psychiatrist Archives - Lawyers With Depression

Unpacking Depression: An Interview with Psychologist Dr. Margaret Wehrenberg

Today’s guest is Dr. Margaret Wehrenberg. Dr. Wehrenberg is a clinical psychologist in Naperville, Illinois. She is the author of six books on the treatment of anxiety and depression published by W.W. Norton, including, “The Ten Best-Ever Depression Management Techniques: Understanding How Your Brain Makes You Depressed and What You Can Do to Change It” and “Anxiety + Depression: Effective Treatment of the Big Two Co-Occurring Disorders.” An international trainer of mental health professionals, Dr. Wehrenberg coaches people with anxiety via the internet and phone. She’s a frequent contributor to the award-winning magazine, Psychotherapy Networker and she blogs on depression for the magazine Psychology Today.

Dan:

What is the difference between sadness and depression and why do people confuse the two so often?

Dr. Wehrenberg:

Because depression comprises sadness. Sadness is a response to a specific situation in which we usually have some kind of loss. The loss of a self-esteem, a loss of a loved one, the loss of a desired goal. Depression is really more about the energy – whether it’s mental energy or physical energy – to make an effective response. So, sadness is an appropriate and transient emotion, but depression sticks around and affects all of our daily behaviors and interactions.

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Do You Need To Take Medication For Your Depression?

Today’s guest post is by Dr. Eve Wood, a psychiatrist who treats patients struggling with depression, anxiety, burnout or extreme stress.

Do you find yourself wondering if you need to be on medications for depression, or hoping you can stop them? If so, you are not alone!

In 1980, Americans filled 30 million prescriptions for antidepressants, and in 2010, 30 years later, the number of prescriptions for antidepressants filled had risen to 264 million in a year!

What are we to make of this? Twenty eight percent of attorneys nationwide are struggling with depression! Why? And, what is to be done about it? In this short blog, I intend to highlight the relationship between stress, burnout, and “depression”, and the role of diagnosis, medical treatments, and other strategies. I encourage you to think broadly about what you can do to make your life better.

What is Depression?

To be totally clear: We do not really know what depression is! We have a lot of theories, and can identify biological correlates, with some depressive symptoms. And, we do know that a small percentage of people suffer with an incapacitating illness that won’t quit. However, much of what is being called Depression today, is probably Burnout, or a normal response to abnormal stress!

While I am simplifying the diagnostic process a bit, I think you will appreciate the point. We diagnose Depression by establishing that you have a requisite number and type of symptoms, to meet the diagnostic criteria, as laid out in the DSM (Diagnostic and Statistical Manual). Over the course of the last 35 years, there have been 6 iterations of the DSM. As the book has gotten longer, and the number of diagnoses has progressively increased, the “illness” criteria has gotten too loose to be useful.

Before the printing of DSM III, the incidence of depression was quite low, prevalence rate of 1.2% in 1996. After the DSM III was released in 1980, a NIMH study found the prevalence of Depression had risen to 5%. After DSM III-R the prevalence rate had risen to 10 % of the adult population in the United States. And, the rate continues to rise.

In my 35 years in medicine, I have not seen the numbers of people with serious depression, true debilitating symptoms that no one could deny were life-threatening, change much. I have, however, seen a significant escalation in the numbers of people told they “have depression” and consequently get treated with medications.

Today, when you might be dealing burnout, exhaustion, disillusionment, or extreme worry, you are given a clinical diagnosis or two, and prescriptions. This strategy stops you from looking at the precipitants to your distress, and proactively identifying solutions. It also exposes you to “side-effects” or unnecessary risks.

But, Isn’t my Depression due to a Chemical Imbalance in my Brain?

Chances are pretty good you’ve been told that your depression is due to a chemical imbalance in your brain, and medications correct that abnormality. The problem is, all attempts to prove that theory have totally failed.

The fallacy is reinforced by the names given to psychiatric medications. For instance, the term SSRI (selective serotonin reuptake inhibitor) was chosen to imply that the medication inhibits the uptake of a neurotransmitter and thus creates benefit. It originated when the pharmaceutical company SmithKline Beecham, was trying to distinguish its medication Paxil, from its competitor Prozac.

