The intersection between music and emotion is complex.
Musical preferences or predilections are often very personal and individual, and are often coloured by a person's past history (e.g. some songs may be associated with positive or negative past life events). Of course, the musical styles that you grow up with often become those you permanently prefer.
I've noticed quite often that patients of mine who struggle with sadness or anger may choose music that has a sad or angry emotional tone. In these situations I worry sometimes about whether the music itself is "feeding" the negative emotion. An extreme example of this would be music in which the performer is screaming, often about how bad life is, where the listener--often using headphones that are socially isolative--is absorbed for hours every day.
But I think that music is an external experience that can touch us, or resonate with emotions. In this way a musical experience can help us feel less alone, more understood, more "in synchrony" with something outside of ourselves, even if the music is laden with the same kind of sadness that we may experience internally.
Therapeutically, I have to acknowledge the value and power of this kind of "synchrony". So I generally would never try to dissuade the fan of "screaming angry music" from continuing their choice of genre (besides, I would be just one more person unsuccessfully attempting such subjectively intrusive and unwelcome advice). Yet I encourage people to gently explore types of music outside of their familiar territory, and to search for music which goes further than emotional synchrony alone, but also soothes, calms, inspires, provides hope, gives energy, or gives a thrill of joy. Some of the great works of music can touch us in our sadness, and therefore "resonate", while also guiding us towards hope or even making us smile with delight.
Here are some specific examples (off the top of my head) which work for me (everyone will have different tastes, of course, but if you're looking for something different, give these a try) :
-anything by W.A. Mozart. the piano sonatas (exquisite, sweet); the piano concertos (poignant and sometimes sad but always ending with hope and joy -- and the tunes stay in your mind); the wind concertos (clarinet & oboe).
And very specifically a vocal piece by Mozart called "Exsultate, Jubilate"; the piece in its entirety is a distillation of the joy of life. The last item in this piece is the perfectly beautiful and energetic "Alleluia". In fact, I would go so far as to make this whole piece--including the composition itself as well as the performers and their backgrounds--a metaphor for joy in life: to have joy, one must work at it for years (as the performers have done). One must hear others and learn from others. One must pursue poignancy as well as virtuosity. One must have moments of tension and dissonance, but they must always be relieved imaginatively and beautifully. Some of the joyous moments may be brief, but they stay with us forever even after they are literally over. My favourite performer of this piece is now Carolyn Sampson. Kiri Te Kanawa was my previous favourite. I'd recommend listening to it on the best possible stereo system available to you.
Another specific selection is the Goldberg Variations by J.S. Bach as played by Glenn Gould (who made two recordings of this piece, in 1955 and in 1980 -- I'd recommend hearing them both, starting with the 1955 version; the final aria at the end of the 1980 version is like a sweetly beautiful farewell from one of the great musical geniuses of the century). Also there's a version by Murray Perahia which is extremely good too, in case you find Glenn Gould's playing too eccentric. This piece is another metaphor for life: it starts with something simple and beautiful; it moves through many variations with different degrees of motion, emotion, and energy, yet always with the same underlying grounding theme; then it ends beautifully and serenely, almost just as it began. Implying a cycle that continues yet changes, beginning and ending at peace, but with lots of work and tension and playfulness and growth in-between.
Other specific suggestions:
1) Chopin, Piano Concerto #1 in E minor, Opus 11. The second movement is an example of sublime beauty.
2) Beethoven: Violin Concerto. Beethoven had a difficult life as a result of his own inner emotional problems (lots of depression, irritability, anger, relationship disappointment) in conjunction with various external sorrows, especially the total loss of his hearing. His music is full of emotion and power; underneath the sorrow there is sweetly touching beauty and joy, and I think the violin concerto is one of my favourite examples. Anne-Sophie Mutter is a great performer of this piece.
3) Beethoven: slow movements from many of the piano sonatas, such as "Pathetique" and "Moonlight".
With all of these suggestions, I realize that for some people, they would just rather listen to something else (musical taste is such a personal thing). Also, when feeling very unwell in any way (emotionally or physically), sometimes even your favourite music can feel irritating or can make you feel worse (it may remind you, for example, of how much you could be enjoying it if you were feeling well; your lack of enjoyment when ill could then remind you again of your illness and make you feel worse).
Showing posts with label Advice. Show all posts
Showing posts with label Advice. Show all posts
Tuesday, July 29, 2008
Monday, July 21, 2008
Reasons for Psychiatric Hospitalization
A psychiatric hospital stay often begins with an emergency room visit, though sometimes can be arranged in advance.
There are different reasons for a hospital stay:
-a high or immediate risk of suicide
-inability to safely care for self at home
-diagnostic uncertainty with serious symptoms requiring a more urgent, comprehensive medical evaluation (e.g. delirium)
-behaving dangerously due to psychiatric symptoms (e.g. a manic state)
-initiating a treatment that is difficult as an outpatient (e.g. ECT, major medication changes)
-respite for self and for other caregivers
-a comprehensive inpatient reassessment of complex or chronic problems (e.g. refractory depression or psychosis)
Many psychiatric hospital stays nowadays are brief--perhaps a few days-- with an aim to be just long enough to help someone through an immediate crisis, while quickly ensuring that there is some kind of follow-up outside the hospital.
Other stays average 2 weeks, allowing for a more thorough evaluation and change in treatments.
Sometimes there are longer stay hospitalizations, which can last for months. Manic states often require longer stays of this type.
There are chronic psychiatric hospitals for those who have severe, active, long-lasting illness and who cannot manage outside the hospital. In general, chronic psychiatric hospitalization is becoming much more uncommon, partly due to a philosophy of trying to optimize outpatient help and community resources, but partly due to budget cutting. It may be that some persons who may benefit from chronic inpatient care, and who are not doing well with other community resources, may be at risk of "falling through the cracks" in the system, and may end up struggling with a very poor quality of life, often in a homeless state.
