WillSpirit!


∞ Where Mental Skills Heal Mental Ills ∞

A former physician writes about mental health and recovery using insights from life, science, and spiritual practice.








  • Red_Exclamation_DotDisclaimer
    • Dear Visitors:
      Although I trained and practiced as a physician, my background does not include formal instruction in psychiatry beyond basic medical education. This journal presents ideas about treatment philosophy, but must not be considered therapeutic advice. Abrupt changes in one's psychiatric medications can trigger profound cognitive, emotional, and physical symptoms, including suicidal thoughts and actions. Consequently, pharmaceutical agents should not be increased or decreased without supervision by a mental health clinician.

    • ON THE OTHER HAND, your brain belongs to you, and your opinion counts. If you decide that changing your medication regimen will serve your best interest, then I believe your providers have an obligation to help you try to achieve your goals. I want everyone to be educated about their options, and do what will be most helpful for themselves. No one should feel pushed around by dogmatic and/or limited viewpoints, whether those of psychiatrists, anti-psychiatry advocates, or myself.


Do Medications Make the Man?

rose tinted glasses on a dog

Sometime back I promised a post about how one’s attitude changes with drugs. When I quit Cymbalta almost a month ago, I quickly lost my confidence, started to feel tired and discouraged, and decided life did not have much value. I fear that without my strong connection, devotion, and commitment to Mandy I would have succumbed at last to the suicidal tendencies that have dogged me since my first major depression at age twenty. Yet not long before things had looked pretty rosy to me.

At present I am coping with some medication-induced injuries that will never leave me, even though I’ve quit the drugs that caused the damage. I find the destruction visited upon my body demoralizing and infuriating. But before stopping the Cymbalta, it seemed like my grip on the situation had improved, and I had hope that with a little time and meditation my distress would abate and I would settle into a more-or-less calm acceptance. Not long after my final dose of that drug (I continue to take several others), the problem started looming large again. I felt, once more, like my life had been destroyed. Given that my passion for breathing (and all the other essential components of human life) has always been lukewarm, suicide started to look like a logical and acceptable solution. How much grief, defeat, and loss can one person take?

As I’ve implied, my agreement with myself and Mandy is that I will stay around for our relationship. So although I had a well-worked out plan for my demise, I never set a time frame and just waited out the foul emotional weather. In just the past day or so, I have started to feel more like I can continue to live without merely gritting my teeth and wishing for natural death. Life has begun to look worthwhile again. Mandy and I have more frequent affectionate moments, I smile more often, and I feel like my energy has returned. Today we happen to be enveloped in smoke, due to a supposed ‘controlled burn’ that escaped its lines and is now raging in Yosemite. Every few hours the wind shifts to carry a thick cloud of particulate haze into our region. If we did not have so much air pollution, I’d be outside catching up on all the chores I neglected as I fought my way through this withdrawal. It feels good to recover the desire to be productive. I hypothesize that my brain is building more serotonin and norepinephrine receptors to compensatefor the reduced levels of those transmitters that followed stopping Cymbalta. (See this discussion about what is probably going on.)

My optimism would be greater if this had not already happened once. About two weeks after cessation there came a previous time of relief from the whirlwind, but it only lasted five or six days. So I will not be surprised if the curtain descends again. But right now I am feeling better, and I won’t spoil it by predicting another setback. This is how I ended my post back at the time of the last break from despair: “What I’ve written so far is the introduction to my real topic: the relationship between the chemicals that traverse my brain and the ‘person’ that the organ produces.”

For a number of reason I never got back on-subject. Today I am going to try to tackle, in a small way, the relation between chemical changes in our brains and the people we think we are.

In my opinion, it comes down to something like different vantage points. I wrote during the last storm break about how my little house in the hills would be invisible to a passenger in one of the airliners that regularly stretch contrails above me. I live my drama down here in the trees, yet those in the aluminum tubes soaring overhead have no clue about my problems and discouragement. They just don’t see my world of concerns. When I am medicated, it is like I am flying in the stratosphere. I observe my anxieties glide beneath me, but they look tiny and far away. Sometimes they get obscured by the pretty scenery, and I can almost forget they exist. But when I stop the drugs, I land flat on my belly on the August-baked earth, and gasp for full breaths in the smoky air. The pharmaceutical agents become the proverbial ‘rose-colored glasses’, that make a dim world look bright.

