already mentioned that it is important for people with mood disorders to avoid alcohol. Abstinence becomes even more critical if depression
has set in, and it is essential if suicidal feelings develop.
Alcohol is disinhibiting—that is, it causes people to lose their inhibitions and become more
impulsive. It’s not diffi cult to see how dangerous this is in the depressed
person.
A signifi cant percentage of persons who commit suicide are intoxicated when they do so; alcohol should be scrupulously avoided by depressed
persons.
Suicide prevention measures also include throwing out old and leftover
medications and asking family members to take possession of the pill bottles
of current medications.
Personss with mood disorders who have access to fi rearms must seriously
examine their need for such. Some studies indicate that in places with more
strict gun control laws, there are lower suicide rates.
What is true in a population as a whole probably has application in the case of the individual.
Is
the risk of access to a highly lethal means of self-destruction justifi able for a
person at greater risk of suicide than the average person?
The answer seems
obvious to me: persons with mood disorders should not have guns in the
house—ever.
Suicidal persons are almost always ambivalent; they do not want to die
but feel they have little choice or option.
Patients with mood disorders need
to recognize that when the light at the end of the tunnel seems to fade out,
this itself is a symptom of their disease, not something to be acted on.
Even though mood disorders do not often cause the affected person to lose touch
with reality, their perception of reality is colored by the mood state.
When I was in the third grade, I fl unked an eye exam at school and was
taken off to the optometrist to get glasses. I’ll never forget the fi rst time I
wore them.
I was astonished at the clarity and brilliance of objects as ordinary as street signs and fi re hydrants and was jolted to realize that my
view of the world had been so dim and foggy without my even knowing it.
Perception is reality.
The depressed individual must not make judgments
about the heaviness of his burden in life.
His perception, his reality, is distorted, fuzzy, and inaccurate. The pessimism and hopelessness he feels are
the hallmarks of illness; they are symptoms to be treated, not true feelings to
be acted upon.
At the risk of sounding fl ippant, I want to quote something
a colleague once said to me: “Suicide is a permanent solution to a temporary
problem.” Perhaps this should be the guiding principle and motto in suicide
prevention.
Ruth certainly needs some help, but she doesn’t need to be here,”
Ruth’s friend told me.
“Here” was the psychiatric unit of the fi nest general hospital in
town. It was only two years old, staffed by expert psychiatric nurses,
social workers with mental health backgrounds, occupational therapists, and other professionals.
There was no lock on the door; the cafeteria and dining room for patients in an adjacent wing were also used
by the hospital to provide dinner when the board of trustees met.
The
decor was beautiful and pleasant, like the dormitory of an expensive
school or perhaps the executive conference and retreat center of a big
corporation.
Ruth’s family doctor had been almost frantic on the phone that
morning. “You must see this patient today.
I’ve been trying to get her
to see you for weeks because I haven’t been able to get her depressive symptoms under control, but she’s kept putting it off. Two of her
friends brought her in today because she isn’t sleeping, hasn’t eaten in
two days, and can’t stop crying.
Also, she told me she was beginning to
have suicidal thoughts.”
When I saw Ruth, she had been distraught and could hardly speak
without bursting into tears.
She had small children at home, felt overwhelmed by the demands of their care, and was beginning to think
that she was a bad mother to them. Her husband was out of town at a
business meeting, and she was terrifi ed of being alone. Her friends had
been up all night trying to soothe and calm her.
I agreed with her family doctor that she was having a major depressive episode.
“I want to admit you to Memorial Hospital; I think it would be
best for you to be someplace where someone can take care of you,
where you won’t have to worry about your home responsibilities. I
want to be a bit more aggressive with medications for depression, and
this means you might be a bit sedated at first.
In the hospital there’ll
be nurses to check your blood pressure and so forth; they know these
medications and can be on the lookout for any side effects or other
problems.
We can change the treatment plan daily or even hourly if
need be.”
“Whatever you think is best,” was her feeble reply.
She was exhausted.
I called the hospital, and there was an empty bed. I sent Ruth
home with her friends to get some clothes and toiletries and told them
I would meet them at the hospital that afternoon.
Stigma
Unfortunately, there is still stigma attached to any type of psychiatric disorder, and mood disorders are no exception.
One patient of mine was doing
extremely well on lithium for some months after having been ill for nearly a
year because she had been incorrectly diagnosed.
She told me she was becoming serious about a young man. “When and how do I tell him I take medication
to keep my mood stable?” I had no easy answer for her. “What do I tell people
when they ask me why I was in the hospital?” patients often ask.
I suppose a good basic fact to remember is that one’s medical history is
very properly considered a private matter.
Those who feel compelled to share
every detail of their gallbladder operations with anyone who will listen probably don’t realize just how boring these details really are.
On the other hand,
people who probe even brief acquaintances for information about what a biopsy showed, what medication they are taking, and so forth are going far beyond the boundaries of politeness and good taste and should simply be told
that those are personal matters that bear no discussion.
Medical records are
strictly confi dential and cannot be released to anyone without the patient’s
permission. Some states require special kinds of permission for release of
psychiatric records.
Close friends and family will understand about a mood disorder, though
they may need some educating.
A trusted friend or coworker, someone whom
you would feel comfortable discussing any other serious medical matter with
and who is in a position to help and support, will be able to handle a mood
disorder just as well as any other personal matter.
My patients are often surprised at how much support they get when they least expect it.
I don’t know
how many times a patient has told me they were worried about telling their
boss about their depression only to have the boss say something like, “My
wife was in the hospital last year for depression. I understand what you’re
going though.
”
Remember that serious depression is a very common illness.
There are few people whose lives have not been touched by it at some time.
Sometimes patients with a mood disorder ask me, “Do I have a mental illness?”
I usually tell them that they certainly have an illness, and that since the stigma
Unfortunately, there is still stigma attached to any type of psychiatric disorder, and mood disorders are no exception.
One patient of mine was doing
extremely well on lithium for some months after having been ill for nearly a
year because she had been incorrectly diagnosed.
She told me she was becoming serious about a young man. “When and how do I tell him I take medication
to keep my mood stable?”
I had no easy answer for her. “What do I tell people
when they ask me why I was in the hospital?” patients often ask.
I suppose a good basic fact to remember is that one’s medical history is
very properly considered a private matter.
Those who feel compelled to share
every detail of their gallbladder operations with anyone who will listen probably don’t realize just how boring these details really are.
On the other hand,
people who probe even brief acquaintances for information about what a biopsy showed, what medication they are taking, and so forth are going far beyond the boundaries of politeness and good taste and should simply be told
that those are personal matters that bear no discussion.
Medical records are
strictly confi dential and cannot be released to anyone without the patient’s
permission.
Some states require special kinds of permission for release of
psychiatric records.
Closee friends and family will understand about a mood disorder, though
they may need some educating.
A trusted friend or coworker, someone whom
you would feel comfortable discussing any other serious medical matter with
and who is in a position to help and support, will be able to handle a mood
disorder just as well as any other personal matter.
My patients are often surprised at how much support they get when they least expect it. I don’t know
how many times a patient has told me they were worried about telling their
boss about their depression only to have the boss say something like, “My
wife was in the hospital last year for depression. I understand what you’re
going though.
”
Remember that serious depression is a very common illness.
There are few people whose lives have not been touched by it at some time.
Sometimes patients with a mood disorder ask me, “Do I have a mental illness?” I usually tell them that they certainly have an illness.
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