There are different reasons for a hospital stay:
-a high or immediate risk of suicide
-inability to safely care for self at home
-diagnostic uncertainty with serious symptoms requiring a more urgent, comprehensive medical evaluation (e.g. delirium)
-behaving dangerously due to psychiatric symptoms (e.g. a manic state)
-initiating a treatment that is difficult as an outpatient (e.g. ECT, major medication changes)
-respite for self and for other caregivers
-a comprehensive inpatient reassessment of complex or chronic problems (e.g. refractory depression or psychosis)
Many psychiatric hospital stays nowadays are brief--perhaps a few days-- with an aim to be just long enough to help someone through an immediate crisis, while quickly ensuring that there is some kind of follow-up outside the hospital.
Other stays average 2 weeks, allowing for a more thorough evaluation and change in treatments.
Sometimes there are longer stay hospitalizations, which can last for months. Manic states often require longer stays of this type.
There are chronic psychiatric hospitals for those who have severe, active, long-lasting illness and who cannot manage outside the hospital. In general, chronic psychiatric hospitalization is becoming much more uncommon, partly due to a philosophy of trying to optimize outpatient help and community resources, but partly due to budget cutting. It may be that some persons who may benefit from chronic inpatient care, and who are not doing well with other community resources, may be at risk of "falling through the cracks" in the system, and may end up struggling with a very poor quality of life, often in a homeless state.
The Emergency Room
Hospital emergency rooms are always open; emergency help is always available. If you can't make it through the day, or through the hour, and your other resources are not sufficient, you can always be seen and taken care of in the hospital.
There are several points of entry to the hospital system. Sometimes an admission to a psychiatric ward can be arranged in advance, but quite often the entry point is the hospital emergency room.
Emergency rooms are chaotic places. There are a variety of frustrations that one might have to deal with. There may be a long wait to be seen by a physician. There might be a lot of noise, and a lot of upset due to various other emergencies being dealt with. The seats or beds may be physically uncomfortable. You would probably be seen by a variety of different people, and it may be very frustrating and exhausting to have to tell your story several times: first to a triage nurse, then to an emergency physician. If psychiatry is consulted, then there might be a student or resident who would see you next, prior to the actual psychiatrist. Along the way, each interviewer may be different in their level of comfort, thoroughness, or rapport with psychiatric interviewing. You may encounter an interviewer who is tired or impatient.
If you are in a time of urgent emotional distress, these frustrations can be especially hard to deal with. I encourage you to bear with it. At the very least, the emergency room is safe, and it can be the beginning of a powerful, sometimes life-saving therapeutic experience.
Here are two suggestions that can make an emergency room visit a little easier:
1) bring a friend or loved one with you, if possible
2) if you have a doctor, therapist, or psychiatrist, ask him or her to call or fax the emergency room, to better inform them about you in advance. This can often make a big difference, and help the process proceed more smoothly.
There are several points of entry to the hospital system. Sometimes an admission to a psychiatric ward can be arranged in advance, but quite often the entry point is the hospital emergency room.
Emergency rooms are chaotic places. There are a variety of frustrations that one might have to deal with. There may be a long wait to be seen by a physician. There might be a lot of noise, and a lot of upset due to various other emergencies being dealt with. The seats or beds may be physically uncomfortable. You would probably be seen by a variety of different people, and it may be very frustrating and exhausting to have to tell your story several times: first to a triage nurse, then to an emergency physician. If psychiatry is consulted, then there might be a student or resident who would see you next, prior to the actual psychiatrist. Along the way, each interviewer may be different in their level of comfort, thoroughness, or rapport with psychiatric interviewing. You may encounter an interviewer who is tired or impatient.
If you are in a time of urgent emotional distress, these frustrations can be especially hard to deal with. I encourage you to bear with it. At the very least, the emergency room is safe, and it can be the beginning of a powerful, sometimes life-saving therapeutic experience.
Here are two suggestions that can make an emergency room visit a little easier:
1) bring a friend or loved one with you, if possible
2) if you have a doctor, therapist, or psychiatrist, ask him or her to call or fax the emergency room, to better inform them about you in advance. This can often make a big difference, and help the process proceed more smoothly.
Thursday, July 17, 2008
Addictions
The area of addiction and substance abuse is challenging for me.
One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.
The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so
One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.
I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.
Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.
In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.
Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.
One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).
Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.
There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.
A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:
http://www.vancouveraa.ca/directory.pdf
One simple definition of addiction is "continuing a behaviour despite harm".
In this sense, I suppose a broad range of human activities could be considered addictions.
The more obvious examples of addiction include more specific symptoms:
-developing tolerance (one has to do more and more of the addictive behaviour to get the same effect from it)
-withdrawal symptoms (discomfort--physical or emotional--if the behaviour is stopped)
-feeling psychologically or physically dependent upon the addictive behaviour
-wanting or trying to stop or cut down, but feeling powerless or unable to do so
One core aspect of addiction in my opinion involves a relationship analogy. The addictive behaviour is a relationship. An addictive relationship is one in which other relationships become less and less important or enjoyable, while the addictive relationship consumes more and more time, energy, commitment, and money. In severe addiction, all of the person's other relationships (with people, work, hobbies, other pleasures, and with self) atrophy, while the addictive behaviour monopolizes. Associated relationships may foster the addiction (e.g. the addict's only social supports may eventually only be fellow addicts). An addictive behaviour often starts off being pleasurable, but eventually the pleasure usually fades. It is a trap. Once inside the trap, it is hard to get out. One of the most powerful, exquisitely difficult aspects of the addictive trap can be that the person entangled in it might not be aware of being in the trap; or so much identity or will may be bound in the addictive relationship, that the person might not want to take any steps to escape, and may angrily reject offers of help.
I have often felt that various symptoms of depression and other mental illnesses have addictive features: in depression, for example, there can be behavioural habits, or habits of thought, that can monopolize a person's life, sapping energy that could otherwise be directed in healthier directions. Like other addictions, these habits can be very hard to change without external help.
In chemical addictions (alcohol or drug), the addictive trap can have an overtly pharmacological aspect, which may need to be treated medically. For example, severe alcohol withdrawal can cause death if it is not treated medically.
Aside from treating withdrawal symptoms, pharmacological treatments for addiction have been less successful or useful, although there are some new medications that are showing some modest benefit.
In heroin addiction, one of the most effective treatments of all is not to "escape the trap" at all, but to provide a continuous supply of the addictive agent or analog (e.g. methadone), so that the addict does not have to live a life of desperation, constantly battling with withdrawal symptoms, or needing to engage in dangerous behaviours to seek the daily supply of heroin.
