Breaking the Cycle of Depression
Wellness Inventory Part Three
There has been an enormous amount of confusion over the last 20 years about the treatment of depression, as well as figuring out what depression is. In order to look at depression in a brighter light, we'll be using the 13 Life Arenas of the Wellness Inventory.
Life's 13 Arenas
2. Play and Entertainment – Passive Fun
3. Creativity – Active Fun
4. Mental/Emotional Well-Being
5. Physical Health and Well-Being
7. Meaning and Purpose
8. Social Connection and Support
10. Movement and Exercise
11. Spiritual Connection to Self, God and Nature
12. Rest, both Mental and Physical
13. Environment and Surroundings
What Is Depression?
I've worked with many people who tell me, “I have depression.” This wording tells me a lot about this person and their relationship with depression. I will respond by saying, “Let's explore whether you have depression, or whether you are feeling depressed.” When you say you “have depression,” you are claiming depression as a diagnosis, as a disease, or that it's like a bad pneumonia that you caught.”
I do not mean to minimize the suffering of depression. Rather, it is the shift in psychiatry over the last 20 years in which every emotion has become a disease treatable by a new drug that is bothersome. There are a couple of kinds of depression that do fall more into the disease model, those being “depression as part of Bipolar Illness” and “Clinical (or Major) Depression,” both of which can have strong genetic underpinnings. These deep biological depressions respond to treatment with medication far better than other depressed moods.
There are limitations imposed by the English language that make it impossible to accurately convey every emotion and mental state. You may feel odd, off, down, blue, confused, just not yourself, lethargic, lost your zest…or wondering if Mars is in retrograde or the full moon tugging on the tides of your brain – because you're just not feeling 100% “normal.” I work hard in assisting people to do their best to explain what they are feeling, even if it is “dysphoric,” which is an unpleasant mood, but not necessarily depressed. The fact is that, over the course of a day, we all go through a variety of moods. That does not make us rapid-cycling bipolars. It might mean that our thoughts, moods, and energy ebb and flow in response to the world around us, challenges and opportunities in our lives, and in our diet. It is very common for people to get labeled as “Clinically Depressed” (and then treated with Paxil or Zoloft because they told their doctor they weren't feeling quite right, or any of other the terms you just read.
Life Arena — Work
Let's say you have an ongoing problem with either your boss or coemployee at work. You've done everything you can think of to communicate a problem you perceive, but the situation is stuck, and nobody is listening. In fact, perhaps you are being blamed for a problem that you didn't create, but you can't change the situation at all. You could easily begin to feel trapped, hopeless, and unable to escape. A change of jobs might be all that's needed to lift your mood, but that may not be an option. Becoming depressed when you find yourself in what feels like a trapped, hopeless situation is a normal response. We might be able to lift your mood with an antidepressant, but we will not have changed the cause at all. You either need to find a way out of that job or need to develop a new way of looking at things. That is easier said than done, but is almost always possible. You “can” change your attitude and outlook when you can't change your circumstances.
While you're looking for ways to truly shift your outlook, you also will want to look for ways to discharge your anger, because if you feel trapped, you are likely to feel angry. You may believe that anger is the last thing you need. You don't want to lose your job. The fact is that becoming aware of how you feel empowers you. If you realize that your situation is making you angry, do some anger release work. Pound on a pillow and put your face up to the pillow and yell into it. Emotion gets stuck in the body and it only takes three minutes of full emotional expression to release almost any emotion. Three minutes of nonstop anger release in the privacy of your home will leave you enormously relieved, and if you were starting to get depressed, that feeling will lighten up. What you've read about depression and work also applies to depression as it relates to social connection and intimacy. In any relationship you can feel trapped.
There are many things that look like depression but are not. Boredom looks like depression, but it is quite different. Grief looks like depression because of the tears and emotional pain, but grief is the normal response to losing someone who you've been close to. People should be encouraged to grieve, and to do so in their own time.
If It Looks Like a Duck
Like all medical specialists, psychiatrists diagnose and treat by taking a history, examining a list of the main symptoms a person has, making objective observations, and then deciding on the diagnosis. By and large, psychiatry mainly uses about 10 diagnoses. The DSM-IV diagnoses “Major Depressive Episode” according to these criteria:
A. Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning:
1) Depressed mood most of the day.