If they worked as well as I describe, I’d have to ask why one should fight the way I do to end my dependence on the medications. But if you look through pink-tinted lenses long enough, you no longer see the pink. Your mind adjusts and everything starts looking the way it did before. So then you are no longer jetting through the upper atmosphere close to the speed of sound, and instead end up bouncing along at ground level in a dilapidated truck. What’s more, even though the chemicals no longer help as much, the side effects continue. That is why I stopped Cymbalta. It helped my mood a bit but the benefit diminished until it no longer seemed worth the heavy cost in adverse reactions (primarily anorgasmia). So I stopped taking my daily green pills and have been fighting to regain my footing ever since.

If my entire opinion about whether to live or die hinges on a chemical called duloxetine marinating my brain, the question becomes, who am I? The suicidal man who feels life has dealt so many injuries it no longer warrants engagement? That is to say, am I ‘really’ this troubled person who emerges upon cessation of the drugs? Or am I instead the (slightly) bubbly soul that can discover benefits even in raw wounds and festering infections? Am I ‘in fact’ the wry middle-aged guy who emerges when the drugs (occasionally) work perfectly well?

Or am I both? Or neither?

At least I now recognize that my feelings change. It used to be hard for me to see that my attitudes shift. If the world felt awful, I believed in an unshakeable way that my feelings at that moment accurately summed up the nature of life as it had always been. On the flip side, if things looked cheery, I had a hard time remembering how it felt to be depressed. After years of gyrating feelings and world-views, I now recognize that tectonic shifts have repeatedly rocked my inner environment. My ability to predict eventual good feelings even when I am mired in deep depression has improved. I have recollection when I feel rotten that life once seemed fun, and vice versa.

As that sort of memory consolidates, I start to appreciate that my feelings are transient little things that have no direct relationship to outside reality. They are my internal filters, and not firmly connected to either the external scenery or my actual ‘self’. The same person (me) and the same life (mine) can look ashen through one set of spectacles, and sunny-yellow through another. I am the person behind the glasses, or even further back: behind the eyes. Possibly the real me looks through yet another screen: the brain. Some believe that our true selves have no material biology, but exist as ethereal spirits. I don’t go quite that far, but there is no question that somewhere separate from all the opinions, all the filters, all the moods and feelings, sits a person who is protected from the storms, and watches with a wise and tolerant eye as all the hurricanes and earthquakes and volcanoes thunder over the landscape. I’ve mentioned Acceptance and Commitment Therapy (ACT) before, and I am touching here on ACT’s core assumption.

I am not the earth’s tremors, or the volcano’s blast. I am not the wind or the sun or the rain. I am the ‘self’ that observes all the changes, all the weather, all the thoughts and feelings. But this is so easy to forget. It is as if, while watching a movie, I confused the events on the screen for things in real life. If I think that somehow my identity is that of a scared and lonely man, hemorrhaging and forlorn, I am overlooking the fact that at other times, with different chemicals in my blood, I feel like ‘someone’ entirely different.

It could be that I am nothing more than a memory stream. A dynamic album of photographs that keeps adding page after page after page. My identity cannot be pinned down to any particular image, not even the most recent ones. Instead, to get any sense at all of ‘me’ as a stable and defined entity, you have to look at the entire book as a unit.

By changing my drug regimen I am not creating a different person. I am just turning the page, putting in new pictures taken through different lenses. What I think and feel today is just an addition to my identity, not the summation of it.

Does this make any sense at all to others? I know these ideas are not mine alone, and no doubt writers more eloquent than I have stated something like the same point of view with greater clarity and logical support. But this is what I meant to bring up two weeks ago, during my previous respite from the Cymbalta-withdrawal nightmare that has been my ‘reality’ since August first. I am aware of some texts I need to read that touch on similar streams of thought. When I get more information, a wider perspective, and time to digest, I will return to this subject of self and how it relates to the turbulent currents of mood, opinion, biochemistry, and experience.

mothdrawing
For now, I am glad of the break from the pain. It feels good to expand again, and fill my wings with blood the way a newly metamorphosed moth pumps itself up before taking flight into the moonlit sky. For now, at least, I can nourish myself again, and savor the nectar of daily life.