“SSRI” came out of their marketing department and was used to market a new “class” of drug, even though all antidepressants (new and old) have some impact on serotonin. And, we have no idea how significant that impact is! The term SSRI gives rise to cool pictures of neurons and chemicals which can be used to sell drugs.

Do Antidepressants Work?

Clinical trials of antidepressants show that only 1/3 of patients get better in 8 weeks. The other 2/3 respond in part or not at all! And, within 3 years, 75% of the responders have quit treatment, likely due to side effects, cost or diminishing efficacy.

In many studies of antidepressant effectiveness, drugs perform no better than placebo. And, several studies have found that the biggest predictor of response is you believe meds will help, and vice versa!

So, do pills work? At times, yes, and they even save lives. But, they don’t help most people consistently. And, other interventions might be just as good, or better tolerated. Examples with clear anti-depressant efficacy include improved work-life balance, therapy, specific breathing practices, yoga, mindfulness, light exposure, meditation, nutritional interventions, cognitive restructuring techniques, spiritual practice, time in nature and exercise.

What Should You About Medication?

You are probably wondering whether you should be on medicine. The answer is unique to you and your history. That said, here is what I have seen in 35 years of work with attorneys. Many of you are experiencing normal responses to extreme stress. While you have tremendous power to self-heal, rebound, and thrive when episodically stressed, you become depleted, and burned out when the pressures on you are continuous.

The symptoms of burnout; emotional exhaustion, interpersonal disengagement, and a low sense of meaningfulness and accomplishment are very similar to those of depression. And, interventions for burnout, often transform depression symptoms. Most of my clients stop, or massively reduce their medication need, as they tackle burnout, build resilience, decrease stress, and improve their lives.

In choosing your next steps, consider when you last felt well, and your attendant life circumstances. What was working, or gave you joy? Have medicines saved your life, or are you taking pills because you can’t seem to make your life work? Do you need training on techniques and tools to promote well-being, and minimize your need for medications?

If your life is not as you wish, you can change it! You are a gifted, capable person, as evidenced by how far you have come. You can learn evidence-based solutions, to transform what doesn’t work!

Dr. Eve A. Wood helps lawyers and judges dealing with depression, anxiety, burnout and extreme stress learn to transform their lives for well-being, joy and professional fulfillment. She offers practical, science-based programs and coaching that promote whole person healing, decrease stress and depletion, transform anxiety/depression and reduce reliance on medication.

The Creativity Cure for Depression: An Interview with Dr. Carrie Barron

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Today’s guest is Dr. Carrie Barron, a board-certified psychiatrist/psychoanalyst on the clinical faculty of the Columbia College of Physicians and Surgeons who also has a private practice in New York City. She has published in peer-reviewed journals, won several academic awards, and presented original works related to creativity and self-expression at national meetings of the American Psychoanalytic Association. Along with her husband, Alton Barron, M.D., a hand and shoulder surgeon, she co-authored the book, The Creativity Cure: How to Build Happiness with Your Own Two Hands.

Dan:

Why is depression such a problem in our culture?

Carrie:

I think the level of stress has gone up enormously because we have so much to do and we’re on twenty-four hours a day. So I think because of technology, which offers us so many great things, but gives us much to do. I think that’s part of it. I also think, especially for children, we’re in a striving, ambitious, be productive all the time mentality – for children and adults. We need to play, we need to hangout, we need to have spontaneous time. I think spontaneous thought does a lot for alleviating depression and anxiety.

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Depression and Suicide: A Catholic Perspective

As a psychiatrist, I had been aware, prior to his death, that Robin Williams struggled with a severe mood disorder – major depression and bipolar disorder, depending on the source of the reporting – along with related problems and drug dependence.

The vast majority of suicides are associated with some form of clinical depression, which in its more serious forms can be a sort of madness that drives people to despair – leading to a profound and painful sense of hopelessness and even delusional thinking about oneself, the world and the future.

I knew all of this, and yet this death still shocked and surprised me, as it shocked and surprised so many others. Williams seemed to be the consummate humorist, the funny man who would be just so much fun to be around. Unlike some comedians who trade only on irony and cutting humor, Williams appeared to us as a warm, big-hearted, endlessly fun, brilliantly quick, incredibly talented man. Though he was a celebrity, he was the kind of person that people felt like they knew – like the cousin, everyone just adores and hopes will show up at the family reunion. Williams was the kind of guy that people wanted to be friends with, the kind of person that one wanted to invite to the party.