2) Markedly diminished interest or pleasure in all, or almost all, activities.
3) Significant weight loss when not dieting or weight gain.
4) Insomnia or hypersomnia nearly every day.
5) Psychomotor agitation or retardation nearly every day (the person walks, talks, and moves slowly).
7) Feelings of worthlessness or excessive or inappropriate guilt.
8) Diminished ability to think or concentrate, or indecisiveness.
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms do not meet criteria for a Mixed Episode or for Bipolar disorder.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement.
These are good solid criteria, but many people are put on antidepressants by their primary care doctor who has no training in psychiatric diagnosis. Likewise, many psychiatrists often diagnose Depression based on a few words or symptoms that sound like what you just read. Here are a few examples of people who could easily be treated with antidepressants inappropriately:
1) Jane visits her doctor because she has been sad, crying frequently, and can't function.
2) John is having nightmares, is experiencing a lot of fear during the day, is depressed, having some suicidal thoughts, and has lost interest in his work and family.
3) Sarah feels blue, feels like her memory and concentration are not what they once were, and feels exhausted.
All three sound like they meet the DSM depression for criteria. But Jane's husband of 30 years died last month and she is going through a normal grief process. If a psychiatrist carefully read all the DSM criteria, which excludes bereavement, she would not be diagnosed with depression. If Jane's grief has left her sleepless for a month, a short course of treatment with sleeping pills would be appropriate. She should be encouraged to know that what she is experiencing is normal grief, and that the crying and tears are normal.
John also sounds depressed, but I have painted a partial picture of post-traumatic stress disorder or PTSD. He could be any of our fighting men and women who have returned from the Iraq War. Upon discharge from the military, John will probably slip through the cracks and it could be a couple of years before his condition gets so bad that he goes to the VA Hospital. If he has not taken too much time to seek treatment, it won't be hard for a VA psychiatrist to diagnose PTSD. If John waited too long, it is possible that the VA will refuse treatment of his PTSD because he missed the window of opportunity for treatment after military discharge. Military men and women are tough. 'They are not trained to be openly emotional and to show their feelings. They also do not like feeling like the weak one in the eyes of their buddies. It is in the military makeup not to seek psychiatry help for emotional problems.
Sarah, who is depressed, exhausted, and feels her memory is not what it was is a sketch of someone with chronic fatigue syndrome. She will almost certainly be treated with antidepressants even if a doctor makes the correct diagnosis. It is standard practice for doctors to treat CFS with antidepressants, even though they do not work.
All three of these examples “walk like a duck, look like a duck, and quack like a duck.” To repeat a common quote, “If it looks like a duck, it's a duck.” If it looks like depression, it's depression. And therein lies a huge problem. Antidepressants are now the 2 nd largest class of prescription drugs, in terms of sales, exceeded only by heart medications. If someone meets the DSM criteria for Clinical Depression, then medication treatment (while not my first choice) is appropriate. The other conditions that “look like depression” require totally different approaches.
Life Arena — Meaning and Purpose
Many people plunge into an existential crisis in which their life suddenly has lost meaning. These people need good social support and help from a spiritual counselor, rabbi, priest, or minister. They need help in exploring purpose and meaning. If they are quickly given an antidepressant, it may numb the emotional pain and make the issue of purpose disappear. There are a lot of situations in which it is best to assist someone in coping with the pain, and embracing that pain as part of their journey toward wholeness. The Dark Night of the Soul involves loss of meaning or a sudden, profound loss in faith or spiritual connection. It can easily be mis-diagnosed as a “mood disorder.”
Life Arena — Movement and Exercise
It is possible to become depressed because of lack of exercise. Healthy amounts of regular exercise produce healthy amounts of neurotransmitters, such as serotonin and norepinephrine. Exercise has effects on the entire body that increase well-being. Someone who is not exercising at all may experience some of the symptoms of depression. If this sounds like you, you need to break the inertia, and begin exercising. Start slowly and don't set your first goals too high. If lack of exercise is the cause of your low mood, a few weeks of exercise will tell you if you have found the correct cause and the treatment.
