The Return: Slipping Back Into Depression

I’ve slipped a bit, lately.

After months of relative peace, a return.

First, it was the sadness.  I feel it when I wake up, eat my lunch, drive home from work, and hit the hay at night.  While its intensity varies, it’s always there coloring my days.

My good sense of humor caught the last bus. A bone-wearying fatigue settles in as I withdraw from activities involving people.

I go into hibernation.  I reserve my limited supply of energy for the essential things: work, a limited amount of outside commitments that can’t be avoided or rescheduled, my wife and daughter, a few clients, and filling up my truck with gas.

Life becomes pared down. It loses its sense of richness.  This as a painful, the absence

My Struggle With Bipolar Depression and Dream to Go to Law School

I’ve struggled to write this blog, just like I’ve struggled to do most things for what amounts to a very long time now-so long that it feels like a lifetime and what came before only fragments of a not well remembered dream.  In actual temporal time, it’s only a few years of melancholy and moderately severe major depression. But in the life of the mind, there is an unbridgeable chasm between the person I am now, who I once was, and who I want to become.  I am so lost in my isolation that my only refuge is in turning inward; a strategy which offers no solace at all-only shame and regret.

I feel so isolated. I suppose that is one of the hallmarks of mental illness – detachment – that it seems impossible to relate to anyone.  Furthermore, I’m not an attorney, just someone who has lived the hells and wonderful peaks of manic depression.  My exposure to the law is through my father, my uncles, my cousins, and Dan Lukasik.  I hope to go to law school one day, but I need to retake the LSAT first.  So why write a blog?  What good could it possibly do?  Hopefully, some of the sentiments I describe will resonate with you.  But hope is fickle; a thinly stitched veneer stretched tautly over an ever-widening mire of unfulfilled promise.  When I look back at what I hoped for, most of it has faded into the mists of time with barely even the trace of memory or, worse yet, has been completely buried beneath the scars of regret.

In the face of my futility, my stupidity, my selfishness, my demons, hope that I can one day return the love and support that has been given me has allowed me to trudge on, kept me from giving up.  Even if it flies in the face of all rational thinking, experience, and who you believe you are the sole advice I would deign to give is to no never give up hope that you can bring yourself to a better place and can make yourself into the person you wish to become.  Though there be no reason to believe, allow belief to inspire you all the same.

“I can only stand apart and sympathize/ For we are always what our situations hand us/ It’s either sadness or euphoria.”

The above is a stanza from Billy Joel’s song “Summer, Highland Falls” that has always resonated with me.  The song itself captures the sense of helplessness, at times even ironic apathy, I have felt towards a disease (or mental illness or whatever I should call it) that has allowed me to leap through the heights of “euphoria”, and to spiral down into the depths of suicidal depression, seemingly completely independent of any of the external aspects of my life.

I once told a friend that in the past three months I had had at least 45 “perfect days” (i.e., days that I could not imagine being any happier in), but that 45 was a conservative estimate and it was probably more.  I’ve also spent weeks on end consumed by vivid images of ways in which I could gruesomely kill myself.  And both of these emotions, which at the time feel so pervasive and all encompassing, occurred while living on the same college campus and surrounded by many of the same people.  So it’s hard not to “stand apart and sympathize” with the fact that regardless of daily accomplishments or minor setbacks, or even in the face of significant change, it doesn’t matter what you do.  That because of who you are, in a very intimate and fundamental sense, you are going to experience “either sadness or euphoria,” and you have little say in how intensely you are going to experience that emotion, or for how long (so let’s hope its euphoria, and it lasts forever).

This complete lack of control has always weighed on me as a moral failure because I’ve recognized what I consider the best version of myself-productive, engaged, intelligent, charming and yet, due to an inherent weakness, have been unable to maintain that persona consistently.

Instead I, and I would like to emphasize the contradiction and confusion surrounding a feeling at once of helplessness and simultaneously of complete responsibility for being who I am, have eventually always succumbed to periodic bouts of anxiety, negativity, and self-doubt.  These periods have always been characterized by an intense sense of isolation in which almost palpable barriers are restricting me from coming into touch with the people and events surrounding me while at the same time engaging/suppressing the most endearing aspects of who I would hope to be as a person.

There are two types of sadness which result from this frustration and alienation.

Painful Sadness

There is a horrible, painful sadness.  For me, this type of sadness is expressed through intense suicidal ideation-constant mental images meant to shock the senses into an acknowledgment of how base you are.  Brutal beatings, stabbings, gouging’s, hangings.  It consumes you until the idea is all there is and it takes every ounce of energy you have to beat it back.  And it breaks your heart to see someone you love not to be able to say that this is how you feel, and it’s not their fault, but you are worlds away and mired in a sadness/loathing that is impossible to understand for those who have not yet experienced it.  And they love you, so they are trying to understand, but, how could they?  And this breaks your heart even more.

Cleansing Sadness

And there is also a beautiful, cleansing sadness.  For me, this beautiful sadness feels more real than anything in the world.  When I have been at the height of mania-during the happiest times of my life, I have still felt intimately in tune with songs that deal with regret-juxtaposing the inadequacy of the self with the intrinsic sublimity of some other-which you have failed.

There is a powerlessness to this beautiful sadness, an inevitability.  It is real because it exists at the core of our most vulnerable selves, and therefore its expression comes out at a time when we are “most alive” and most in tune with our emotional intuition-when we are most ready to admit to and grasp on to that which we truly hope for and believe in.  This sadness is not manifested in horrifying suicidal ideations but rather in the awe-inspiring idea that we are not worthy of the wonderful phenomena we call life.  That we are ashamed of our ugliness amidst so much beauty and yet, in spite of our baseness, we have the opportunity to exist within as well as work towards some greater good.