Treatments for addiction need to address a variety of factors:
-the behaviour itself needs to either stop or be reduced substantially (abstinence)
-or the addictive need has to be provided continuously ("harm reduction")
-Once these changes have taken place, the relationships outside of the addiction need to be rebuilt -- if there are no such external relationships left, then an addicted person is isolated, and understandably drawn quickly back into the familiarity of the addictive behaviour.
One common resource for addictions is a "12-step group". I think the greatest strength of such groups is the mutual understanding among members, and the daily community support. Addictive behaviours have a magnetic allure, that often draws a person back into the addiction on an hourly or daily basis, and so a therapeutic resource that is available on an hourly or daily basis can be extremely important and necessary. A problem with 12-step groups can be that they may be quite dogmatic, they have a specific belief system not unlike a religion, and the views may conflict with other resources (e.g. some groups may be strongly opposed to the use of psychiatric medication).
Yet, in approaching addictive problems, I encourage people to give 12-step groups a try, to try repeatedly, perhaps to try several different groups to find one that suits them best.
There are other resources out there as well, and once again I think that finding good primary medical care (a gp) is an excellent first step. In severe chemical addictions, a detox centre may be needed to discontinue the addiction in a medically safe setting.
A day away from an addictive behaviour is a powerful start. A week away is a path away from the trap of withdrawal symptoms. A month away is the start of rebuilding healthy relationships. And a year away seems to be a qualitatively powerful and significant period of abstinence; rates of successful long-term abstinence are much higher for those who can be abstinent for a year. But a single day at a time is a good place to start. And you may need help to get through that day, don't be afraid to seek it. Here is a link to the Vancouver AA meeting schedule:
http://www.vancouveraa.ca/directory.pdf
Wednesday, July 16, 2008
Bipolar Disorder
I have neglected so far to discuss a very important diagnostic category: bipolar disorder.
In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.
The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".
A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.
In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.
For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.
In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.
The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".
A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.
In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.
For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.
Tuesday, July 15, 2008
Some alternative ideas that can be worth a try
1) Learn to meditate. Mindfulness-based meditation has a growing evidence-base, showing benefits for psychiatric problems as well as other physical problems such as chronic pain. You may need to attend a course, or several courses, to find the best setting for you to learn (there might be variations in the quality of teaching offered, so you may need to try several different times). Some of my patients did not benefit immediately from meditation techniques, but after many months of practice are now finding the skills very useful in managing ongoing symptoms.
2) Have a pet. It can help to care for, and bond with, another living creature. But, of course, you do need to be well enough to handle the responsibility. If you can't have a pet, consider finding a place to be around animals -- e.g. volunteer to do some dog-walking; or take some horseback riding lessons. Or visit your friend's pet once in a while.
3) Exercise. Try different types. Weightlifting can be great for some, endurance training (running or cycling) could be best for another. Swimming is often uniquely therapeutic. It can help to try a different exercise activity than what you're used to. Consider hiring a personal trainer to get you going, if you can afford one.
4) Activity clubs. There are groups out there dedicated to various activities, such as hiking, cycling, chess, reading books, gourmet cooking, etc. This could be a good way to make new friends and get going with a healthy activity. Local community centres often have classes, groups, or programs of all sorts to attend. Some groups of this type now advertise on internet community discussion boards, etc. Remember that you may have to try several times to find a group that "clicks" with you; it can be disappointing if you work up the nerve to join a group, only to find that it doesn't feel right.
5) Toastmaster's. A place to practice public speaking. This is excellent "behavioural therapy" for the great many of us who have some social anxiety. Attending can build confidence, speaking skill, and other social skills.
6) Consider taking an acting or theatre class. The theory of theatre & acting technique reminds me of psychotherapeutic theory. And the practice is excellent behavioural therapy, in that you are communicating clearly in a group, conveying emotion deliberately, and opening yourself to a bit of vulnerability. Sometimes it can also be quite liberating for a shy person to discover that they can perform theatre with relative ease. You can find these at community centres, continuing education groups, as well as acting schools & colleges.
7) Art therapy: another wonderful resource, if you have the chance to try it out. I think art therapy is underutilized in the therapeutic community these days. At the very least it can be a helpful and enjoyable adjunct to other therapy.
8) Music therapy: music can be powerfully soothing and therapeutic. Consider music therapy, or take a music lesson, or join a choir (you don't have to have strong musical skills to benefit). Also there is a phenomenon called "drum circles" in which a percussionist/therapist leads a group in pounding African drums, creating rhythms. A wonderful experience, and there are good therapeutic results in a variety of different populations. Once again, no prior musical experience is necessary.
Here's a link to Vancouver community centres; you can find the various courses they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
2) Have a pet. It can help to care for, and bond with, another living creature. But, of course, you do need to be well enough to handle the responsibility. If you can't have a pet, consider finding a place to be around animals -- e.g. volunteer to do some dog-walking; or take some horseback riding lessons. Or visit your friend's pet once in a while.
3) Exercise. Try different types. Weightlifting can be great for some, endurance training (running or cycling) could be best for another. Swimming is often uniquely therapeutic. It can help to try a different exercise activity than what you're used to. Consider hiring a personal trainer to get you going, if you can afford one.
4) Activity clubs. There are groups out there dedicated to various activities, such as hiking, cycling, chess, reading books, gourmet cooking, etc. This could be a good way to make new friends and get going with a healthy activity. Local community centres often have classes, groups, or programs of all sorts to attend. Some groups of this type now advertise on internet community discussion boards, etc. Remember that you may have to try several times to find a group that "clicks" with you; it can be disappointing if you work up the nerve to join a group, only to find that it doesn't feel right.
5) Toastmaster's. A place to practice public speaking. This is excellent "behavioural therapy" for the great many of us who have some social anxiety. Attending can build confidence, speaking skill, and other social skills.
6) Consider taking an acting or theatre class. The theory of theatre & acting technique reminds me of psychotherapeutic theory. And the practice is excellent behavioural therapy, in that you are communicating clearly in a group, conveying emotion deliberately, and opening yourself to a bit of vulnerability. Sometimes it can also be quite liberating for a shy person to discover that they can perform theatre with relative ease. You can find these at community centres, continuing education groups, as well as acting schools & colleges.