This is not the typical stereotype of mental illness, which why the typical stereotype must be relinquished: Quite simply, it is false.

Mental illness can afflict anyone, of any temperament and personality. In the wake of his death, the strange truth gradually began to sink in: In spite of outward appearances, Williams’ mind was afflicted by a devastating disorder that proved every bit as deadly as a heart attack or cancer. He suffered in ways that are difficult for most people to imagine.

Why couldn’t Williams see himself as other saw him – as a person of immense gifts and talents, a man who stood at the pinnacle of achievement in the world of comedy and entertainment?

Why couldn’t he see himself as God saw him – as a beloved child, a human soul of immense worth, a person for whom Christ died?

This is the tragedy of depression, which is so often misunderstood by those who have not suffered its effects.

Novelist William Styron – whose memoir Darkness Visible represents one of the best first-person attempts to describe the experience of depression – complains that the very word “depression” is a pale and inadequate term for such a terrible affliction. It is a pedestrian noun that typically represents a dip in the road or an economic downtown. Styron prefers the older term “melancholia,” which conjures images of a thick, black fog that descends on the mind and saps the body of all vitality.

Indeed, the title of his book – Darkness Visible – comes from John Milton’s description of hell in Paradise Lost. We’re not talking about hitting a rough patch in life or the everyday blues that we all experience from time to time. We are talking about a serious, potentially fatal, disorder of mind and brain.

Fortunately, in most cases, depression is amenable to treatment. Because the illness is complex – involving biological, psychological, social, relational and, in some cases, behavioral and spiritual factors – the treatment likewise can be complex. Medications may have a very important role, but so do psychotherapy, behavioral approaches, social support and spiritual direction.

In some cases, hospitalization may be necessary, especially when an afflicted individual is in the throes of suicidal thinking or when one’s functioning is so impaired from the illness that he or she has difficulty getting out of bed or engaging in daily activities. For the severely depressed, even brushing one’s teeth can seem like an almost impossibly difficult chore.

This level of impairment is often puzzling to outsiders – to the spouse or parent who is trying to help the loved one. Unlike cancer or a broken bone, the illness here is hidden from sight. But the functional impairments can be every bit as severe.

I recall one patient, a married Catholic woman with several children and grandchildren, who had suffered from both life-threatening breast cancer and from severe depression. She once told me that, if given the choice, she would choose cancer over the depression, since the depression caused her far more intense suffering. Though she had been cured of cancer, she tragically died by suicide a few years after she stopped seeing me for treatment.

Depression is neither laziness nor weakness of will, nor a manifestation of a character defect. It needs to be distinguished from spiritual states, such as what St. Ignatius described as spiritual desolation and what St. John of the Cross called the dark night of the soul.

Tragically, even with good efforts aimed at treatment, some cases of depression still lead to suicide – leaving devastated family members who struggle with loss, guilt, and confusion.

The Church teaches that suicide is a sin against love of God, love of oneself and love of neighbor. On the other hand, the Church recognizes that an individual’s moral culpability for the act of suicide can be diminished by mental illness, as described in the Catechism: “Grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide.”

The Catechism goes on to say: “We should not despair of the eternal salvation of persons who have taken their lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.”

Robin Williams’ death – like the death of so many others by suicide who have suffered from severe mental illness – issued from an unsound mind afflicted by a devastating disorder. Depression affects not just a person’s moods and emotions; it also constricts a person’s thinking – often to the point where the person feels entirely trapped and cannot see any way out of his mental suffering. Depression can destroy a person’s capacity to reason clearly; it can severely impair his sound judgment, such that a person suffering in this way is liable to do things, which, when not depressed, he would never consider. Our Lord’s ministry was a ministry of healing, in imitation of Christ, we are called to be healers as well. Those who suffer from mental-health problems should not bear this cross alone. As Christians, we need to encounter them, to understand them and to bear their burdens with them.

We should begin with the premise that science and religion, reason and faith are in harmony. Our task is to integrate insights from all these sources – medicine, psychology, the Bible, and theology – in order to understand mental illness and to help others to recover from it. In cases where recovery proves difficult or impossible, we pray for the departed and never abandon those who still struggle.