Mania

In many senses, for me, the mania of bipolar has been synonymous with stripping away the debilitating fear and anxiety which were so constricting for so long, and a constant struggle has been not to glorify it.  My Mom is taking a wonderful self-help course entitled “Fearless Living” and those two words, again from my experience, imbibe what it means to be manic or hypo manic; imbued with amazing amounts of self-confidence and gratitude, it’s unbelievably easy to live a carefree, upbeat, happy-go-lucky lifestyle, all the while being extraordinarily productive.  Thus thinking in the binary can be dangerous-there is a natural tendency to see every aspect of the mania as better than every aspect of the depression.

However, beyond the fact that I have never been able to sustain mania, there is also a depth of feeling engendered by the sincere melancholy of depression that I have never encountered in the euphoric whirlwinds of mania.  And I think the small silver lining to what is a dark cloud is the depth of meaning such great sorrow can expose you to-in a way an almost redemptive suffering.  At the very least, though depression has taught me to hate myself many times over, it has also taught me to love life.  The sad beauty of such a self-effacing distinction, to hate your being while loving your existence, is something to be thankful for and, hopefully in time, something to build off of for the future.

I would like to close this blog with what have for me been some solid building blocks for sheltering myself from, coping with, and eventually recovering from depression.

Exercise

When there seems to be nowhere to turn and the prospect of getting through the day seems unbearable, working out and (especially) yoga exercises are blocks of time where you don’t have to interact with other people, can be totally in your head, and when you’re done you feel a little better physically, even if not mentally.  Really any small thing that you can do consistently and through which you can mark progress-I’m getting stronger, better endurance, or greater flexibility-is a wonderful way to establish extrinsic markers of success-I’m better at this than I was a few weeks ago, which, in turn, can catalyze good feelings about yourself as a person.

Think of something you’ve always wanted to do or be good at, and then identify manageable steps that you can take on a consistent basis that gradually takes you towards your goal.  Don’t say I need to be as good as someone else or make an arbitrary benchmark-rather say I want to get in better shape relative to how I am right now, so I’m going to run or go to yoga more often.  Or I’ve always wanted to know how to tie my flies, shuffle a deck of cards, play an instrument, or speak a foreign language, so I’m going to work on this task a few minutes each day as opposed to watching TV or surfing the web.

Taking little steps like these that are working towards longer goals, even if you are not aware of any specific professional or extrinsic benefits to achieving those goals, can be inherently rewarding in and of themselves.  If you’re better at an activity, any activity, then you were a few weeks ago, that can be one small thing that you feel good about, even as the rest of your world remains shrouded in darkness.  It can help motivate you to get through the day, can serve as a spring towards other “productive” behavior, and eventually be something you can hang your hat on.  However, it’s important not to beat yourself up after a day in which you failed to take your positive “step”-rather have a little self compassion and say tomorrow is a new day, and it’s not the end of the world, indeed its completely ok, that I wasn’t able to do anything “productive” today.

Finally, reading and writing can be extremely cathartic.  Reading great literature can give you an emotional connection to characters, ideas, and feelings during a time when you felt completely isolated and estranged from the outside world.  Fiction and non-fiction distract you from the constant stream of negative and self-critical thinking that can paralyze you.  And, in a way similar to the steps discussed above, finishing a book you’ve always wanted to read or one on a subject that you’ve wanted to know more about, can generate a (no matter how small) sense of accomplishment that, no matter how insidiously it attempts to, the depression cannot take away.

On the other hand, for me, writing is more of a risk.  I can be very critical of myself as a writer-a case in point is this blog which has been taxing at times-and sometimes end up feeling worse after sitting down to write.  At other times, writing has been akin to therapy in that it has helped me to sincerely articulate-in the best way I know how the complex matrix of emotions enmeshed within me.  Even if journaling or poetry don’t make sense to a single other person, the fact that they make sense to you can temporarily relieve part of the burden imposed by self-guilt and personal shame.  It can be an outlet for your anguish, space where you can be authentically yourself.  Sometimes, you can be so overwhelmed by your depressive thinking that you need some way to release that thinking-writing can be an effective way to do this.

In any case, don’t immediately sit down and assume that because of your depth of feeling you’re going to write the next great American novel.  Rather start with a paragraph or a poem.  It might end up being useless junk that you never look at again, and that’s ok, because part of what depression is, is a needless anguish and self-doubt that is inhibiting you in your quest to live a full life and should be discarded as soon as possible.  But amidst the uselessness you may stumble upon small snippets of truth-a rhyming couplet here, a few sentences there-that satisfactorily express for you one of the tragic and meaningful aspects of your condition (or symbolically the human condition more generally).  These small snippets are worth holding onto as they reflect the deeper truths embedded within a malaise that so often brings us to our knees and which, on sublimely rare occasions, reveals insights that one (I believe) can only obtain through suffering.

Anonymous

Further reading:

Bipolar Disorder Overview

Writing Your Way Out of Depression

The Bipolar Disorder Survival Guide: What You and Your Family Need to Know

Yoga for Depression: A Compassionate Guide to Relieve Suffering Through Yoga

The Bipolar II Disorder Workbook: Managing Recurring Depression, Hypomania, and Anxiety

Is Bipolar II Easier to Live With Than Bipolar I

 

The Neuroscience of Depression: An Interview with Dr. Alex Korb

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The following is an edited transcript of the podcast recorded interview with Dr. Alex Korb.  This transcript has not been reviewed and is not a word-by-word rendering of the entire interview.