7) Art therapy: another wonderful resource, if you have the chance to try it out. I think art therapy is underutilized in the therapeutic community these days. At the very least it can be a helpful and enjoyable adjunct to other therapy.
8) Music therapy: music can be powerfully soothing and therapeutic. Consider music therapy, or take a music lesson, or join a choir (you don't have to have strong musical skills to benefit). Also there is a phenomenon called "drum circles" in which a percussionist/therapist leads a group in pounding African drums, creating rhythms. A wonderful experience, and there are good therapeutic results in a variety of different populations. Once again, no prior musical experience is necessary.
Here's a link to Vancouver community centres; you can find the various courses they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
Monday, July 14, 2008
ECT
ECT (electroconvulsive therapy) is a hospital procedure in which the patient undergoes general anesthesia, after which an electric current is passed through the brain using externally-applied electrodes. In order for the treatment to work, a generalized seizure must be induced by the current.
This treatment arouses a lot of strong feeling and controversy in the public.
In my opinion, ECT can be almost miraculous in how well it works. There are a few instances in my career in which I have watched someone who had languished in a severe depressive state for months, wasting away, despite the intense caring efforts of family, nursing, perhaps many other types of treatment -- in these cases it appeared that the person was about to die from malnutrition. Sometimes it was believed that these individuals were in fact dying of "natural causes" or were simply elderly and terminally ill.
I can remember instances of clinical situations like this in which ECT caused the person to have a complete recovery from such a state. Truly miraculous. And no complaint of ECT-induced side-effects either.
ECT is used only for very treatment-resistant depression nowadays. It can also work particularly well for individuals who have depression with psychotic features (i.e. they have symptoms such as hallucinations or delusions with their depression). It can also work well to treat severe manic states.
Unfortunately, individuals in the treatment-resistant depressed group less frequently respond to any new therapy (though it is important to continue the search until something is found that works!). So when ECT is used in a treatment-resistant population, even ECT may not work. The people who have had ECT yet remain unwell may feel worse still. It is much like cardiac disease (in fact cardiology is one of the other branches of medicine in which a radically effective treatment, such as cardioversion, involves a carefully applied electric current passing through human tissue)--in chronic cardiac disease, the disease may worsen despite best efforts. The best treatment may not work, and the patient may even do worse afterwards. Likewise, with ECT, sometimes it does not work.
Yet the evidence does show that it has an important role in treating severe, resistant depression. It can sometimes work miraculously well. It is not without side-effects, but a careful look at the evidence will show that sustained measurable cognitive side-effects are uncommon. A recent article demonstrated some possible cognitive side-effects attributed to ECT in bipolar patients. Yet these side-effects were subtle, and quantitatively far less severe than the symptoms of the primary mental illness.
Ironically, ECT is also an anti-seizure treatment. ECT treatments cause the brain to subsequently be more resistant to having a seizure. It is sometimes used to treat seizure disorders. It is ironic this way. People need to acquaint themselves with what the research shows on this subject, and not assume in advance that an invasive treatment such as ECT must cause tissue damage. There is even some evidence that ECT treatments promote the growth of new nervous system tissue, rather than cause tissue destruction. Once again, I invite the reader to study the evidence. There is certainly no one who has an agenda to profit from giving or promoting ECT (independent of it being an actual helpful treatment), so I can't see any reason for bias in the evidence; ECT equipment is not expensive, there are no huge drug companies at play here, there is no one earning a fortune giving ECT, and there are long waits for patients needing anesthesia or psychiatric care for other reasons.
I do not mean to celebrate ECT as a perfect treatment. It certainly is not. But I think it has been demonized in the public, perhaps causing many people to rule out a therapeutic possibility that can be remarkably effective, often life-saving.
This treatment arouses a lot of strong feeling and controversy in the public.
In my opinion, ECT can be almost miraculous in how well it works. There are a few instances in my career in which I have watched someone who had languished in a severe depressive state for months, wasting away, despite the intense caring efforts of family, nursing, perhaps many other types of treatment -- in these cases it appeared that the person was about to die from malnutrition. Sometimes it was believed that these individuals were in fact dying of "natural causes" or were simply elderly and terminally ill.
I can remember instances of clinical situations like this in which ECT caused the person to have a complete recovery from such a state. Truly miraculous. And no complaint of ECT-induced side-effects either.
ECT is used only for very treatment-resistant depression nowadays. It can also work particularly well for individuals who have depression with psychotic features (i.e. they have symptoms such as hallucinations or delusions with their depression). It can also work well to treat severe manic states.
Unfortunately, individuals in the treatment-resistant depressed group less frequently respond to any new therapy (though it is important to continue the search until something is found that works!). So when ECT is used in a treatment-resistant population, even ECT may not work. The people who have had ECT yet remain unwell may feel worse still. It is much like cardiac disease (in fact cardiology is one of the other branches of medicine in which a radically effective treatment, such as cardioversion, involves a carefully applied electric current passing through human tissue)--in chronic cardiac disease, the disease may worsen despite best efforts. The best treatment may not work, and the patient may even do worse afterwards. Likewise, with ECT, sometimes it does not work.
Yet the evidence does show that it has an important role in treating severe, resistant depression. It can sometimes work miraculously well. It is not without side-effects, but a careful look at the evidence will show that sustained measurable cognitive side-effects are uncommon. A recent article demonstrated some possible cognitive side-effects attributed to ECT in bipolar patients. Yet these side-effects were subtle, and quantitatively far less severe than the symptoms of the primary mental illness.
Ironically, ECT is also an anti-seizure treatment. ECT treatments cause the brain to subsequently be more resistant to having a seizure. It is sometimes used to treat seizure disorders. It is ironic this way. People need to acquaint themselves with what the research shows on this subject, and not assume in advance that an invasive treatment such as ECT must cause tissue damage. There is even some evidence that ECT treatments promote the growth of new nervous system tissue, rather than cause tissue destruction. Once again, I invite the reader to study the evidence. There is certainly no one who has an agenda to profit from giving or promoting ECT (independent of it being an actual helpful treatment), so I can't see any reason for bias in the evidence; ECT equipment is not expensive, there are no huge drug companies at play here, there is no one earning a fortune giving ECT, and there are long waits for patients needing anesthesia or psychiatric care for other reasons.