Aaron Kheriaty, M.D., is associate professor of psychiatry and human behavior at the University of California-Irvine School of Medicine. He is the co-author with Msgr. John Cihak of The Catholic Guide to Depression.

Depression: A Psychiatrist’s Recommendations for Self-care

Psychiatrist Monica Starkman, M.D. writes, “In clinical research, one uses the scientific method and studies just one treatment alone in order to assess its effectiveness. But in clinician mode, I am convinced that a combination of effective techniques increases the probability of a strongly positive result – and I don’t really care which of them did the most good. Here are five simple yet powerful treatments I recommend because they are both scientifically valid and clinically effective. Read her entire blog.

Book Review: ‘Ordinary Well: The Case for Antidepressants

Dr. Abigail Zuger writes in The New York Times, “Dr. Kramer’s bottom line is well summarized by the double meaning of “Ordinarily Well: The Case for Antidepressants” — he argues that antidepressants work just about as well as any other pills commonly used for ailing people, and that the drugs keep people who take them reasonably healthy.” Read the News

Depression and Faith: An Interview with Rabbi Mark Gellman

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Today’s guest on our show is Rabbi Mark Gellman.

Rabbi Gellman is the Rabbi Emeritus at Temple Beth Torah in Melville, New York where he has served since 1981. He earned his Ph.D. in Philosophy from Northwestern University in 1981 where he also completed doctoral work in the History and Literature of Religions specializing in Buddhism and Judaism. He is the recipient of many honorary degrees.

Rabbi Gellman writes a weekly column, “The Spiritual State,” for Newsweek magazine and the syndicated column,“The God Squad,” read by readers around the world.

Welcome to our show Rabbi Gellman.

Dan:

Rabbi, during your time that you’ve been a Rabbi, and I understand that’s been decades now, have you counseled people with depression?

Rabbi Gellman:

Yes, I have. Although my general orientation, and I hope it’s the orientation of most clergy, is to refer people to professional psychiatrist or psychologists who specialize in this. It’s not something that clergy should enter, in general, because they’re not trained for it.

Dan:

Once you’ve referred those people and they are treating with a psychologist, psychiatrist, or both, do the clergy have some role in comforting the people with spiritual support with this kind of condition?

Rabbi Gellman:

Yes, I think we serve two roles.

One is what I would call “psychiatric first responders.”

We’re the ones who first alert people to the fact that they are depressed and that they need some kind of professional treatment in order to get back to some level of functioning life. The second purpose which we serve as clergy, if we are doing our jobs well, and our calling well is to provide to the community a message of hope. The antidote to depression, of course, is hope. And in a communal sense, Rabbis can provide that hope. In fact, it is my view that the search for hope that is the primary motivator for people to affiliate with religious denominations and to seek personally their own way to God. It is the search for hope, ultimately.

Dan:

Many people who I speak to around the country, and myself included, I am a practicing Catholic, and so often in the throes of depression, or maybe even at the beginning, I would often ask God, “Why me?” I think that so many people, and maybe it’s true for any kind of suffering that afflicts people, ask that seminal question. In your faith, and in your experiences, how do you respond to that?

Rabbi Gellman:

Well, I have a rather unconventional view of many things. And I have an unconventional view of that question. First of all, I don’t think it’s a common question. People say it is, but I don’t believe it. I’ve never heard it. Most people are not really consumed by the question of why this has happened to them.

There’s two reasons for that. First, they can think of a lot of reasons it’s happened to them. So, they know the reasons it’s happened to them. Second, the question, “why me,” presumes a kind of spiritual and ethical arrogance that most people are mature enough not to have. By that, I mean the question, “Why me?” if you sort of unpack it a little, means, “I am so righteous, I am so good, I’ve done so much for the world, and for my family, and for my community, that my virtue is so enormous, that it should protect me against all evil.

Now, no one really believes that.

No one believes, in their right mind, in the list of the greatest human beings that have ever lived, Gandhi and Mother Teresa, that they should be No. 3. I honestly don’t think people ask the question, “Why me?”

My approach has always been on two levels. One on a level of personal counseling to try to get people to find some resources to find some reasons to hope and I have some techniques that are very effective in that way.