Hi, I’m Dan Lukasik from lawyerswithdepression.com. Today’s guest is Dr. Alex Korb.  Dr. Korb is a neuroscientist, writer, and coach.  He’s studied the brain for over fifteen years, attending Brown University as an undergraduate and earning his Ph.D. in neuroscience from UCLA. He has over a dozen peer-reviewed journal articles on depression and is also the author of the book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time. Interesting, he’s also coached the UCLA Women’s Ultimate Freesbie team for twelve seasons and is a three-time winner for Ultimate Coach of the Year.  His expertise extends into leadership and motivation, stress and anxiety, mindfulness, physical fitness, and even standup comedy. Welcome to the show.

Dr. Korb:

Thank you, great to be here.

Dan:

Let’s begin for our audience.  You’re a neuroscientist. What is neuroscience?

Dr. Korb:

Neuroscience is simply the study of the brain and nervous system. It’s a branch of biology, but it also incorporates aspects of psychology, psychiatry, and neurobiology.  It’s anything that’s going on in the brain and nervous system all under the purview of neuroscience.

Dan:

You’ve studied depression as a neuroscientist?

Dr. Korb:

Yes, that’s what I wrote my dissertation on. The aspect of neuroscience that I’m most interested in is what underlies the neural basis for our moods and emotions, behaviors, and psychiatric illnesses. Some peer-reviewed articles look at schizophrenia as well as other psychiatric disorders like depression which have a lot of basis in neuroscience and we just don’t fully understand what is happening in the brain.

Dan:

Based on your research, can you tell us what’s going on in the brain when someone is suffering from depression?

Dr. Korb:

The best way to describe it is a dysfunction in frontal-limbic communication. To simplify it, there’s a problem with the way the thinking, feeling, and action circuits in the brain are communicating with each other.  Those all have different regions of the brain that are more dedicated to each aspect of thoughts, feelings, and actions. But, normally, there’s a dynamic of how these regions are supposed to communicate with each other, and there’s something with depression that’s a little bit off.

Dan:

Can the same be said for anxiety as far as what’s going on in the brain?

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Dr. Korb:

Yes, anxiety and depression have a lot of overlap regarding the neuroscience and neurobiology behind them.  A lot of the same brain regions are involved. For example, the amygdala, which is often called the fear center of the brain, but is involved in a lot of emotional expressions, that’s one of the core emotion regions in the brain, and it plays a role in both depression and anxiety.  And there’s just a lot of overlap in brain regions, and neurochemistry that underlies these disorders and it’s one of the reasons why anxiety is one of the most common features of depression and they often co-occur together.

Dan:

When I’ve tried to explain what I was suffering from, and my symptoms and I called it “depression,” most people didn’t have any frame of reference for that. They usually thought of it as “sadness.” With respect to sadness and depression, are there different areas of the brain that pertain to sadness that are different from clinical depression?

Dr. Korb:

There’s a lot of overlap between sadness and depression, but a lot of the misunderstanding that people have is that we use the term depression and sadness, “I’m feeling depressed” or, “I’m feeling sad,” we use those colloquially, very interchangeably.

But medically, or neuroscientifically, they’re very different.

Depression and the diagnosis of depression are a lot more than simple sadness.  In fact, a lot of people who suffer from depression don’t feel sad per se. They can often feel an emptiness where emotion should be.  They have a lot of other symptoms such as hopelessness and feelings of helplessness, guilt and shame, isolation, and anxiety can be a part of it.

They can have fatigue, problems falling asleep or staying asleep or even sleeping too much and, generally, the things that they used to find enjoyable they no longer find enjoyable. Everything just feels very difficult.

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It’s hard to explain to someone why it’s difficult because it seems like it shouldn’t be. It’s a much deeper feeling of being stuck than most people experience.  I think the average person if you can think of how you felt after the week of your greatest heartbreak, that sort of touches the edge of what it means to be depressed. It’s not the depth of how badly you feel, but that you can’t escape it. For example, I like to think of depression as a traffic jam.  When you enter a traffic jam, sometimes there’s an accident. The cars are stopped, and you sit there and wait.  And you don’t know how long the traffic jam is going to be. But for most people, it was just a little stoppage on their way. But for people with depression, it’s something that their brain just can’t quite escape. They can try and try, but their brain is stuck in the pattern of activity that just drags along, and the traffic jam just continues.

Dan:

That’s a great explanation of the experience of depression. Both what’s going on in the brain and psychologically. I think people want to know what are some of the causes of depression? Many people once they’ve often been diagnosed try to figure out for themselves, and people who care about them try to figure out?

Dr. Korb:

Depression can have a huge number of different causes. This is where the traffic jam analogy does a lot to help us understand depression. If you see a traffic jam, you can say, “Oh, what caused it?” Well, a traffic jam can come from any number of causes. There’s construction on the freeway, or there was an accident, there was heavy rain or fog, or it could just be that everyone decided to leave work at the same time, and there’s no specific “cause,” it’s just that the interaction – the dynamic interaction – of all those cars just reaches a tipping point.

With depression, it’s the same way. Often, it can be precipitated by a big life event such as a divorce, or breakup, or death in the family. Or smaller life events such as a perceived emotional embarrassment or you didn’t get that promotion.  But, often it’s not “caused” by anything.  It’s just the dynamic interaction of your brain circuits with each other, combined with the sum of your current life circumstances, which causes the brain to get stuck in a certain pattern of activity and reactivity.

