Monday, December 5, 2011

Caring For Depression

Techniques that helped me: 

• Perhaps the biggest solace was realizing and accepting that this horrible feeling is only temporary and is the result of the disease, and that reality is not as bad as I perceive it to be. It stopped me from trying to resist it, which was vain and enervating, and helped me accept it. When the fog would come over me and torment my mind, I learned to "lay low" and "wait out the storm" by not trying to resist it. It is still difficult but takes less energy that vainly trying to break free from it.
• One thing that unfailingly makes me feel good when I feel hopeless and worthless, is reminding myself that other people felt the same way or even worse, thereby making it OK for me to feel this way. Like Abraham Lincoln, despite having severe depression he went on to do great things. It validates my feeling, and makes me feel like I'm not alone.
• The other solace is being able to relate to somebody else who was going through the same thing. It put things in perspective.
• Writing about my feelings (blogging and journaling), listening to validating music (I listened to Korn a lot), reading a validating book (like a memoir)
• Also, “coming out” was a great relief. It was hard to tell others, but telling friends took a huge burden off my shoulders of keeping it a secret. Letting others know about my illness makes me feel like I am breaking down the silence around it and that something good has come out of my experience. Sharing with others that you have a mental illness is difficult at first because you are vulnerable and stigmatized, but I noticed that, as a rule, when I share something personal others tend to share something about themselves. Also, it’s surprising how many people want you to share your experiences because they themselves are depressed. They are hoping that somebody will help them but are just too afraid to say reach out.
• Meditation. I paid $375 (which was already a 50% student discount on the full $750 fee) to learn transcendental meditation. The technique is really simple and does not require much training; however, paying the money made me commit to it more. The technique involves sitting still for 20 minutes in the morning and at night and repeating a mantra in your head--it can be anything, like "one" or "ohm"--while not thinking about anything else, and if you catch your mind drifting, gently bring it back to the mantra. Meditation is extremely effective at easing anxiety and worry. However, it is really hard to get into the habit and takes a few tries before you can calm your mind down effectively.
• Books. I bought several self-help books and memoirs, which helped tremendously. Reading memoirs helped me feel less alone and understand that what I was experiencing was normal, and reading self-help helped me understand what I was going through better and feel like I had some control over my well being. The memoirs I read were: An Unquiet Mind, and Darkness Visible. Recently I also read Lincoln's Melancholy, and Unholy Ghost. I also bought The Feeling Good Handbook by David Burns, which has a lot of helpful information and exercises. My therapist also recommended me the Dialectical Behavior Therapy Skills Workbook to help manage my emotions.

Other suggestions for how to get the most from depression treatment: 

Monitor your mood. Monitoring your moods and behavior from time to time can help your doctor treat your depression before it becomes hard to control. Try to observe any patterns of mood swings each week and call your doctor if you aren’t feeling at the top of your game. 
Strengthen your social support. While you cannot control your depression diagnosis, there are some things you can control. You can seek or create a positive support system for yourself. Whether your social network stems from your spouse, family members, close friends, co-workers, religious organizations, or community groups, support is available. 
See a depression expert. Any doctor can prescribe depression medication, but a prescription alone isn't the best treatment. You should seek out an expert, like a psychiatrist or a psychologist. Your condition is, by definition, hard to treat. It's important to talk with a trained professional during your treatment. Although psychologists cannot prescribe medication, they are well-trained in psychotherapy. You can work with a psychologist while taking antidepressants prescribed by your regular doctor, or you can see a psychiatrist for both your depression medication and talk therapy. Try to find someone who has a lot of experience helping people with treatment-resistant depression. 
Develop good habits. Take your depression medicine at the same time every day. It's easier to remember if you do it along with another activity such as eating breakfast or getting into bed. Get a weekly pillbox, which will make it easy to see if you've missed a dose. Since people sometimes forget a dose now and then, make sure you know what to do if that happens. 
Don't ignore side effects. Side effects are one of the main reasons that people give up on medication. For instance, in a British study of just over 1,000 people with depression, 65% said they stopped taking their medicine at some point. Of this group, about 45% said side effects were the reason. The results were published in Current Medical Research and Opinion in 2003. If you have side effects, talk to your doctor. See if there's any way to minimize or eliminate them. However, keep in mind that side effects might be worse when you first start a medicine. Side effects often ease up over time. 
Maintain regular sleep habits. Talk to your doctor if you have difficulty falling asleep or maintaining sleep. There are new non-addictive medications available that can help resolve sleep problems. Also, cognitive behavioral therapy has been shown in recent clinical trials to be a helpful adjunct treatment for patients who have impaired sleep efficiency, or anxiety and fears about poor sleep.