Second, in my teaching, to explain to people that there are two reasons why bad things happen to them. The first is that they caused them to happen. People who have lung cancer after a lifetime of smoking really have no right to say, “Why me?” They did it to themselves. People who have neglected their physical fitness and have developed different pathologies that come from obesity or inactivity have done it to themselves. So, much of what happens to us, that is evil, is self-produced.

The second reason why bad things happen is because of what Aristotle called, “natural evil”. That is just the way the world works. A Rabbi said a phrase, “Olam K’minhago nohgge,” which means the world goes according to its own order. It means if you’re walking along the street and a brick falls from a scaffolding and you’re underneath, it’s bad luck on you. But, that’s just the way the world works. If you happen to be in a place where a tornado hits, or a hurricane hits, it’s the way the world works and this natural order of the world is not evil. It’s just the natural working of the laws of the world. A Tsunami is not evil. If a wave crashes over an uninhabited island it’s not evil. It’s only if people are there. Well, people choose to be there. The point is there are things we do to ourselves and there are things that happen to us because the world is the way it is.

Dan:

With respect to “the way the world is, would that include our bodies, our brains, and our genetics? There are now studies which show that many, many people, especially with the more severe forms of depression, have a strong genetic vulnerability to depression. Or, other people grow up in neglectful homes where they are neglected or physically abused. Those people have high rates of adult-onset depression. Can you follow-up on this?

Rabbi Gellman:

Sure, I mean, sometimes you draw some bad cards. You draw environmental bad cards, you grow up in an abusive, deprived upbringing, and, in some cases, you draw a bad genetic card. But, I would say to both those things that there are ways that people overcome those inheritances.

For example, there are people who grow up in very, very difficult circumstances. And for some reason, they are disciplined and hopeful, and they are able to move out into better circumstances for the rest of their life. Other people surrender to the difficulties of their environment. How do you distinguish between one and the other? Why is someone able to pull themselves up by their bootstraps and someone else isn’t from the same deprived neighborhood? So, something else is at work here.

As far as the genetic inheritance, it may be true, it probably, certainly is true, studies in schizophrenia certainly seem to indicate it is true, that there’s a strong genetic component to depression. However, there’s a problem with focusing on that medical fact and the problem is that it gives people an excuse to wallow in their depression, to surrender to their depression. Hey, look, I’ve known people who are obese, who say, “Look, I can’t lose weight because I’m genetically fat.”

You know, that’s ridiculous.

You may have a genetic predilection to obesity, you my have a genetic predilection to depression, but that doesn’t mean you can’t fight it. And if you believe that this was your inheritance, it’s just another reason to surrender. And depression requires vigilance, and it requires very strong emotional dedication to becoming well again.

Dan:

Can you give us some insights into how the Jewish faith, the Jewish religion, views depression, and, specifically, do you give examples from the Old Testament that you believe are insightful into how people can see their depression and overcome their depression? You minister and you preach. Can you give us a little insight on that?

Rabbi Gellman:

The first is a personal understanding. I think it comes out of scripture, but not directly.

It’s a technique that I developed which I call, “spiritual balancing.” The history of this is that my wife and I, Betty, were living in Evanston near Northwestern University. We were remodeling an old house and the fellow that was helping us do some spakling was carrying two big containers of this spakle up the stairs and I said to him, “Why don’t you just carry one bucket up? Why carry two at once?” And he said, “Well, if I carry one it throws me off and it hurts my back. If I carry two, it keeps me in balance and I can carry twice as much.”

For some reason, it was an epiphany for me. It was a life-changing moment, just watching this guy carry spakle up the stairs. What I realized at that moment, and developed it as a counseling technique, and have spoken to psychiatric associations about it, is this technique of spiritual balancing.

So it works this way. Someone comes to me and they’re depressed, they’re in grief, they’re in a bad place. So I say, “Here’s what we’re going to do. We’re going to do five minutes of you telling me, in as much excruciating detail as you can, why your life is miserable. Five minutes.

And then, for the next five minutes, I want you to tell me why your life is wonderful. What are the wonderful things in your life. But it has to be for the same amount of time.

I do this often with people in grief. “Give me five minutes of how sad you are, and how broken you are that you’re loved one died and how unfair it is and how awful it is, and how it’s breaking you, and then five minutes what you loved about the person. And what was great about the person.”