That’s much more likely to happen for some people than others because some people’s brains are just more at risk for falling into that pattern. This can be based on the genes you got from your parents, and your early childhood experiences and the coping patterns you’ve been doing your whole life shaped the neurocircuitry and neurochemistry of your particular brain.  So, it’s not always a specifically, identifiable cause.  I think that’s one of the reasons why people, sometimes, don’t quite believe that it’s real or don’t think they should be suffering it. But, it’s very similar to that traffic analogy where it just “sort of happened” for seemingly no reason. It’s just caused by the fact that is vague, nonlinear, dynamic system.

Dan:

Why did you write the book, The Upward Spiral? There are plenty of scientists out there who study depression, but not many of them write a book for the general public on the topic.  What is it that led you to write this kind of book?

Dr. Korb:

I just realized that there was so much useful neuroscience out there that wasn’t being effectively delivered to the people who needed it most. One of the things that made me realize that is from when I was coaching Ultimate Freesbie. After a few months, one of the girls on the team revealed to me that she had been suffering from major depression and that she’d been suffering for years, and, tragically, many months later she ended up committing suicide. It was a devastating event in my life. This was back when I was still studying neuroscience, but before I had decided to go to grad school and study depression. That event led me to want to understand exactly what was going on in her brain that could lead her to do something like that. How could the brain get stuck in a disease like this?

That lead me to going to grad school and doing my dissertation on depression to try and understand and share some of these things with other people. As I was doing my dissertation, I realized that, yes, it’s good to advance the science, but there was already so much good science out there that was so beneficial. I didn’t think that anyone was doing a good enough job communicating clearly exactly about what was happening in the brain in depression and about all the little life changes that you can make that have measurable effects on brain activity and brain chemistry.

gratitude-2

Dan:

The second part of your book is devoted to eight specific things you can do to alleviate depression. Quickly, they exercise your brain, set goals and make decisions, give your brain a rest, develop positive habits, biofeedback, develop the ‘gratitude circuit,’ the power of others, and your brain in therapy. We don’t have enough time to focus on all eight, so why don’t we focus in on one or two. What I thought was fascinating is that you give the backdrop for what is going on in the brain when you do these things.  A few things that popped into my mind were gratitude and your brain in therapy. What about gratitude? How can it help depression?

Dr. Korb:

Gratitude can have a lot of powerful effects on the brain. And one of the reasons going back to why I wrote this book, is that there are tons of books out there that will tell you different life changes that you can make that will help with depression, but I’ve found that a lot of them are unsatisfying because they don’t explain, why. Therefore, it’s not as convincing, and it’s very easy for people to dismiss.

So when I talk about gratitude and how practicing gratitude can be so powerful in overcoming depression, a lot of people can resist that idea because it sounds so hokey.  But if I can point to specific neuroscience studies that show that it has measurable effects in changing brain activity and brain chemistry, then you’re much more likely to do it and it gives you a much better understanding of what’s going on. Gratitude has been shown to, if people who keep a gratitude journal, improve the quality of their sleep, and sleep symptoms of depression are one of the causes of depression. The reason why I called my book, The Upward Spiral because depression can sort of be seen as a “downward spiral” where one symptom or one event can lead to seemingly to a whole cascade of events that keep you stuck. So, gratitude can help break the downward spiral that’s coming from sleep problems that are leading to difficulty in concentration, and that’s one place to break the loop.

Dan:

After reading the chapter on gratitude, I picked up a spiral notebook and started a gratitude list. It was more of a lifetime gratitude list. It’s amazing. I came up with eighty things. I was surprised. So often my experience with depression is that we ruminate about negative things. We just don’t take the time, or don’t have the skill to savor and reflect on the good things in our lives.  It seems what you’re saying is that this practice has effects in the brain.

Dr. Korb:

Yes, when you’re in a depressed state it’s much harder to see the positive aspects of your life. But that’s why it’s all the more important to build a habit of looking for those positive things because often the most important feature of gratitude is not finding something to be grateful for. It’s remembering to look in the first place because that activates the prefrontal cortex which is the more thinking part of the brain which helps it to regulate the emotional regions of the brain that are going haywire in depression.

And gratitude increases activity in the key region of the brain called the cingulate cortex that sits at the intersection between the emotional limbic system and the rational prefrontal cortex and helps modulate communication between those. Remembering things in your past that you are happy or grateful for actually increases the production of the neurotransmitter serotonin in that same brain region and serotonin is one of the most common targets for antidepressant medications.  Practicing gratitude is having effects in key brain regions that we know contribute to depression and in the neurotransmitter systems that are contributing to depression.

Dan:

I also found it interesting your chapter on our brains and therapy. What’s interesting is that many people who treat with a therapist find comfort and solace in going to therapy when they are struggling with depression. They walk out, and they often do feel better at times don’t’ always understand why they feel better.  Or, we know, there’s a recent study from National Institute of Mental Health, which concluded that as many as eighty percent of people in this country get no treatment for depression whether it be antidepressants or therapy.  So, why is it important, if at all, for people to go to therapy who struggle with depression?

Dr. Korb:

The chapter that I wrote on therapy encompasses not just psychotherapy – going to talk to someone – but it also includes medical therapy such as antidepressant medication or other forms of therapy like neuromodulation techniques. These have been demonstrated through rigorous, double-blind studies that show they have powerful effects on treating depression.  Going to see a professional if you think you are depressed is a hugely important step because they can put at your disposal all the advances of western medicine.