(Click here to link to a nice video showing a moth feeding on nectar.)

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Do Medications Make the Man? was published on August 28th, 2009 . 2 comments






Some Problems with Psychiatric Diagnosis

rose_mosaic

One of the sites I’m fond of is Hopeworks Community. A number of things can appeal to me about a site. Some are heartfelt. Some are lyrical. Some provide pragmatic advice. Some take political stances. In fact, most do all these things. Hopeworks provides reasoned analysis of issues relevant to people affected by mental illness (but see Hopeworks and what I write below for some discussion of the ‘illness’ concept). Any time I get engaged in a topic, my fingers go nuts and before long my text has morphed from an intended sentence or two into a mini-essay. That happened yesterday on Hopeworks, when I wrote a comment discussing two posts: ‘What diagnosis depends on‘, and ‘On the words we use‘. The subjects were diagnosis and semantics in mental illness. Important subjects. Since I was happy with my little response, and since I won’t have much time to write today, I am posting my discussion below.

I promised to write about the relationship between ‘who we are’ and ‘what goes on in our brain’. That topic is so vast that covering it in a blog post is presumptuous to the point of grandiosity. But I do have some ideas that can be squeezed into one of my longish essays. The interrelationship between mind and body (especially, of course, brain) fascinates me, as it has philosophers for ages. I want to do it justice. I have touched on it before, and no doubt I will come back to the subject over and over until the day I die (hopefully a long time from now, for those who monitor me for suicide risk). So the much-anticipated essay will be produced soon. But not today.

Instead, here is my 2¢ about diagnostics and the labels that result.

[Comment to Hopeworks with regard to psychiatric diagnosis:] Having had medical training, and even one-time aspirations to become a psychiatrist, I started out with faith in the DSM. The more time I spend as a patient, and reading blogs, and thinking about how I’m going to get to a better place, I see the fallacy in labeling people as mentally ill. My latest thinking is that our brains are as different as our mugs. Maybe I even brought this up on your blog before. You can categorize faces: male, female, European, African, Asian, old, young, attractive, ugly. And you can separate facial expressions: happy, sad, angry, etc. But just saying someone (like me) is a male, of European descent, middle-aged and with a look of concentration at this moment does not mean that is all I am or will ever be. It is not enough information for you to recognize me on the street, or to know what would work to make me more comfortable with being alive.

Psychiatric diagnoses have that level of precision. Some people have fluctuating moods. Some are chronically sad. Some worry all the time about everything. Some hear voices and have ‘odd’ ideas. Each of these persons can be diagnosed with a DSM label, and so by that definition they are mentally ill.

It’s a bit like saying only a particular race or gender is capable of running things. Only a certain emotional make-up is healthy; deviate far from that norm and you have a disease. Maybe you should be locked up and sterilized. You certainly can’t be in a position of leadership or responsibility (is anyone else old enough to remember Thomas Eagleton?).

Like you say, what matters is what works. And what works is what makes life a more satisfying experience. Dulling emotional responses, or squelching internal voices may help accomplish that for some people. But not for all. Some would be happier to be left with their minds in their native condition. Some can get a lot more happiness out of life by accepting their quirky brains than they ever can by acquiescing to long-term psychiatric drugs.

As someone who once bought the mental disease model intellectually and emotionally, I am astounded to find myself about to write that I am not sure that mental illness is a valid construct. I took all my meds diligently for years (I was a very ‘compliant’ patient). But I still felt rotten. Now I feel better even though I am on a milder chemical cocktail (hopefully soon to be none at all). So was I really sick? Or just confused?