Andrew Solomon's interview (author of The Noonday Demon):
from documentary DEPRESSION: Out of the Shadows

What advice would you give others?
  1. First piece of advice: Deal with it early. Don't wait until it escalates out of control. Like any illness, it's easier to treat before it becomes acute.
  2. Second piece of advice: Find the right therapist and psychopharmacologist. Sometimes that's one person and sometimes it's two people; seek the best. There a lot of bad treatments and too many incompetent shrinks, so if you're not getting better, try seeing someone else. It's exhausting and annoying shopping around, but as in all other areas of life, there are some people who are highly skilled and others who just aren't very good. There are also people who work well for one patient and aren't right for another.
  3. Third piece of advice: If you have a chronic condition, treat it in the long-term. Have the courage to stay on your meds, and don't be tricked into thinking that brave people get better on their own. If you had lung cancer, you wouldn't try to cure it by breathing carefully. Don't trivialize depression. Remember that it can be fatal: A large number of depressed people commit suicide.
  4. Fourth piece of advice: Don't keep it all a big secret. Depression is stressful and keeping secrets is stressful. But tell people selectively and carefully. Some people can deal with it and others can't. And get yourself a support structure. Love won't cure depression, but it will make it a whole lot easier to tolerate.

Treatment facts:
• Treatment works for 80% of patients.
• If left untreated, the average duration of a major depressive episode is six months.
• The average duration of an episode of six months. 20% of these episodes can last two years or more, with 50% of depressive episodes ending spontaneously.
• After the major depressive episode is over, 20% to 30% of patients have residual symptoms.

Alternative (to medication) treatments:
 – Lifestyle changes/adjusting daily schedule
    • Physical exercise
    • Diet/Nutritional therapy (incl. multivitamins and omega-3 oil)
    • Getting enough and consistent sleep
    • Change in job/location
 – Herbal remedies
    • 5-HTP
    • St. John’s Wort
    • SAM-e
 – Meditation
 – Writing/Journaling
 – Music
 – Making new friends/creating a support network
 – Volunteering
 – Yoga
 – Getting a pet/Pet therapy
 – Hobbies
    • Dancing
    • Drawing/Art therapy
    • Hiking in nature
    • Gardening

Here are some of the supplements for mood and health that helped me. I've used Omega 3 and multivitamins for a long time and they've helped my mood a lot. 5-HTP helped take the edge off of stress and anxiety.

5-HTP: Nature's Way
I also suggest you take 5-HTP for mood and appetite control. This is 50ml capsules. You should take them every 4 or 5 hours. Start with 100ml per day, and then increase to 200ml per day if you don't get side effects. These are very powerful, so you should be careful when taking them, make sure to space them out and monitor your mood.

Omega 3 Mood: Country Life
Currently it's $15.12 for 45 days (90 1g softgels, twice a day)
In a nutshell, why it's good:
The ideal ratio of Omega-6 to Omega-3 should be 1:1, but the typical American's ratio ranges greater than 20 to 1. This is because we consume much more Omega-6, which is a fat found in corn, soy, sunflower and other oils. Also, countries with high consumption of seafood (which contains Omega-3), like Japan, have much lower rates of depression than America. There are two types of important Omega-3 fat: EPA and DHA. Fish oils are the best source of these. The EPA helps support mood, among other benefits, because it educes inflammation. The best ratio of EPA:DHA is 7:1 (some say it's 3:2, but 7:1 works for me). To have any effect, take 2g of Omega-3 per day for a few weeks. If you don't experience any effect, up your dose to 3 or 4 g/day (but not more). 
This one is the cheapest ever: $6.67 for a month supply. The doses in Alive are effective for depression. This multivitamin also increases energy.

Note: According to the book "Chemistry for Joy", these are the effective doses for depression (much higher than the RDA). Alive comes close to these.