What’s interesting – and it’s the last chapter in the book – and it’s funny how many comments I get because they say, “You left antidepressants to the end because it’s not that important and there are other life changes people can do.” Another psychiatrist will say to me, “Why are you so dismissive of antidepressant medication? They are hugely important in the treatment of depression.”  It’s neither of those. I agree that antidepressants and psychotherapy are extremely important in the treatment of depression, and if you think you are suffering from depression, you should go to see a health professional whether it’s just your doctor or you go to see a psychotherapist.

I just don’t think antidepressants are the entire answer.

For some people, I would say about one-third of people suffering from depression; antidepressants are the answer. You can get over your depression completely simply be taking a pill. You don’t know if you might be one of those people. So, you might as well see a doctor and find out.

For the other half or two-thirds of people, antidepressant medication can still be a huge part of the answer, even if it’s not the entire answer. Taking antidepressants can also help you make these other small life changes such as increasing exercise, or changing your sleep habits, or practicing gratitude.  As you make the other small life changes, then things can start to spiral upward.

Dan:

It’s been an informative and very interesting interview with you Dr. Korb.  I want to thank you for being on the show and I highly recommend listeners to pick up and read his book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time.  Join us next week for another interesting interview at Lawyerswithdepression.com.

I encourage everyone to check out Dr. Korb’s website at alexkorbphd.com.

 

8 Ways to Persevere When Depression Persists

Therese Borchard blogs, “Although I like to cling to the promise that my depression will get better — since it always has in the past — there are long, painful periods when it seems as though I’m going to have to live with these symptoms forever. In the past, there was a time when I had been struggling with death thoughts for what seemed like forever. The death thoughts did eventually disappear, but I’m always mindful of my depression. Every decision I make in a 24-hour period, from what I eat for breakfast to what time I go to bed, is driven by an effort to protect my mental health.” Read her entire blog here.

Out of the Blue of Depression

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August.

It seems like the sweet sun’s been high in a blue sky for months.

It’s steamy outside. But that’s just fine with me.  My feet aren’t cold, dark clouds don’t threaten snow, and everyone’s outside watering yards and going for walks at night.

Author Natalie Babbitt captures some of  summer’s magic when she writes:

“The first week of August hangs at the very top of summer, the top of the live-long year, like the highest seat of a Ferris wheel when it pauses in its turning. The weeks that come before are only a climb from balmy spring, and those that follow a drop to the chill of autumn, but the first week of August is motionless, and hot. It is curiously silent, too, with blank white dawns and glaring noon’s, and sunsets smeared with too much color.”

I’ve been upbeat and productive these past few months.  I wake with the light thrown through cracks in my bedroom curtains. I charge up on coffee, create a killer to-do-list, and fly out the door with a sort of crazy, off-kilter optimism.  Looking out at the sun-baked, south of France Monet-like landscape, all is good.

I am out of the blue of depression. And haven’t been in that god forsaken place since a murky week-long stretch last spring.  I am sure the stinky weather had something to do with it.  Months of accumulated winter darkness had tipped me into a dark well. Happily, it didn’t last too long.

And for this, I am grateful.

One of the things I do to stay healthy is to take time to reaffirm the goodness in my life when things are on-kilter and going well. It’s like building up a reservoir of fresh water that I can tap into when my streams run dry. I do this by taking the time to be grateful for the good people and things in my life. It warms my soul. And may even put a smile on my face.

Yes, it can be very hard to feel grateful when depressed. When in a bog of waist deep misery, it’s not only unlikely that we’ll give thanks, it might be impossible. We just can’t conjure up the goodness at such times. Everything feels like a mess.  We’re fragmented, lonely, and depressed.  There isn’t much to hope for. We sort of trudge through our days existing, but not really living.

The devil of depression seems to squeeze out all the goodness out of life. We’re left high and dry. When this happens, we need loved ones and a therapist to help us reap the goodness both past and present.  We can’t do it alone.  But when we’re feeling well, man is it a great practice.

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Here’s a neat and timely tome on this theme from humorist and NPR’s Prairie Home Companion creator Garrison Keillor:

“To know and to serve God, of course, is why we’re here, a clear truth, that, like the nose on your face, is near at hand and easily discernible but can make you dizzy if you try to focus on it hard. But a little faith will see you through. What else will do except faith in such a cynical, corrupt time? When the country goes temporarily to the dogs, cats must learn to be circumspect, walk on fences, sleep in trees, and have faith that all this woofing is not the last word. What is the last word, then? Gentleness is everywhere in daily life, a sign that faith rules through ordinary things: through cooking and small talk, through storytelling, making love, fishing, tending animals and sweet corn and flowers, through sports, music and books, raising kids — all the places where the gravy soaks in and grace shines through. Even in a time of elephantine vanity and greed, one never has to look far to see the campfires of gentle people.”

The goodness of others is grace. It’s the universe’s way of reminding us not to fret too much, that things will work out, that our important jobs are, well, just a part of life, and that uplifting fortune cookie messages sometimes do come true.  If I could, I would stick this quote by author Anne Lamott on one of those skinny wrappers:

“I do not at all understand the mystery of grace – only that it greets us where we are but does not leave us where it found us.”

Think of the kind people you’ve had in your life from your past and today; the everyday saints who were dropped into your life for no other reason than to remind you that life can be good, that you are special and that life is worth living.

These people always leave us feeling better than when they found us.

Take the time today to reflect and take in the goodness in your life.  Depression may be part of your life.  But it isn’t the whole enchilada.