What I discovered quickly, using this technique, is that in the end, people felt much better, at the end of the counseling session. The reason they felt better was not that anything had changed, but that they had balanced the miserable, depressive thinking that they had, that had imbedded itself in their brain because of their trauma, with positive, endorphin producing, hopeful thoughts that were also in their brain, but they weren’t accessing them because they weren’t thinking about it. They were obsessed with the loss. That’s the purpose of the Psalms, of many different passages in the Bible which is to get you at the moment you are most depressed to thing about the goodness that is still in your life and to overcome that natural tendency to focus on your burdens by turning in a conscious way to a meditation on your blessings.

Then you will discover when you do this that there is not a single day in which you wake up where your blessings do not exceed your burdens – not one single day.

Depression and Anxiety in Later Life

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I’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.

“Plop, Plop, Fizz, Fizz” – Oh, What a Relief it is? Our Relationship with Antidepressants

Most folks with depression have a complicated relationship with their antidepressant medications.

I certainly do.

While these pills saved my life years ago when major depression struck, years later, I often wonder if I still need to take them, or, if they’re still effective.

If I feel tired and flat on a particular afternoon, is it depression, the side effects of my meds or a jumble of both? Or maybe, it’s just my persistently pensive nature?

I think about this a lot these days – and maybe you do as well.

While the one-two punch of Cymbalta and Lamictal have kept me out of the dungeon of major depression for years, its comes with a cost. I have interludes of passivity, numbness, and fatigue. Maybe a low-grade depression at times, as well. If I ditch the drugs, maybe I will feel more “alive,” I think. I fantasize that cutting my ties with meds could lessen the days lost to the deadening grayness of a medically induced sense of normalcy I sometimes go through.

But I also feel anxiety. If I went cold turkey and lived medication-free, would it end, well, in disaster? A return to the swampland of depression? A deadman’s land if ever there was one. Can I take that chance? Should I?

There’s scary research that suggests once you stop antidepressants that work (or sort-of-work) for you and try to go back on the same ones because being off of them caused your depression to return (or you just couldn’t tolerate the horrible side effects that can come with discontinuation), there’s a good chance they won’t be as effective.

So, what’s a depressed person supposed to do? What should I do?

There are two camps that offer some guidance on this issue. Both have persuasive arguments about why those afflicted should or shouldn’t stay on meds.

The Stay on the Meds Camp

If depression is an “illness,” like diabetes or heart disease, I need these meds to balance out my of whacky neurochemistry. Given my risk factors: a family history of depression (genetics), a crazy childhood with a nutty, abusive and alcoholic father, and a high-pressure job with too much stress, I should stay on the pills.

In his insightful essay in the New York Times, In Defense of Antidepressants, psychiatrist, Peter Kramer, author of the best-selling books, Listening to Prozac and Against Depression, suggest that studies show this: for mild or moderate depression, talk-therapy is as or more effective that medication. But for the Moby Dick sized sucker called Major Depression? Medications are warranted, and, indeed, lifesavers. They help many to function and live productive lives, albeit with a range of mild to more severe side effects.

The Get off the Meds Camp

Some people (including psychiatrists) see meds as the devil’s handiwork: supposed chemical solutions to emotional problems that flat-out don’t work. Many psychiatrists’ (and family doctors who write the overwhelming majority of scripts for these drugs in the U.S.), they maintain, are “pill pushers” who do the bidding of “BigPharma”, a multi-billion dollar industry in this country. Antidepressants aren’t so much a cure as a curse.

Irving Kirsh, Ph.D., author of The Emperor’s New Drugs: Exploding the Antidepressant Myth, writes:

“Putting all [the research] together leads to the conclusion that the relatively small difference between drugs and placebos might not be a real drug effect at all. Instead, it might be an enhanced placebo effect, produced by the fact that some patients have broken [the] blind and have come to realize whether they were given drug or placebo. If this is the case, then there is no real antidepressant drug effect at all. Rather than comparing placebo to drug, we have been comparing ‘regular’ placebos to ‘extra-strength’ placebos.”

The remedy from this group? Psychotherapy. They see depression as the result of off-kiltered, negative thinking patterns. The way out of these ruminative, pessimistic thoughts involves working with a therapist who uses, most often, Cognitive Behavioral Therapy, to challenge and encourage patients to replace such thoughts with more realistic and positive ones.