I do not mean to celebrate ECT as a perfect treatment. It certainly is not. But I think it has been demonized in the public, perhaps causing many people to rule out a therapeutic possibility that can be remarkably effective, often life-saving.
Light Therapy
A Light box -- produces 10 000 lux of light intensity, mimics a sunny summer afternoon. For some people their moods really do respond noticeably to light stimulation, and external weather. A light box could be tried adjunctively even for people who do not clearly have seasonal depression, since this treatment involves very little risk. It is important to get a light box that produces 10 000 lux of bright white light. The more convenient, smaller, coloured, or lesser intensity models may not be sufficient.
Augmentations
If an antidepressant is not working, what can be added to make the drug work better?
1) a second antidepressant, usually from a different class
2) lithium
3) an atypical antipsychotic such as risperidone, olanzapine, or quetiapine
4) a type of thyroid hormone (tri-iodothyronine)
5) a stimulant
One or more of these options can be systematically tried. Before adding anything new, though, it is important to give the first drug a good chance at the highest possible dose, and for a trial of at least 2-3 months in cases of resistant depression.
1) a second antidepressant, usually from a different class
2) lithium
3) an atypical antipsychotic such as risperidone, olanzapine, or quetiapine
4) a type of thyroid hormone (tri-iodothyronine)
5) a stimulant
One or more of these options can be systematically tried. Before adding anything new, though, it is important to give the first drug a good chance at the highest possible dose, and for a trial of at least 2-3 months in cases of resistant depression.
Which antidepressants have no sexual side effects?
1) Bupropion - minimal sexual side effects
2) Mirtazapine - probably no sexual side effects; but this drug is quite sedating and often leads to a lot of weight gain
3) Trazodone - does not diminish sexual function, but can cause rare instances of priapism in men (abnormally sustained erections, which could be a medical emergency). Trazodone on its own is probably not a potent enough antidepressant though, or at least for it to be effective the dose would have to be raised so high that there would be a lot of sedation. It may be a useful adjunctive medication, perhaps to add on to something else to help with sleep.
4) Moclobemide -- often forgotten! No sexual side effects. There is a good body of literature from Scandinavia demonstrating its effectiveness in controlled trials. This drug is available in Canada, perhaps not in the U.S. This drug is an example of an antidepressant that has "fallen out of fashion"--it isn't prescribed very often. Yet the evidence base is similar to that of the other antidepressants. Such phenomena are self-perpetuating: because moclobemide is prescribed less often, and people are less familiar with it, it will be more often prescribed as a second or third-line treatment option. Any treatment used after something else has NOT worked will automatically tend to have a smaller chance of working. So we see moclobemide work less often, and falsely assume that it is an inferior antidepressant. If it were prescribed with equal frequency as a first-line agent, people would probably see that it works as well as the other antidepressants.
2) Mirtazapine - probably no sexual side effects; but this drug is quite sedating and often leads to a lot of weight gain
3) Trazodone - does not diminish sexual function, but can cause rare instances of priapism in men (abnormally sustained erections, which could be a medical emergency). Trazodone on its own is probably not a potent enough antidepressant though, or at least for it to be effective the dose would have to be raised so high that there would be a lot of sedation. It may be a useful adjunctive medication, perhaps to add on to something else to help with sleep.
4) Moclobemide -- often forgotten! No sexual side effects. There is a good body of literature from Scandinavia demonstrating its effectiveness in controlled trials. This drug is available in Canada, perhaps not in the U.S. This drug is an example of an antidepressant that has "fallen out of fashion"--it isn't prescribed very often. Yet the evidence base is similar to that of the other antidepressants. Such phenomena are self-perpetuating: because moclobemide is prescribed less often, and people are less familiar with it, it will be more often prescribed as a second or third-line treatment option. Any treatment used after something else has NOT worked will automatically tend to have a smaller chance of working. So we see moclobemide work less often, and falsely assume that it is an inferior antidepressant. If it were prescribed with equal frequency as a first-line agent, people would probably see that it works as well as the other antidepressants.
Which Antidepressant is Best?
A lot of people have strong opinions on this one.
Here is my opinion, based on experience and a review of the evidence:
1) there is no single antidepressant on the market today that is consistently or markedly superior to any other, in terms of its ability to treat depressive symptoms or reduce depressive relapses
2) statement -1- is true in general, yet it is possible that for a given individual, there may well be one particular antidepressant, or combination of antidepressants, that does work best
3) many of the comparative statements made about antidepressants in advertising try to emphasize differences which are often clinically irrelevant
4) differences in pharmacology (e.g. receptor binding, etc.) can be prominently described in advertising, yet in many cases these facts are not clinically relevant
5) there are few if any consistent differences in side effects between the different SSRI's. There may be differences for a given individual, however.
6) For a given individual, the evidence is clear that if one antidepressant fails to work, there is a reasonable chance that a different antidepressant or combination could work, even if the new drug has a similar mechanism of action.
7) There are side effect differences between the different subtypes of antidepressants. SSRI's may cause nausea, mild fatigue, mild sleep disturbance, etc. Tricyclic antidepressants have "anticholinergic" side effects of dry mouth, constipation, faintness due to blood pressure drops, etc. Mirtazapine causes sedation and weight gain. Bupropion can have more "stimulating" side-effects sometimes, such as nervousness or insomnia. The newer antidepressants are safer in overdose, but the old tricyclics can be dangerous or lethal in overdose.
8) Venlafaxine XR and Escitalopram are both vying for the position of "best antidepressant", in terms of being an antidepressant that has the highest chance of leading to total remission of symptoms. It is clear to me that these both can be good antidepressants, and for a given person may well end up working better than anything else. I have seen quite a few people react quite poorly to venlafaxine, though, in terms of side effects. And, if there are true advantages to these two drugs, I think the differences are small. It is worthwhile for any individual to give several different antidepressants a try, if one particular one is not working.