I spend time on the local psychiatric unit, counseling patients about their legal rights when they face involuntary confinement. Some of these people are quite out-of-control, and would have trouble being safe on the streets. I can’t say what the answer is in those cases. Maybe when things go that far there really is a sickness going on. But that does not mean that the person has a mind that can never be trusted again. That they now should carry a lifetime diagnosis of, say, bipolar I. That they will require drugs forever, and can never learn to live safely and well without medication. Maybe it is the all-too-frequent permanence of mental illness diagnoses that is their biggest problem.

We are all different. ‘Some of us are more different than others.’ The problem with the ‘illness’ label, is that it automatically means there is something defective. Maybe all that is wrong is that our eyes are open. That we see and feel more pain, or are more in touch with imaginative influences in our minds. Or we are more conscientious and want everything to be just right. Or impulsive. Or scared. These are not illnesses, they are responses to life. Maybe they are exaggerated and do not serve us well. Maybe medications can help us live fuller lives. But I object to being told my brain is abnormal, and that the person who never soars into ecstasy or crashes into sadness is healthier and (by implication) better.

It cannot be overstated: what matters is what works. If having a diagnosis in hand makes one feel vindicated, so now they can show people they aren’t just lazy or selfishly pessimistic, then it is a good thing. If it helps select a medication to get someone balanced enough that they can go home and work on better solutions, then maybe a diagnosis is useful. The same if being given a name of their ‘lllness’ leads a person to the most helpful shelf in the bookstore. But if it means I can never get long-term care insurance (I can’t), or be trusted to practice medicine (a psychiatry program I applied to reported me to the medical board), or that I will always need to take medications that wreck my body and undermine my self-image, then they are most definitely not OK. thornsThat kind of thing happens so often, that it is easy to understand why people with mental/ emotional/ behavioral/ brain/ psychiatric – illnesses/ conditions/ disorders/ diseases/ abnormalities/ challenges/ dysfunction/ gifts object to the psychiatric model. When diagnostics work they help a little. But when they are overused, misinterpreted, or otherwise go awry, they do an incredible amount of harm.

(I slightly modified this post on 2009 August 17, c. 08:30 PDT.)

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Some Problems with Psychiatric Diagnosis was published on August 16th, 2009 . 19 comments






Do Medications Change Who We Are?

contrail

Last night sleep came. Since stopping Cymbalta 13 days ago, most nights have provided only a few hours of true dozing. Once or twice in the past fortnight I took zolpidem to knock myself out. But that does not lead to refreshing slumber, just a kind of drugged unconsciousness. Even with the sleeping pill, no more than five hours were spent sleeping; the rest of the night passed with me either laying in bed trying to relax, or else reading and eating blueberries (there must be a bumper crop this year, the prices are so low). But yesterday I retired early, then slept almost ten hours without awakening. What’s more, after arising I sat in our hot tub like I often do, but afterward got out and dozed for another hour.



We have a two-person spa on our deck, with a fine view to the east. Most mornings as dawn brightens I sit in water heated to 104° F (40° C), while I take in my surroundings in a silence broken only by a few buzzing insects and the first active birds. I leave the nozzles turned off, since I dislike the mechanical noise. I overlook a line of forested ridges rolling toward Yosemite, where the horizon is jagged with granite peaks. With an early enough start I am rewarded by a view of the sun rising into a salmon-colored sky, usually cloudless and marred only by the contrails of passenger jets in the stratosphere. These aircraft cross over the Sierra Nevada mountains on the last leg of their flight to San Francisco. One time I looked out the window during such a flight, and saw Yosemite Valley below the wing, looking like a small broken slab of gray stone. As I soak in the morning, loosening the tension in my damaged neck, I look up at those specks gliding through the twilit sky, and wonder about the travellers drinking morning coffee while looking down at the expanse of conifer forests and rock mountains. I wonder if it occurs to them that someone lives among those trees, watching them as they soar in the upper reaches of the atmosphere. I think about how insignifcant my corner of the world must look from their perspective, my home invisible in the green carpet of sugar pines. It amazes me that we will never know each other, that we will each live our entire complicated stories, each entirely unaware of the other’s drama. Our only connection is my fifteen-second reverie about a stranger in a jumbo jet, drinking coffee as her plane travels hundreds of miles per hour, drawing a rose-colored line across the dome of morning sky. Today such warm water thinking put me back to sleep.