There is always the other side of the coin.

And it’s sweet when we think about it.

By Daniel T. Lukasik

Further Reading:

The Neuroscience of Why Gratitude Make us Healthier by Ocean Robbins in the Huffington Post.

How Gratitude Combats Depression by Dr. Deb Serani in Psychology Today.

9 Ways to Promote Gratitude in Your Life by Therese Borchard at Everyday Health.

 

Depression and Anxiety in Later Life

file0tt4iKI’m Dan Lukasik from Lawyerswithdepression.com. Today’s guest is Dr. Charles F. Reynolds, III, co-author of the book, “Depression and Anxiety in Later Life: What Everyone Needs to Know.” He is a professor in Geriatric Psychiatry at the University at Pittsburgh School of Medicine and Director of its Aging Institute and Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders. Dr. Reynolds is internationally renowned in the field of geriatric psychiatry. His primary interests focus on mood, grief, and sleep disorders in later life.  Thanks for being here with us Dr. Reynolds.

I think the first place to begin for our audience and listeners is to have an understanding of what clinical depression is.

Dr. Reynolds:

The term clinical depression really refers to a syndrome or collection of symptoms which are debilitating and cause suffering and distress. At the core of the notion of clinical depression are two symptoms. The first is a lack of pleasure or interest in usual activities. The clinical term for that being anhedonia and the other core aspect of depression is a persistent lowering of mood – a sense of sadness and pessimism or even of hopelessness. These symptoms occur most days for at least two weeks and typically for a longer period of time and then as the full syndrome of depression develops, Dan, you also see other changes, for example, in sleep, concentration, or appetite, or energy levels and of great importance is the emergence, in many people, of suicidal feelings as part of the clinical syndrome of major depression.

Dan:  

Part of the title of your book is anxiety – what is clinical anxiety?

Dr. Reynolds:

Well, like depression, clinical anxiety refers to a syndrome or collection of symptoms that are both distressing and impairing in day-to-day function. The principle types of anxiety are first, excessive worrying such as we see in generalized anxiety disorder or panic attacks such as we can see in panic disorder with or without agoraphobia. Like depression, anxiety disorders can be quite debilitating and distressing. It is also important to understand that anxiety and depression can co-occur in the same patient and often represent risk factors for each other.

Dan:

In the book title you say depression and anxiety in later life.  When you talk about “later life,” what does that mean?

Dr. Reynolds:

Later life generally refers to folks sixty and older. That varies somewhat according to the study that you’re reading, but most of us accept age sixty or sixty-five as a threshold for beginning the later years of life. That being said, Dan, it’s important to understand that the later years of life can and often do cover several decades. And so we often speak of “young old,” say sixty-five to seventy to eighty, and “old-old” as covering the years beyond seventy-five or eighty. That distinction, young-old and old-old is important for clinical practice because the various benefits and risk of the treatments that we have may shift gradually with the age of the patient.

Dan:

When we think of depression in our society, how common is depression statistically and is there any difference in the older population?

Dr. Reynolds:

If you look, Dan, at primary care medicine clinics where most people get treatment for depression, older adults, if they get treatment at all, at any one point in time six to ten percent of the patients attending primary care clinics will have major syndromal depression and then another ten percent or so will have a clinically significant level of depressive symptoms. So this is by no means a rare disorder.  The other important thing to remember, and this is to your point about depression’s occurrence in older adults, it frequently coexists with medical issues and often with cognitive issues as well. The depression typically doesn’t exist in pure culture, but rather is an “unwanted co-traveler” of many of the common medical problems that afflict older adults and thereby amplifies the disability and distress of those disorders.

Dan:

What causes depression, Dr. Reynolds?  When we think of depression – and we’ve come a long way in understanding some of the causes – many people don’t know the difference between sadness or “the blues” and clinical depression. What are we talking about? What are the causes?

Dr. Reynolds:

The causes are many, Dan, and I think it’s very helpful to think in terms of there being many pathways to depression in older adults. In some cases, it’s possible that there is a genetic cause because depression can run in families.  Although in late life, depression, we think that genetic factors are maybe less important than they are in younger adults or kids who develop depression. Depression also occurs in the context of the life events that can occur in later life such as bereavement or other major transitions in social role functions. It’s also not unusual to see depression in the wake of certain medical events like a heart attack, or a stroke, or depression to develop in the context of things like age-dependent macular degeneration which results in a decreased ability for a person to see. These are important contextual factors and a good treatment plan will take these contextual social and medical factors into account.

Dan:

When we think of depression, once it’s been diagnosed, what can older adults do to manage depression?

Dr. Reynolds:

I think there are many things that older adults can do, Dan, but also they can be helped by family members and caregivers as well. This is a key point. I almost always will try to see family members and caregivers as well as the adult with depression themselves. Adopting a healthy lifestyle is very important set of strategies, Dan, both for preventing and treating depression and among these healthy lifestyles are physical activity, maintaining good social connections, and social support, and getting primary medical problems attended to such as blood pressure, blood fat, and blood sugar levels and having your immunizations and cancer screenings done on time.  Behaviorally, it’s very important for people to engage in the activities that give them pleasure. Behavioral activation, as we call it, is at the core of many psychosocial treatments for depression including problem-solving therapy, cognitive and behavioral therapy. Medications are also very helpful. There are antidepressant medications now available which are safe and generally well tolerated by older adults. I would say that upwards of eighty percent or eighty-plus percent of older adults with depression can be successfully treated to good response if not remission particularly using a combination of counseling and medication and then we have other treatments for other people whose depressions are difficult or resistant to treatment.