9) sometimes a particular antidepressant's side-effects can work well with a person's symptoms. For example, if a person is having severe insomnia, and has lost a lot of weight with a severe depression, than mirtazapine would be a good choice. If a person has a lot of fatigue, maybe some concentration problems, but not a lot of panic symptoms, with their depression, than bupropion could be a good choice (buproprion can help modestly with attention deficit problems). If a person has a chronic pain condition (e.g. neuropathic pain or recurrent migraine), then a tricyclic antidepressant could be a good choice (the tricyclics can help independently with chronic pain conditions).
Here is my opinion, based on experience and a review of the evidence:
1) there is no single antidepressant on the market today that is consistently or markedly superior to any other, in terms of its ability to treat depressive symptoms or reduce depressive relapses
2) statement -1- is true in general, yet it is possible that for a given individual, there may well be one particular antidepressant, or combination of antidepressants, that does work best
3) many of the comparative statements made about antidepressants in advertising try to emphasize differences which are often clinically irrelevant
4) differences in pharmacology (e.g. receptor binding, etc.) can be prominently described in advertising, yet in many cases these facts are not clinically relevant
5) there are few if any consistent differences in side effects between the different SSRI's. There may be differences for a given individual, however.
6) For a given individual, the evidence is clear that if one antidepressant fails to work, there is a reasonable chance that a different antidepressant or combination could work, even if the new drug has a similar mechanism of action.
7) There are side effect differences between the different subtypes of antidepressants. SSRI's may cause nausea, mild fatigue, mild sleep disturbance, etc. Tricyclic antidepressants have "anticholinergic" side effects of dry mouth, constipation, faintness due to blood pressure drops, etc. Mirtazapine causes sedation and weight gain. Bupropion can have more "stimulating" side-effects sometimes, such as nervousness or insomnia. The newer antidepressants are safer in overdose, but the old tricyclics can be dangerous or lethal in overdose.
8) Venlafaxine XR and Escitalopram are both vying for the position of "best antidepressant", in terms of being an antidepressant that has the highest chance of leading to total remission of symptoms. It is clear to me that these both can be good antidepressants, and for a given person may well end up working better than anything else. I have seen quite a few people react quite poorly to venlafaxine, though, in terms of side effects. And, if there are true advantages to these two drugs, I think the differences are small. It is worthwhile for any individual to give several different antidepressants a try, if one particular one is not working.
9) sometimes a particular antidepressant's side-effects can work well with a person's symptoms. For example, if a person is having severe insomnia, and has lost a lot of weight with a severe depression, than mirtazapine would be a good choice. If a person has a lot of fatigue, maybe some concentration problems, but not a lot of panic symptoms, with their depression, than bupropion could be a good choice (buproprion can help modestly with attention deficit problems). If a person has a chronic pain condition (e.g. neuropathic pain or recurrent migraine), then a tricyclic antidepressant could be a good choice (the tricyclics can help independently with chronic pain conditions).
Friday, July 11, 2008
A Rambling List of Helpful Ideas
This is just brainstorming now. Thinking of things that help with mental illness:
-find a good family physician
-have your overall health checked carefully
-have blood tests done to check thyroid, fasting glucose, ferritin (a measure of iron stores), B12 levels (a vitamin), and other basic bloodwork
-allow time in your daily life for rest, relaxation, hobbies, or other simple pleasures. It's particularly good to actually build this time right into your schedule
-have some structure in your day -- get up at roughly the same time, try to go to bed around the same time, eat meals consistently
-try to appreciate the simple pleasures of life -- the taste of your toast in the morning, the colour of the flowers, the texture of the sidewalk -- see, feel, experience, enjoy what you can
-do meditative things. For some this is a meditation class, for others it might be listening to music, a quiet evening walk, for others it could be a workout, for others it could be prayer or another religious activity
-examine your lifestyle...be willing to make changes, to let go of things (small and large) that are unhealthy for you, inconsistent with your personality or lifestyle; be willing to add things (small and large) that are healthy for you, consistent with your personality, values, and lifestyle. Be careful about these decisions though, because a depressive state can cause you to feel unhappy about every external thing, and your depressive symptoms may therefore prompt you to make changes that are not really helpful to you. Imagine that your mind is like the "senate", make sure all the different opinions are heard, from a depressed perspective, to an intellectual perspective, to a happy perspective, etc. Then decide & make changes if necessary. Some changes are hard to make -- e.g. letting go of the need to keep up with the mortgage by maintaining an extremely unpleasant job -- maybe you need to consider letting go of the house, simplifying your life, and doing something with your time that is more enjoyable or meaningful.
-do altruistic activities, in some way. Volunteer. Help others out. Do what you can.
Here's a link to search for volunteer opportunities in Vancouver:
http://www.volunteervancouver.ca/volunteering/search.asp
-exercise. every day. in moderation.
-eat healthy food. learn about nutrition. insist on the best quality your budget will allow. If you indulge once in a while in decadent foods, make it something REALLY GOOD. Not McDonalds.
-no more than 1 or 2 drinks of alcohol per day, ever. (it is possible that very light regular drinking is healthier than not drinking at all. But if you ever drink more than 2 per day, it is very bad for your emotional and physical health; also some people may not be able to healthily drink at all.
-don't smoke.
-don't use street drugs. There's a big marijuana lobby out there that makes claims about the health virtues of cannabis. Go examine the evidence for yourself. It's not good for you!
-reserve a little bit of energy, every day, or every week, for friendships. For many of us, this is an energy-consuming activity, and we neglect this. The energy could be spent in conversation, in doing an activity, or in expressing something positive about your friendship.
-be willing to move away from, or let go of, friendships that are not healthy for you.
-be willing to make new friends. This can be hard to do. You may need to try many different ways to meet new friends, such as joining recreational groups, clubs, churches (in my opinion, one need not have to espouse the literal belief system of a church to benefit from its social community, altruistic focus, and positive values), formal or informal educational classes (e.g. an acting class, or an art class, etc.), or internet sites (be careful of course!)
-be willing to try new things. a new activity. a new hobby. a new skill. a new language. a new place to travel. a new group.
Here's a link to Vancouver community centres; you can find the various programs & services they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
-some people change their lives for the better through months or years of slow, steady work...be open to this. Others can make a "radical life change", where improvements in life, meaning, and joy can happen almost immediately. Be open to this too.
-consider finding a therapist. you may need to give this time, just like any new experience. But be willing to change therapists, if the one you find doesn't feel right, or if you feel that you aren't getting anywhere after giving it a good chance.