Mineral Amount/day
Calcium 750-1500mg
Magnesium 375-750mg
Chromium 200-300mcg
Copper 1-2mg
Zinc 7-30mg
Manganese 5mg

A (beta-carotene) 25000IU
C 200-500mg
D 800IU (20mcg)
E 400mg
B6 10-50mg
B12 20-100mcg
Folic Acid 400mcg
Selenium 200mcg

More information about depression:

DEPRESSION: Out of the Shadows + TAKE ONE STEP: Caring for Depression, with Jane Pauley

Medication Ambivalence

Many people I know, and even I used to resist taking any kind of medication. This is especially true with prescription medication and those that affect mood, such as antidepressants. Looking back at the reasons I gave against taking antidepressants I realized that most of them were irrational and were based on irrational, culturally constructed beliefs. Through talking to people and personal experience, I devised a list of the most common reasons people give for- and against taking antidepressants.

Reasons People Give Against Taking Antidepressants

• Shortcut, does not involve work. Like plastic surgery
• Not a “natural” solution
• Involves changing something in you. Feel uncomfortable because the better "you" isn’t actually you
• Fear of changes in personality
• Temporary solution
• Fear of dependency and getting addicted (possibly on other drugs as well)
• Fear of having to take it for the rest of your life
• Possible side effects, e.g., nausea, insomnia, sexual dysfunction
• Possible withdrawal effects (under 20% of cases)
• Possible tolerance development (in about 20% or case, antidepressants loose effectiveness)
• Distrust of the pharmaceutical industry
• Cost (can be anywhere from 5 to 100 dollars a month)
• If you stop you can relapse into the illness
• Stigma of taking prescription medication
• Don't want to admit that there is something wrong with you (that you are sick and it’s not under your control) rather than a lifestyle choice.

Reasons For Taking Antidepressants

• If the depression is severe, antidepressants are most effective (scientifically proven)
• A last resort, if alternative remedies have not worked
• Many potential benefits, such as the possibility of complete remission (no more depression)
• Changes in personality
 – Greater self-confidence and less anxiety
 – Greater resilience in the face of set-backs
 – More joy
 – Positive changes in careers and relationships

My Own Concerns:

My initiate concerns about taking medication (form my journal, April 2009):
  • May have adverse unanticipated effects that will cause me to become worse off than I already am
    • Can cause relapse when discontinued, and leave me with even worse symptoms
  • may be unsafe and useless
    • Only half of the people relieve half of their symptoms
  • May cause dependency
    • Especially if it has been used regularly for an extended time or if it has been used in high doses
  • Addresses the symptoms and not the problem
    • Pharmacological interventions are largely palliative
    • Paxil is a symptom suppressant and too many people are taking it under the false assumption that it will cure their ills
    • [Drugs] release people from personal accountability, where lifestyle and self-perception changes would serve better
  • Might interfere with therapy
    • Can interfere with the mechanisms of successful therapy.
  • Can change my state of mind (alter my perception of the world and myself).
    • It will cause me to lose judgment and my ability to control my emotions and actions by deforming my way of thinking and feeling. 
    • They were "spellbound" by the drugs themselves: by the pharmacological properties of the drugs themselves and by the professionals who convinced them that the drugs were going to help.
    • The person taking these drugs is and cannot be objective about the drugs
    • Since Paxil affects chemical communication in your body, your ability to perceive daily experiences or self identity can be affected.
Questions I Had For My Psychiatrist:
  • Q: What is the probability of full remission from the symptoms of depression?
  • Q: What are the probability, duration, and severity of Paxil withdrawal symptoms/discontinuation syndrome (when gradually decreasing the dose).
  • Q: What is the probability of getting physical and emotional symptoms that were not present prior to Paxilor worsened pre-existing symptoms—after withdrawing from the medication.
  • Q: For how long after quitting Paxil will I experience the side effects? (How long does it take for Paxil to be completely out of the system?)
    • Duration: 2/3 chance of symptoms subsiding within a month
  • Q:  Is there a test to predict susceptibility to dependence and likelihood of severe withdrawal symptoms, what they will be, and what the chance of relapse after I quit?
    • Cytochrome P450
    • CYP2D6
    • 5HTT (Serotonin Transporter)
  • Q: What is the probability of relapse after stopping medication?
  • Q: Why did my psychiatrist not inform me of the possibility of withdrawal symptoms when prescribing the antidepressant?
  • Q: If I miss a psychiatrist appointment, how do I ensure that I receive more of the medication, so I wont be forced to quit cold turkey and have withdrawal?
  • Q: What is the probability of developing tolerance?
    • approximately 20 percent of people who take antidepressants — the so-called "poop-out" effect. In such cases, the medications simply stop being effective.
  • Q: How will I know if I'll be taking this medication long-term?
  • Q: Are there harmful long-term effects, such as brain damage?