Dan:

Let’s turn our attention now to the topic of anxiety and that’s certainly an important topic you address in your book where you talk about anxiety in later life. For our audience, what is anxiety? We talk about it. A lot of people talk about being “stressed out”. We’re a stressed-out culture. But what is the difference between stress, being stressed-out, and true clinical anxiety?

Dr. Reynolds:

That’s good, Dan. You’ve made an important distinction there. All of us can experience stress, for example, in relation to life events which feel threatening to us or which seem to turn our worlds upside down, but there is a difference with anxiety disorders.  Anxiety disorders are constituted by specific symptoms that often last for months and months and months and can be disabling and distressing.  Principal among these things are obsessive worry or panic attacks which seem to come out of nowhere. These constituent actual distinct mental disorders and there are useful treatments for them. We rely heavily, for example, on teaching people relaxation techniques as well as better problem solving skills. There’s a good deal of literature also to support the use of medications called Selective Serotonin Reuptake Inhibitors. These are medications that have shown to be effective in the treatment of anxiety disorders in older adults. The reasons you want to treat these disorders is that the symptoms are burdensome, they cause distress and impairment, they undermine the quality of life, and also increase the risk for depression.

Dan:

When we talk about clinical depression and clinical anxiety, and you’ve just done a wonderful job of distinguishing them from everyday sadness and everyday stress, do they ever happen together?  Can we have a person who has both clinical depression and anxiety?

Dr. Reynolds:

We see that, Dan, in really about a third of our patients. So at any one point in time, probably a third of our patients with major depression, also can be diagnosed with one or another anxiety disorders. So they do co-occur and they need to be treated. Sometimes it can be challenging to treat that combination, but we learned how to do that. The other thing to remember though is that people living with anxiety disorders are at risk for the subsequent onset of depression.  So it’s important for that reason to address anxiety disorders. The other part of this constellation that I like to pay a lot of attention to is sleep disturbance. Sleep disturbances themselves represent a risk factor themselves for the onset of common mental disorders. Sleep disturbances are also a symptom of common mental disorders and when I’m treating depression or anxiety and my patient continues to have sleep disturbance, then I focus additional effort on helping them to get a better night’s sleep because if their sleep disturbance isn’t addressed independently, then it constitutes a risk factor for an early relapse or recurrence of depression or anxiety.

Dan:   

Can you tell us a little more about your work at the Aging Institute at the University at Pittsburgh Medical College and the Center and Treatment of Late Life Mood Disorders?

Dr. Reynolds:  

For the last five years I’ve served as Director of the Aging Institute at the University at Pittsburgh Medical Center.  The Aging Institute was created by the UPMC Health System and its health plan and also by the six schools of the Health Sciences at the University at Pittsburgh and by the Provost at the University at Pittsburgh.  Basically, Dan, we do three things.  We geriatricize the work force.  That is to say we teach the skills of caring for older adults to clinicians across all parts of medicine: doctors, nurses, pharmacists, social workers, etcetera.  The second thing that the Aging Institute does is to develop new models of care to improve the long-term delivery of care to older adults and their family members. And finally, the third thing we do is to sponsor research. We are very interested in innovative pilot research that can lead subsequent National Institute of Health and other federal support. The other thing I do at Pitt is to direct the Center for Depression Prevention and Treatment Research. This is a Center of Excellence, one of only two or three in the United States funded by the National Institute of Mental Health. We have been working now since 1995 and are in our twenty-first year. We do a great deal of intervention research. We also train the next generation of younger scientists, both physicians and Ph.D.’s, to do intervention research in older adults at risk for living with mood disorders like major depression or bipolar disorder.

Dan:

One of the things you mention in your book, and by the way, it’s a remarkable, insightful read, “Depression and Anxiety in Later Life,” one of things you mention in your book, you talk about the importance for older people to find and maintain a sense of purpose.  Why is that so important and how do older people go about finding a sense of purpose if it’s lacking?

Dr. Reynolds:

Yea, it’s a really key point, Dan, and I think that all of us need to have a sense of purpose; a sense that our lives matter to other people to help us get up in the morning.  Feeling a sense of connection, feeling a sense of belonging is very strong medicine to preserving a sense of wellbeing throughout all of the years of life. There’s also a substantial body now of research, of epidemiological research, that shows that being a member of a community of faith may both help buffer depression and but also help to recover from depression and keep it at bay. So I think that’s one key strategy to create a sense of belonging and purpose. Those are two key words that I like to use – belonging and purpose.

Dan:

And in closing Dr. Reynolds, for those in our audience that are interested in this, interested in being evaluated and treated at your center, how do they go about doing that?

Dr. Reynolds:

You can give us a call in Pittsburgh.  We are happy to take calls. We’re also happy to help callers find local resources from wherever they may be calling because we’re part of a network of colleagues around the country. One good way to seek help though is to call the help desk at the University at Pittsburgh Medical Center because we’re able to connect callers with all kinds of resources they may need. We typically get over 600 calls per year now, both from family caregivers and health care professionals.  I recommend that people visit our website or call us at 866-430-8742.

Dan:

Dr. Reynolds, thank you so much for taking the time to talk with us today. It’s been very informative, insightful and encouraging. I’m Dan Lukasik with Lawyerswithdepression.com.  Join us next week for another interesting interview.

 

The Trauma of Stress in the U.S. and its Connection to Depression

The NFL football draft just happened. I followed it because I’m a lover of the game.