-consider other types of therapy: if you have had only open-ended, "classical" psychotherapy, consider trying cognitive-behavioural therapy. And vice-versa.
-consider seeing a psychiatrist. You may need to give this time too, and may need to see a different one if the experience doesn't feel right to you.
-consider medications. Some patients I've seen have had life stories that sound like their problems would be solved by talking things through, by working things out in talking therapy. Sometimes they have given this years of effort, but have not improved. Then they try an antidepressant, or find a combination of medications, and feel truly well for the first time in their lives. For others, they have the opposite story: they may have tried one medication after another to treat their symptoms. Nothing works. Then they engage in a good psychotherapy experience, and this becomes the first treatment that helps; sometimes these patients may discontinue their medications. For the majority of patients I see with chronic or recurrent depression, though, what seems to help best is a mixture of psychotherapy, a medication combination, and healthy lifestyle changes.
-find a good family physician
-have your overall health checked carefully
-have blood tests done to check thyroid, fasting glucose, ferritin (a measure of iron stores), B12 levels (a vitamin), and other basic bloodwork
-allow time in your daily life for rest, relaxation, hobbies, or other simple pleasures. It's particularly good to actually build this time right into your schedule
-have some structure in your day -- get up at roughly the same time, try to go to bed around the same time, eat meals consistently
-try to appreciate the simple pleasures of life -- the taste of your toast in the morning, the colour of the flowers, the texture of the sidewalk -- see, feel, experience, enjoy what you can
-do meditative things. For some this is a meditation class, for others it might be listening to music, a quiet evening walk, for others it could be a workout, for others it could be prayer or another religious activity
-examine your lifestyle...be willing to make changes, to let go of things (small and large) that are unhealthy for you, inconsistent with your personality or lifestyle; be willing to add things (small and large) that are healthy for you, consistent with your personality, values, and lifestyle. Be careful about these decisions though, because a depressive state can cause you to feel unhappy about every external thing, and your depressive symptoms may therefore prompt you to make changes that are not really helpful to you. Imagine that your mind is like the "senate", make sure all the different opinions are heard, from a depressed perspective, to an intellectual perspective, to a happy perspective, etc. Then decide & make changes if necessary. Some changes are hard to make -- e.g. letting go of the need to keep up with the mortgage by maintaining an extremely unpleasant job -- maybe you need to consider letting go of the house, simplifying your life, and doing something with your time that is more enjoyable or meaningful.
-do altruistic activities, in some way. Volunteer. Help others out. Do what you can.
Here's a link to search for volunteer opportunities in Vancouver:
http://www.volunteervancouver.ca/volunteering/search.asp
-exercise. every day. in moderation.
-eat healthy food. learn about nutrition. insist on the best quality your budget will allow. If you indulge once in a while in decadent foods, make it something REALLY GOOD. Not McDonalds.
-no more than 1 or 2 drinks of alcohol per day, ever. (it is possible that very light regular drinking is healthier than not drinking at all. But if you ever drink more than 2 per day, it is very bad for your emotional and physical health; also some people may not be able to healthily drink at all.
-don't smoke.
-don't use street drugs. There's a big marijuana lobby out there that makes claims about the health virtues of cannabis. Go examine the evidence for yourself. It's not good for you!
-reserve a little bit of energy, every day, or every week, for friendships. For many of us, this is an energy-consuming activity, and we neglect this. The energy could be spent in conversation, in doing an activity, or in expressing something positive about your friendship.
-be willing to move away from, or let go of, friendships that are not healthy for you.
-be willing to make new friends. This can be hard to do. You may need to try many different ways to meet new friends, such as joining recreational groups, clubs, churches (in my opinion, one need not have to espouse the literal belief system of a church to benefit from its social community, altruistic focus, and positive values), formal or informal educational classes (e.g. an acting class, or an art class, etc.), or internet sites (be careful of course!)
-be willing to try new things. a new activity. a new hobby. a new skill. a new language. a new place to travel. a new group.
Here's a link to Vancouver community centres; you can find the various programs & services they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
-some people change their lives for the better through months or years of slow, steady work...be open to this. Others can make a "radical life change", where improvements in life, meaning, and joy can happen almost immediately. Be open to this too.
-consider finding a therapist. you may need to give this time, just like any new experience. But be willing to change therapists, if the one you find doesn't feel right, or if you feel that you aren't getting anywhere after giving it a good chance.
-consider other types of therapy: if you have had only open-ended, "classical" psychotherapy, consider trying cognitive-behavioural therapy. And vice-versa.
-consider seeing a psychiatrist. You may need to give this time too, and may need to see a different one if the experience doesn't feel right to you.
-consider medications. Some patients I've seen have had life stories that sound like their problems would be solved by talking things through, by working things out in talking therapy. Sometimes they have given this years of effort, but have not improved. Then they try an antidepressant, or find a combination of medications, and feel truly well for the first time in their lives. For others, they have the opposite story: they may have tried one medication after another to treat their symptoms. Nothing works. Then they engage in a good psychotherapy experience, and this becomes the first treatment that helps; sometimes these patients may discontinue their medications. For the majority of patients I see with chronic or recurrent depression, though, what seems to help best is a mixture of psychotherapy, a medication combination, and healthy lifestyle changes.
Tuesday, July 8, 2008
Treatments
For some people, simple changes of environment or lifestyle can permit the body & mind to heal itself. In this way, perhaps depression or anxiety can be the body's signal to make a healthier change. Perhaps this might be the "normal" role of negative emotions, to influence us to make a necessary or protective life change.
Many medical illnesses feature an over-reaction of the body's natural protective mechanism. In autoimmune or inflammatory disorders, for example, the body's protective mechanisms attack and harm normal tissue. It is not a matter of simply making a positive life change -- the protective mechanism itself is malfunctioning. In treating such disorders, steps have to be taken to change the abnormal inner process, not to change the environment.
Likewise, in depression or anxiety disorders (and probably many other types of mental illnesses too), the mind's normal tendency to experience negative emotion, perhaps in reaction to adverse events -- malfunctions, and becomes out of control.