The Biggest Mental Illness Myth: You Can Control Mental Illness

Having major a.k.a. clinical depression is having a disease. And like any other disease, such as cancer or diabetes, you cannot cure yourself with your mind by simply being optimistic and "strong". Treatment can take months and sometimes years, with very gradual improvements. There is usually no single cause to depression, and it is wrong, ignorant, hurtful, and unhelpful to ask people with depression "why are you depressed", act like you know what is causing their depression, or tell them to simply "be happy". It is necessary to accept that there is nothing you can do to help a person with depression other than maybe keep him company.

The Myth: Mental illnesses are all in your head, and you can just get over them if you really want to. 

This earned the number one spot, not only because it’s general, but because it’s probably the most damaging myth about mental illness, since it prevents the acceptance of depression as a real disease. Some people still believe that mental illnesses are all imagined by their sufferers, or that people who suffer from mental illness can’t really be having that much trouble or just don’t care enough about getting over it. People are especially likely to be dismissive if they don't know much about the illness.

The fact that the same symptoms have been experienced by so many different people should prove that they are real — they can’t all be independently inventing the same symptoms. Any mental disorder, by definition, seriously affects the lives of the people who suffer from it, usually for the worse, or it would not be considered a disorder. And they are certainly not easy to get over. Most mental disorders are caused at least in part by a difference in the brain or an imbalance of chemicals. Even when it comes to the non-physical reasons, it’s very difficult to un-learn a thought pattern or habit — just choose any habit and try it. Plus, the disorder itself may stop someone from trying to get help: people with depression might think no therapist will be able to help them, and be too tired to try to find one, anyway. If we could overcome mental illnesses just by wanting to, the world would be full of much happier and more productive people. 

The Just World Hypothesis

There is also the belief that if something bad happened to you than you deserve it. The need to see victims as the recipients of their just deserts can be explained by what psychologists call the Just World Hypothesis, a cognitive bias. According to the hypothesis, people have a strong desire or need to believe that the world is an orderly, predictable, and just place, where people get what they deserve. It's the belief that the wrong-doers will always be punished and good-doers will always be rewarded. This belief leads to the conclusion that victims of misfortune deserve what happens to them. So those with afflictions are seen as at fault, whereas none is due. You wouldn't blame a cancer patient for getting cancer, nor should you a depression patient. Sure, some of the cancer patient's life choices (bad diet, lack of exercise) contributed to him getting cancer, but we don't blame him for getting it. This belief also leads to other terrible conclusions, such as that rape victims and victims of child abuse are somehow responsible for their misfortune. There are other, more subtle beliefs that stem from the Just World Theory, such as that poor people are wicked and rich people are righteous. This idea comes from the Bible, which says that if you commit a sin, several generations will pay for it. It's also present in some eastern thought, as "karma", or everything bad that happens to you is punishment for something you did in your past life. Such a belief plays an important function in our lives since in order to plan our lives or achieve our goals we need to assume that our actions will have predictable consequences. Moreover, when we encounter evidence suggesting that the world is not just, we quickly act to restore justice by helping the victim or we persuade ourselves that no injustice has occurred. We either lend assistance or we decide that the rape victim must have asked for it, the homeless person is simply lazy, the fallen star must be an adulterer. These attitudes are continually reinforced in the ubiquitous fairy tales, fables, comic books, cop shows and other morality tales of our culture, in which good is always rewarded and evil punished.

The Fallacy of Control

This belief that you can always control how you feel probably stems from Americans' overly individualistic view of the world. We believe that we alone are responsible for our fortune and misfortune. This is actually very rarely true. In real life, there are many things (such as our emotions) that are out of our immediate control, and most of the time the perception of control is an illusion. This is especially true for people with depression, who cannot cure their depression with their minds anymore than a person with cancer can cure his cancer. Even thought the majority (80 percent) of people with depression eventually (in six months on average) recover (due to mostly unknown reasons), a minority (20 percent) has what is called treatment-resistant depression, which does not respond to treatment. If you are one of a few people who are unemployed in a nation, it's probably your responsibility, but if you are one among the 10% of the nation's unemployed, this isn't a personal problem anymore but a social problem. However, when we see an individual who is unemployed, we discount all the social forces that caused him to be unemployed and assume that he is just lazy or unwilling to find work. 