After all that, my point is that I feel better. Yesterday my mood stayed pretty solid, with only a slight dip toward depression in the afternoon, something I experienced my whole life up until starting SSRI antidepressants. This morning, after finally getting up for good, I have been productive and energetic. Could it be I am finally getting past the Cymbalta withdrawal syndrome? The past two weeks have been brutal. If I did not have a strong commitment to survive and be here for my wife, suicide would have been the likely result of how badly I felt. Life seemed so very pointless, and not at all worth the torment roiling in my heart and soul. Countless times each day I dreamt and prayed (to the extent that I pray, since the God of my belief is not the kind that keeps an ear to the mutterings of mammalian nervous systems) that I just drop dead on the spot. Now I feel ready to engage my corner of the earth once more. Not that I am thrilled to be alive, singing like Julie Andrews on a grass-blanketed mountainside. No, I am still the not-too-optimistic failed surgeon. I sit before a small computer screen connected by a wire to my even smaller laptop, typing with nine fingers and one elbow (actually a finger in a thick dressing). The hillside I gaze upon is covered by an expanse of dead weeds baking in the August afternoon sun. But today I am pleased enough with this little drama of mine to stay in the production until it finishes its natural run. Once more, I survived all-out assaults launched by the mood-demons who dwell in the darkest recesses of my mind. Thank you, big Pharma, for marketing a drug that required me to weather such torment in order to release myself from its grasp.

That altering my brain chemistry by withdrawing a drug had such an effect on my worldview brings to mind, once more, my curiosity about what it means to exist as a human consciousness. I wrote earlier about the origins of decisions and intention. This ordeal has made me wonder, too, about the locus of attitudes and feelings about life. When something as fundamental as whether I think my story is worth living can be affected by removing a synthetic chemical from my bloodstream, then who am I? Is there ‘nothing’ more to ‘me’ than proteins, and cell membranes, and DNA, and myriad organic molecules? That kind of musing resurrects my whole philosophy about the relationship between living things and (what I for convenience call) ‘God’.

Aside from feeling that the Cymbalta wash-out may be behind me, I also cheered up after looking a bit at my web statistics. OK, OK, I know doing that is pointless. Numbers are not my objective, and obsessing about how many computers connect with my site will drive me (even more) nuts. Still, I noticed that my post ‘Is Depression Sane?‘ has been viewed two-and-a-half times as often as any other. This strikes me as great news, because I enjoyed writing that essay, and it touched on a number of philosophical points. I like to include in my blog my homespun views about the mind, mental distress, and how one can lead a satisfying life. Knowing that one of the essays that most does that also attracted the most interest encourages me to continue.

I resolved to keep my posts short. What I’ve written so far is the introduction to my real topic: the relationship between the chemicals that traverse my brain and the ‘person’ that the organ produces. In particular, how does an organism acquire the gifts of pleasure and pain, instead of just having a drive to move toward or away from certain stimuli and experiences? Rather than launching into that now and even further exceeding my supposed daily word quota, I will put the topic out there as something to either look forward to or avoid, depending on your attitude.

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Do Medications Change Who We Are? was published on August 13th, 2009 . 1 comment






Stopping Medication and Wondering What’s Next

Photo of tree and bruised sky.
Five days ago I quit Cymbalta. Because of some its side effects, periodically I stop it for two days. This time it ended up being three, and after that I just could not bring myself to restart it. Today, day five, passed with little problem. I feel a bit nauseous, kinda sweaty, and I am not sleeping well at all. I have a familiar aching dread in my chest, and a sinking feeling in my gut, as I always get with depression. But I am not depressed. My body feels all the awful stuff, but my mind is staying pretty upbeat, or at least neutral. I am prepared for a rough few weeks coming up. Don’t be surprised if I give up and start the drug again. Somehow, however, I think this might work. My attitude has shifted. That last post really cemented my developing philosophy of accepting and even savoring my ‘negative’ moods. So they don’t scare me as much. So I can tolerate the feelings better. So maybe I’ll succeed.