Life Arena – Creativity, Play, and Fun
Our society faces an epidemic of boredom. Our kids have not grown up in a culture which encourages good, clean fun, playing with other kids, playing a sport, practicing a musical instrument or any number of creative and fun activities. Instead, the computer and video games have become societal babysitters. These kids are bored, and have not developed important internal resources. Many adults are also bored. Boredom is not the same as depression, but it can
“look like a duck.” Antidepressants can numb the uncomfortable feeling of boredom, but if a low mood is coming from this life arena, the cure also comes from this life arena.
Life Arena— Physical Health
There are many health problems that look like depression, including: hypothyroidism, hypoglycemia, systemic candida, adrenal exhaustion, hormone imbalances, post-partum depression, and post cardiac surgery syndrome. People with illnesses affecting the brain, including multiple sclerosis (MS), often experience depression. Anything affecting the brain can cause neurotransmitters to get out of balance, which can lead to depression, anxiety, or any thing related to all the things the brain does.
Depression and Pain
Chronic pain is part of a vicious cycle that includes insomnia and depression. The person with chronic pain lies in bed hurting, and finds it difficult to sleep. Chronic pain and insomnia gang up to wear a person down, bringing on despair and depression. While the cure is not easy, the pain and insomnia need to be the first things that are treated. There can be a role for antidepressants, but, in general, pain needs to be understood as a complex problem that is best treated by a multi-disciplinary team that might include psychiatrists, psychologists, pain management doctors, acupuncturists, chiropractors, and more. If pain is treated as if it “is” depression, there won't be adequate progress, and you may come to believe that you “have” depression.
If you feel depressed, carefully read the DSM criteria for depression, and also review the 13 Life Arenas. By taking action in many of Life's Arenas, depression can be diagnosed accurately and appropriately treated in a comprehensive, holistic way.
If your doctor has recommended treatment with antidepressant medication, you have the right to know why. Do you meet the criteria for Clinical Depression? If not, are you in a transition or crisis that might benefit from the support of medication for a few months, while you look at deeper issues and at bringing your entire life back into balance?
Remember this. If you are feeling down or blue, avoid thinking that you “have” depression. Stay with the feeling and sensations and when you talk to someone about how you're “feeling,” tell them (including doctors) that you are feeling blue, sad, or depressed. If you are told that you “have depression,” don't buy into that, for you might be buying into years of medication treatment, and you will not be embracing an approach that empowers you. Taking on a diagnosis can be disempowering. So, first stay with how you are feeling, and secondly, look at all of Life's Arenas. Realize that you can change your life and your depressed mood by changing any one of the 13 Life Arenas.
David Gersten, M.D. practices Nutritional Medicine and Integrative Psychiatry out of his Encinitas office and can be reached at 760-633-3063. Please feel free to access 1,000 on-line pages about holistic health, amino acids, and nutritional therapy at www.aminoacidpower.com.
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Caught in a Relationship Triangle?
Are you caught in a triangle? Everyone is familiar with two people having an affair without the knowledge of a spouse or significant other. What you may not know is that other triangles also cause problems ––parent and child against the other parent –– friends, couples/in-laws, co-workers siding with one another in shifting alliances. Extricating yourself from any of these tangles can be a challenge because they're typically a smokescreen for deeper issues.
Here's the tip: Check if you're prepared to dig for feelings you've been avoiding. Guaranteed, if you're in a troublesome triangle, you are sad, mad, or scared about things you've been unable to discuss with those involved. If ready, see if you're afraid of hurting feelings or incurring wrath. Ask yourself, “What would help me feel safe enough to speak openly about my feelings to each person involved.
You may need to let go of the belief that conflict should be avoided. If this seems scary, take a breath. The reality is communicating about feelings strengthens bonds – especially if it's done without blaming. Drop into your heart. Plan to speak tenderly and courageously about what you feel and what you need. Stop all secrets. Let the truth do its job. While this may initially bruise egos, it usually leads to healing connections in all directions. You'll no longer be an agitated hub of shaky geometry, but a strong, steady spoke in a circle of healthy communication. ©
Penelope Young Andrade, LCSW www.penelopetalk.com Call: 858-481-5752 fax: 858-484-8374 email: firstname.lastname@example.org
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