There are a variety of treatments:
1) wait for the symptoms to pass. This is painful, the symptoms may be highly disruptive while they last, and they may cause other life disruptions that could take many years to repair.
2) Learn mental or behavioural techniques to calm the mind or control the symptoms. So-called "cognitive-behavioural therapy" is one of the most well-researched techniques for managing symptoms of the mind, and the results are very robust.
3) Medications. The various medications for mental illnesses can help substantially. Some of them relieve symptoms immediately (e.g. benzodiazepines), while others are thought to be "disease-modifying agents" that can relieve symptoms in the long-term and prevent relapses (e.g. antidepressants, mood stabilizers, and antipsychotics). This reminds me of the treatment of inflammatory diseases such as rheumatoid arthritis, in which there can be immediate anti-inflammatory treatments (e.g. prednisone), while there are long-term treatments which reduce relapses (e.g. gold salts and immunosuppressives). With arthritis, treatments such as prednisone can be powerful reliefs, but should be minimized because such treatments weaken the body if used frequently. Similarly, the acute treatments in psychiatry, such as benzodiazepines, are very important, but can be counterproductive if used long-term, unless an individual patient cannot manage without them.
4) Psychotherapy
A supportive relationship with a therapist can be a powerful source of comfort, safety, security, and a framework in which to focus on growth & wellness. There are many styles of therapy, some styles perhaps more theoretically dogmatic than others, but I think the most important features of a healthy therapy relationship are feelings of safety, confidence, reliability, feelings of being heard and understood. Sometimes this supportive relationship itself becomes the strongest factor leading to recovery.
Many medical illnesses feature an over-reaction of the body's natural protective mechanism. In autoimmune or inflammatory disorders, for example, the body's protective mechanisms attack and harm normal tissue. It is not a matter of simply making a positive life change -- the protective mechanism itself is malfunctioning. In treating such disorders, steps have to be taken to change the abnormal inner process, not to change the environment.
Likewise, in depression or anxiety disorders (and probably many other types of mental illnesses too), the mind's normal tendency to experience negative emotion, perhaps in reaction to adverse events -- malfunctions, and becomes out of control.
There are a variety of treatments:
1) wait for the symptoms to pass. This is painful, the symptoms may be highly disruptive while they last, and they may cause other life disruptions that could take many years to repair.
2) Learn mental or behavioural techniques to calm the mind or control the symptoms. So-called "cognitive-behavioural therapy" is one of the most well-researched techniques for managing symptoms of the mind, and the results are very robust.
3) Medications. The various medications for mental illnesses can help substantially. Some of them relieve symptoms immediately (e.g. benzodiazepines), while others are thought to be "disease-modifying agents" that can relieve symptoms in the long-term and prevent relapses (e.g. antidepressants, mood stabilizers, and antipsychotics). This reminds me of the treatment of inflammatory diseases such as rheumatoid arthritis, in which there can be immediate anti-inflammatory treatments (e.g. prednisone), while there are long-term treatments which reduce relapses (e.g. gold salts and immunosuppressives). With arthritis, treatments such as prednisone can be powerful reliefs, but should be minimized because such treatments weaken the body if used frequently. Similarly, the acute treatments in psychiatry, such as benzodiazepines, are very important, but can be counterproductive if used long-term, unless an individual patient cannot manage without them.
4) Psychotherapy
A supportive relationship with a therapist can be a powerful source of comfort, safety, security, and a framework in which to focus on growth & wellness. There are many styles of therapy, some styles perhaps more theoretically dogmatic than others, but I think the most important features of a healthy therapy relationship are feelings of safety, confidence, reliability, feelings of being heard and understood. Sometimes this supportive relationship itself becomes the strongest factor leading to recovery.
Monday, July 7, 2008
Links to Vancouver community resources
The Red Book Online is a good collection of community services for Vancouver; hopefully other communities have similar sites:
http://www2.vpl.vancouver.bc.ca/
DBs/Redbook/htmlPgs/home.html
Here's a link to Vancouver community centres; you can find the various programs and services they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
Here's a link to the Vancouver Alcoholics Anonymous (AA) meeting schedule:
http://www.vancouveraa.ca/directory.pdf
Here's a link to Volunteer Vancouver (a place where you can search for volunteer opportunities):
http://www.volunteervancouver.ca/volunteering/search.asp
http://www2.vpl.vancouver.bc.ca/
DBs/Redbook/htmlPgs/home.html
Here's a link to Vancouver community centres; you can find the various programs and services they offer:
http://vancouver.ca/parks/rec/programs/refunds.htm
Here's a link to other classes & programs through the Vancouver school board:
http://www.continuinged.ca/nr/vsb/cie/session.asp
Here's a link to the Vancouver Alcoholics Anonymous (AA) meeting schedule:
http://www.vancouveraa.ca/directory.pdf
Here's a link to Volunteer Vancouver (a place where you can search for volunteer opportunities):
http://www.volunteervancouver.ca/volunteering/search.asp
Links to Research
Here are some sites I recommend when researching medical evidence:
1) the U.S. national institute of mental health; their research is funded by the U.S. government:
http://www.nimh.nih.gov/
2) PubMed: this is a medical research database, with access to abstracts, sometimes to the full texts, of research papers. I invite you to go look at the research yourself, directly. I do think it is important to develop a critical eye, though, for the signs of strong vs. weak research evidence (e.g. size of study, randomization, length of follow-up, source of funding, etc.). If you have read a newspaper headline about a research finding, I think it is usually important to go to the primary source, and have a look at the findings yourself. Sometimes the media presentation of the research findings is misleading or incomplete.
http://www.ncbi.nlm.nih.gov/PubMed/
1) the U.S. national institute of mental health; their research is funded by the U.S. government:
http://www.nimh.nih.gov/
2) PubMed: this is a medical research database, with access to abstracts, sometimes to the full texts, of research papers. I invite you to go look at the research yourself, directly. I do think it is important to develop a critical eye, though, for the signs of strong vs. weak research evidence (e.g. size of study, randomization, length of follow-up, source of funding, etc.). If you have read a newspaper headline about a research finding, I think it is usually important to go to the primary source, and have a look at the findings yourself. Sometimes the media presentation of the research findings is misleading or incomplete.
http://www.ncbi.nlm.nih.gov/PubMed/
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