Wish me luck. I’ll probably need it.

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Stopping Medication and Wondering What’s Next was published on August 5th, 2009 . 3 comments






Is Depression Sane?

”

My last several posts talked about depression. Actually, they mainly discussed anti depression, but that prompted the rationale for today’s installment: you can’t consider how to cure an illness (if it is one, vide infra) without knowing a little about it. So, what is depression, anyway?

The word gets tossed about more often than it gets defined. Here is the MedLinePlus medical dictionary definition:

(1) : a state of feeling sad (2) : a psychoneurotic or psychotic disorder marked especially by sadness, inactivity, difficulty with thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal thoughts or an attempt to commit suicide

Definition (1) is straightforward: feeling sad. Number (2) starts with feelings: sadness, plus dejection and hopelessness. It then captures both thought dysfunction (impaired thinking and concentration) and the ‘vegetative signs’ of depression (inactivity, appetite changes, and disordered sleep). The final component is suicidality, either in thought or action.

So to simplify we have: sad feelings, impaired thinking, changes in bodily functions, and suicide. Does that sound like depression to you?

Everything listed can be true for me to varying degrees at different times. What this source fails to mention, though other dictionaries probably would, is ‘anhedonia’ or loss of ability to experience pleasure. Inability to enjoy anything often constitutes the crux of depression for me. If I could experience pleasure, life would not look so hopeless. Maybe I would then be motivated to eat, sleep, and think properly. Life is meant to be enjoyed, after all.

Or is it? In my opinion, our culture has fed us a huge depressing lie: that the purpose of life is enjoyment. More likely, the purpose (if there is one) is to experience what life brings, whether good or bad. Enjoyment is nice but not central to a meaningful life.

I grew up in a well-to-do household with many financial advantages. I attended good schools, went to a fancy summer camp, and lived in a house with a panoramic ocean view. The neighborhood had lovely landscaping, access to mountain trails, and a kid could bicycle to the beach in twenty minutes.

However, it was not a happy childhood. For those interested, here is an incomplete list of the traumas I experienced:

  • Intense parental discord starting with my earliest memories.
  • Prolonged and isolated hospitalization at age three.
  • Parental divorce at age four.
  • Annual moves for the next six years.
  • My mother suffered from clinical depression, with numerous hospitalizations and shock treatments.
  • She killed herself when I was six.
  • My father’s second wife (his former mistress during the marriage) abused me with breathtaking sadism.
  • My father was narcissistic, suffered from alcoholism, and disliked children.
  • My sister a psychotic break (precipitated by heavy LSD use) when I was ten.
  • My stepmother inflicted sexual humiliation on me between the ages of eleven and fourteen.
  • I became involved in drugs and alcohol at age twelve (daily use by age fourteen).

So I suffered a traumatic, unhappy childhood in pleasant and prosperous surroundings. My high school had its share of celebrity children, and the prevalent attitude was that life should be happy and fun. Money worries should not exist. Everyone should be gorgeous and sexy. The neighborhood was not far from Hollywood, and many of the kids I went to school with grew up to continue the tradition of exporting these standards to the entire world.

How realistic are these expectations? Not long ago I attended a support group where one African-American attender came from a different environment: crack sales on the corner; imprisoned or dead fathers; drive-by shootings; endemic destitution; pervasive squalor. He had trouble understanding the concept of depression. When he first received the diagnosis, apparently, he told his psychiatrist that his feelings of despondency and hopelessness were normal. That would be the natural conclusion for someone growing up in such a habitat, wouldn’t it? How many of his classmates expected to some day meet a gorgeous spouse from a well-to-do and intact family, spawn a couple of genius kids, develop a fascinating and lucrative career, and live to an advanced age surrounded by loving children and grandchildren? White middle to upper-middle class people do not think such dreams to be wildly unrealistic. Improbable, perhaps, but not out of the question. In the American ghettoes, however, to fantasize like that would appear psychotic to your companions.

pollution

Maybe we ought to look again at what modern life typically brings. A huge proportion of marriages end in divorce. Financial security is a fading dream. Death is inevitable and illness almost so. The chemical byproducts of industrialization degrade the planet, posing a very real threat of ecological collapse. People move all the time, making stable communities a historical memory. War never ends. We’re no longer surprised by genocide and terrorism. And meeting people who grew up in truly loving and healthy families happens almost as rarely as finding four-leafed clovers.