I played as a kid. I now watch the games on TV with my other brother, Wally over pizza, hot chicken wings and lots of libations.  It’s almost a religious experience, full of pageantry, mystery and a sense of belonging that we feel as fans.

football collision

But as I grow older, my passion is tempered by news of the devastating toll playing such a violent game has on players.

I read a news piece a few days ago about former NFL player Brian Schaefering who played pro ball for five years.  He started a Gofundme page to raise $3000 to buy a service dog to assist him with stability issues resulting from the traumatic brain injury he sustained playing football.  Wow.

Jerome Bettis, a retired running back from the Pittsburgh Steelers, said that each collision he suffered during a game “was like being in a car accident.” What a tremendous cost to pay, I thought.

For many of us, daily life is so demanding and stressful, that, like a football player, it’s like being in a series of car accidents. The word “stress” doesn’t even seem to do justice the corrosive experience of so much stress– “trauma” is more like it.

The trauma isn’t the type inflicted by bone jarring hits during a football game, but it’s no less real – and can be disastrous for our physical and mental health.

trauma

In his book, The Everyday Trauma of Life, psychiatrist Mark Epstein writes in a recent New York Times article,

“Trauma is not just the result of major disasters. It does not happen to only some people. An undercurrent of trauma runs through ordinary life, shot through as it is with the poignancy of impermanence. I like to say that if we are not suffering from post-traumatic stress disorder, we are suffering from pre-traumatic stress disorder. There is no way to be alive without being conscious of the potential for disaster. One way or another, death (and its cousins: old age, illness, accidents, separation and loss) hangs over all of us. Nobody is immune. Our world is unstable and unpredictable, and operates, to a great degree and despite incredible scientific advancement, outside our ability to control it.”

Such trauma not only impacts our psychological/emotional and spiritual selves, but our physical brains.

brain

In a brilliant article in the Wall Street Journal, Stress Starts Up The Machinery of Major Depression, Robert Sapolsky, Ph.D., points out that there are many factors that increase our risk of major depression including genes, childhood trauma, and endocrine and immunological abnormalities.

But stress is a frequent trigger.

Sapolsky writes, “The stress angle concerns ‘anhedonia,’ psychiatric jargon for ‘the inability to feel pleasure.’ Anhedonia is at the core of the classic definition of major depression as ‘malignant sadness’”.

As a person who has a genetic history of depression in his family and childhood trauma, I was drawn into Sapolsky’s article. What was the connection between stress and the malignant sadness I’ve experienced off and on since being diagnosed with depression twelve years ago?

Who would have thought that rat brain research would help me understand the link?

Sapolsky gives us a little background about our brain structure by letting us know that our abilities to anticipate, pursue and feel pleasure revolve around a neurotransmitter called dopamine in a region of the brain called the nucleus accumbens. Then he turns to the rats for further illumination:

“Put a novel object – say, a ball – in a mouse’s cage. When the mouse encounters the ball and explores it, the arousing mystery, puzzle and challenge cause the release of a molecule in the nucleus accumbens called CRF, which boost dopamine release. If an unexpected novel object was a cat, that mouse’s brain would work vey differently. But getting the optimal amount of challenge, what we’d call ‘stimulation,’ feels good.”

We humans need just enough challenge and stress to make life interesting.

“CRF mediates this reaction: Block the molecule’s actions with a drug, and you eliminate the dopamine surge and the exploration,” writes Sapolsky. “But exposing a mouse to major, sustained stress for a few days changes everything. CRF no longer enhances dopamine release, and the mouse avoids the novel object. Moreover, the CRF is now aversive: Spritz it into the nucleus accumbens, and the mouse now avoids the place in the cage where that happened. The researchers showed that this is due to the effects of stress hormones called glucocorticoids. A switch has been flipped; stimuli that would normally evoke motivated exploration and a sense of reward now evoke the opposite. Strikingly, those few days of stress caused that anhedonic state to last in those mice for at least three months.”

Sapolsky concludes:

“But meanwhile, these findings have an important implication. Life throws lousy things at us; at times, we all get depressed, with a small letter “d.” And most people—as the clichés say—get back in the saddle; prove that when the going gets tough, the tough get going. What then to make of people who are incapacitated by major depression in the clinical sense? Unfortunately, for many, an easy explanation is that the illness is a problem of insufficient gumption: ‘Come on, pull yourself together.’ There is a vague moral taint.”

The trauma of everyday stress is an important player in major depression. When combined with genetic history and childhood neglect or trauma, it can tip the applecart and result in what Andrew Solomon calls “The Noonday Demon”.   The takeaway is that the better we get at managing the “trauma of everyday life”, the better chance we have at preventing depression.

My worry is that the society we’ve created and the hectic lives we lead make the management of stress very difficult, indeed.

 

 

 

Why Is Depression So Tenacious?

Psychologist Jonathan Rottenberg writes, “Why has depression become so prevalent? An ancient mood system has collided with a highly novel operating environment created by a remarkable species. Depression is worse in humans than in other mammals not because our species has more flaws but because of our unique strengths. Advanced language enables wallowing; our ability to set ambitious long-term goals sets up new opportunities for failure; our elaborate culture presents expectations for happiness that cannot possibly be fulfilled.” Read the Blog

When Words of Depression Block My Mind

Blogger John Folk-Williams writes, “The words I hear when I’m depressed are limited, negative and decidedly lacking in color, but they can all too easily block my mind and feelings. I’m stuck on “I can’t” when I want to do something important to me.” Read the Blog

 

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