In his book Undoing Depression: What Therapy Doesn’t Teach You and Medication Can’t Give You, Richard O’Connor, Ph.D. argues that both therapy and medication are effective, but limited in certain respects. He advocates an additional factor often overlooked in depression recovery: our own habits. Unwittingly we get good at depression. We learn how to hide it, how to work around it. We may even achieve great things, but with constant struggle rather than satisfaction. Relying on these methods to make it through each day, we deprive ourselves of true recovery, of deep joy and healthy emotion.

The book teaches us how to replace depressive patterns with a new and more effective set of skills. We already know how to “do” depression-and we can learn how to undo it.

Some Recent News on the Meds and Therapy Conundum

The New York Times reports that a large, multicenter study by Dr. Charles Nemeroff, then a professor of psychiatry at Emory and now at the University of Miami, found that for depressed adults without a history of abuse, there was a clear ranking order of treatment efficacy: Combined psychotherapy (using a form of cognitive behavior therapy) and an antidepressant (in this case, Serzone) was superior to either treatment alone. But for those who had a history of childhood trauma, the results were strikingly different: 48 percent of these patients achieved remission with psychotherapy alone, but only 33 percent of these patients responded to an antidepressant alone. The combination of psychotherapy and a drug was not significantly better than psychotherapy alone.

So what’s a depressed person supposed to do?

I don’t know, really.

We’re in a pickle, aren’t we?

Maybe there’ll be a soon-to-be discovered test that can guide us on precisely what to do. But for now, many of us will stay-the-course and, for better or worse, stick to the “plop, plop, fizz, fix”.

I see myself somewhere in the middle of all this. I’ve never been hospitalized or tried to commit suicide. But I have known depression’s scorching winds, gales that have torn the flesh from my body. I will never forget this pain. It’s scarred me. And I never want to return to it.

If you’re thinking of discontinuing your meds, here’s a great article on how to do it safely.

I welcome your comments about your depression journey with or without medicaton.

by Daniel T. Lukasik

The Person I’m Supposed to Be: One Person’s Depression Journey

There’s a wretched place depression drags me off to after taking control of my thoughts and feelings. It’s the place where the longing for relief mutes every other desire, even the desire to wake up in the morning. There are days when I wonder if I’ll lose everything: my job, my relationships, my last stitch of sanity. It feels as though I’m breathing hot black smoke.

Yet I believe the same depressions that pin me to the mat so often also serve a bigger purpose in my life. They don’t come empty-handed. I believe the purpose of suffering is to strengthen us and help us understand the suffering of others.

At 16, my first episode hit me hard enough to think I’d literally gone to hell. Now, at 35, when I start dreaming of haunted houses and worrying uncontrollably about the future, I know another episode is looming. I’ve got a week’s notice, maybe two. And then it’s as if I’m drifting off to exile inside myself with only a shell remaining.

It used to be that rising from the ash after the depression cleared was like resurrection. The burial over, I’d catch myself laughing or looking forward to the next day. I’d pig out at my favorite deli. But now, when I look closely, I find mental illness leaving other significant gifts in its wake — things I didn’t discern when I was younger.

The discovery is like that scene from The Matrix when Neo finally comprehends his identity. Through the whole film, he’s been beaten up by evil agents. But the fighting transforms him into a warrior. And at the right time, he understands and uses his power. He’s peaceful, even when confronting an enemy. I believe my own years of struggling with depression have left me with similar gifts: inner strength and calm I can rely on, diminished fear and compassion.

I believe the painful nights that close in on all of us in some form are the cocoons from which we might shed our weaknesses. I believe pain tells us something critical about ourselves and life: that developing strength and empathy and bravery is more essential than our personal comfort. And when I think of it like that, I’m more willing to accept suffering on its terms.

That’s important, because if my pattern holds consistent, my next episode is due to arrive soon. I live with this reality, but I’m no longer afraid of it. The depression has, in the end, equipped me for its next visit — and that’s enough. Of course, I’ll take my medicine. I’ll talk to my gifted psychiatrist. But when the dark does come, I’ll stand up and breathe deeply, knowing I’m becoming the person I’m supposed to be.

By Andy Blowers. This piece first appeared on National Public Radio’s All Things Considered.