Does this sound like a world where we might expect to be happy? You could even ask, of course, if human existence has ever been conducive to widespread joy and contentment. So maybe sad feelings, dejection, and hopelessness are not pathological. I realize this is a ‘depressing’ viewpoint. But before we start drugging ourselves because we feel ‘sad’, we might ask if it is really a sickness or just a normal human reaction (especially for sensitive people with concern for others, like most of us who get diagnosed with depression).

I am not suggesting we just live in misery. I will continue to work against depression until my last breath, if necessary. But it helps to know the true enemy. Is it really my brain, the way the mental health system teaches? Do I need to conclude I am a ‘sick’ person because the combination of a horrible upbringing and living in a discouraging world has left me susceptible to sad feelings? Maybe those of us who feel the pain of this life are actually the sane ones. Could it be that happy people are just in denial?

OK, that last statement probably takes the point too far. Still, I do believe that sadness must be considered a natural reaction. Any discussion of depression treatment would do well to start from that realization. Then we can proceed to identify endless despair and lack of pleasure as on over-reaction, but perhaps not an entirely pathological one. So when we look at what we should do, we will know that what we are fighting is, in part, the state of the world. Then the problem becomes, how can we find tranquility in the face of all the problems?

band_aid

Starting from that position, using a psychiatric medication is nothing but a band-aid that covers rather than heals. After all, we could suck cocaine into our noses and feel better. But is that the best way to deal with life on this planet? Psychiatrists and drug companies, if they bothered to read this, would go bananas at the comparison. They would insist that psychiatric pharmaceuticals have long half lives, produce sustained benefit, and don’t lead to life-destroying behavior. And in truth there is a quantitative difference in side effects and social problems. But there is no qualitative difference in philosophy. Whether you buy the drug in a pharmacy or on the sidewalk out front, you are still treating life’s pain with chemicals.

Personally, I think that is not the best approach. Better to learn tools to cope with the tragedy and hardship than to drug yourself until you no longer care about it. And it is possible to retrain yourself to find peace and satisfaction in life in the face of its heartache and struggle. However, you will probably still feel sad. Part of the reason I became so miserable was my belief that things should be better. As a child, I saw relatives with happy families, and I envied them. As an adult, I resented that my colleagues continued in their careers, while mine ended because of a badly damaged neck. My resistance to making peace with my fate, not the misfortune itself, made me miserable. Now that I can accept my hardships as not being all that unusual, and certainly not ‘unfair,’ I can just be sad, without abandoning all hope for joy. It is OK to be sad. It is natural, maybe even healthy. My goal is to learn to experience the sadness but also allow myself to bask in contentment from time to time.

I believe that sadness is not the problem, despite how the definition of depression emphasizes it. Anhedonia is the real enemy. The inability to enjoy anything because of sorrow is a confusion about how feelings work. You can be sad a lot, but still find things to enjoy. But to get to this point I have had to abandon the unrealistic expectations fed to me by our modern culture. What a lie to believe one should get through life without being seared to the bone by tragedy and suffering! The fact is, every human frame will sometimes feel the flames of hell. But in our hearts we can look around, see the autumn trees outside the hospice window, and smile despite the pain.

Not long ago I posted a ‘Tweet’: The surest path to satisfaction is to lower your standards. What surprises me is that I now actually accept that to be true.

hollywood_parade

In closing, I would like to point people toward Acceptance and Commitment Therapy. It is not a therapy so much as a philosophy of recognizing the truth, and even the beauty, of pain. You don’t need a therapist to ‘get it’ (try this book–and I’m not getting a kickback from Amazon). ACT is not all that different from Buddhism, actually. But it is a good path for westerners who need to escape our society’s crazy message that life is supposed to look like a TV commercial, while grief, defeat, illness, and pain are for losers.