The Mind-Body Separation

What I've noticed is that people are much more reluctant to accept the existence of mental illnesses then physical ones. This reluctance has the effect of preventing insurance parity (equal treatment) between physical and mental problems. One person I know is OK with taking fat burning pills that contain the supplement 5-HTP (an appetite suppressant and mood enhancer), but he is not OK with taking 5-HTP by itself.

Friday, December 2, 2011

Life's So Goddamn Fucking Easy

Coming out of depression is exciting--there is so many new things that you can do, and actually enjoy them--enjoy life. But it's also like I have my life to take care of. I feel like I deserve a vacation. But life doesn't wait. There is all these responsibilities to take care of. 
I can finally "stand up and feel the warmth", and it is a feeling of deep happiness and sadness. 
—From my journal, 4/9/10 1:14 AM

When I was depressed, my lifestyle choices—like eating, exercise, and sleep—were supremely healthy—it's the only way that I could keep my head above water. Life was extremely hard, and the mundane tasks took tremendous effort. When I recovered I thought, "I deserve a vacation", and so I just gave in to the current and climbed onto a cozy boat and frivolously and effortlessly floated downstream without a care in the world. So after I recovered, I looked at how careless I was about my lifestyle choices, and I thought, "have I learned nothing from this experience?"

When I was depressed, I thought, "life's so goddamn fucking hard. How does anybody have the strength to handle this pervasive pressure and piercing pain? Why don't more people kill themselves?" In reality, the lives of those who don't have mental illness are extremely easy compared to the challenges that those with mental illness face daily. So, if everyone was depressed like I was, many more would kill themselves. In fact, over one million people worldwide already kill themselves annually, and 10 to 20 million try to.

Even when you are recovered from depression, bipolar, OCD, or whatever other mental illness you have, there is still a risk of relapse that you have to watch out for, because if you don't stop it in its early stages, it will be a train heading your way at speeds. And if you are battling your illness at present time, yo are indeed faced with a challenge most people won't have to face. Your feelings dip and fly out of control from the slightest stresser, your concentration fails you at inopportune times, when you need it most: when you are studying for an exam, reading a book, or listening to a lecture. Your good old friend, your mind, who was there has suddenly caved in and you can no longer rely upon him. You can no longer do the things you used to do with such ease. This is frustrating and demoralizing. You are mad at yourself for not being able to do the basic tasks that other can--that you once could--do so effortlessly.

When I was depressed, there was nothing that I wouldn't give to just have one second of my life now: to be free of the eternal internal torture, the grayness, the misery, the utter loneliness. It is a matter of life and death. More accurately, it is a matter of life and "provisional existence", a term used by Victor E. Frankl to describe the state of the prisoners in the death camps. It isn't life, it isn't death, and it isn't mere existence. It is provisional existence. Knowing that you will in some not too distant future fade away in the abyss. Without a speck of faith for what's in store.

When I was depressed, I was not—and I could not—be thankful for anything in my life. Everything brought me pain. I had no rest from the torture. Now, I am able to be--and I am--thankful for everything in my life. I am thankful that I can take a deep breath and enjoy the air filling my lungs. I am thankful for my car starting up today, I am thankful to live in America, where my civil liberties are protected. I am thankful for my job, which I love. I am thankful that I have the freedom to go outside and walk and be able to choose which way I want to go.

When I was depressed, I seized to be able to do the things I used to be able to do, like study and pay attention in classes. But now that I'm not depressed and able to effortlessly do so many things I wasn't able to do, like concentrate, have resilience to stress, and experience joy, I feel like I have superpowers, and I appreciate these things much more than I used to.

Script from the movie "Awakenings". Leonard, the "awakened" patient, is played by Robert De Niro, and Kaufman is a doctor:
I'm curious... I can tell this is important to you but I'm not sure why. What would you do if you went out?
I'd walk around. I'd talk to people, I'd look at things. I'd decide whether I wanted to go this way, or that way, or keep going straight. I'd do the things you do everyday and take for granted.