In the end, every one of us loses everything we love. What could be sadder? The trick has been to allow sorrow to rain on my parade, and just keep marching and pounding that drum.

Note: the author of Health and Life directs me to this article which expands on the topic of antidepressant (in)efficacy. It also cites the STAR*D study, which made a mammoth attempt to assess and compare treatments. The short form of their result is that drugs, and even accepted therapies, don’t work all that well. But such a short wrap-up does the project a disservice, since it studied issues that always get ignored by drug companies. Some day I may devote an essay to it.

(I modified this post in several places on 2009 August 4, c. 13:45 PDT. I did not introduce any substantive changes in the message or opinion.)

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Is Depression Sane? was published on August 3rd, 2009 . 14 comments






Wouldn’t it be great if long-term antidepressant treatment worked?

Before antidepressants.

Before antidepressants.

After 1 year on antidepressants.

After 1 year on antidepressants.

This is a response to a post on the Hopeworks Community blog.I’m sharing it here because it rebuts arguments one commonly hears in favor of antidpressant medication.

Dear Hopeworks Community,

Personally, I believe you overstate the value of medications, especially in bipolar II/depression. (They are indeed quite effective against manic escalation. It is not impossible for someone with Bipolar I to go without meds, but it is difficult and takes discipline.) However, the efficacy of antidepressants is regularly exaggerated by psychiatrists and pharmaceutical representatives. Are you aware of a single long term placebo-controlled study that demonstrates sustained benefit of any antidepressant over time frames longer than a few months? I’m not. Approval trials typically last six weeks. And even in that short time period, usually not much more than half the population benefits (compared to 30% that respond just to placebo). Yes, when people first start antidepressants, they often feel better. But if they are someone with longterm problems with low moods, and many recurrences, (which is the story for most bipolar II patients) when you look a year later they are usually back to fighting depression. Only now they are stuck on medication that causes even worse moods and other symptoms if they try to halt drug treatment. Realistically, don’t you notice that mental health clinics are filled with clients in awful depression who also happen to be taking 3 or 4 or 5 medications? If pharmaceutical therapy works so well, why are there so many people like this? For acute depressions, especially prolonged situational depression, psychoactive agents can really help. They may also give those with more chronic problems a bit of relief while they learn better ways of dealing with their moods. But as a sustained strategy: medication just does not work. If long term antidepressants were often effective, I would be in favor of them; I am not reflexively anti-medication. But they are not.

The psychiatrist who claims he has “seen a few BP2 people who do not have deep depression make it [without medications], but they are the rare exception” is a psychiatrist who loses his patients after they realize they can find ways to deal with recurrent depression and hypomania without drugs. The only ones he sees are those who come back asking to be restarted on pharmaceuticals. Not only that, but once established on long-term drug treatment, it is all-too-true that patients find it exceedingly difficult to stop. But to say that bipolar II patients can’t come off drugs is very different from saying they are better off than if they had never been established on longterm treatment in the first place. And how hard does he work to very slowly taper his patients while providing behavioral means to manage their moods? A close family member required a 2-year taper off prozac, and she was just on the one drug. Imagine how much patience it would take for a psychiatrist to help patients get off 4 or 5 medications. Does he work that hard to achieve something he obviously does not believe in?

Therapy and counseling are indeed helpful. Not always those based on opening up (though for clients coming from traumatic backgrounds, as many with bipolar II diagnoses have, it may be vital), but especially those that provide behavioral advice (including promoting exercise) and cognitive training, along with something like meditation or spiritual support. And peer interaction can be lifesaving. But meds? They are not a rock opposing a hard place. They are just an ineffective pebble (with crushing, boulder-like side effects and dependence potential) opposing a condition that can often be ameliorated without longterm drugs. Unfortunately, those who have difficulty succeeding with behavioral/cognitive changes are unlikely to be helped by ongoing medications. Instead, they will just have drug dependence, with attendant adverse effects, added to their list of woes.

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Wouldn’t it be great if long-term antidepressant treatment worked? was published on August 3rd, 2009 . 3 comments






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