discu 7

Lecture: Mood Disorders & Suicide
Additional Readings:
1. Sims’s Chapter 18th
2. Fernandez’s “Healing: Listening and Talking” pgs 46-48; My sad Tree, and Missing in Action pgs 137-139.
http://www.suicidology.org/(Links to an external site.)
http://www.afsp.org/(Links to an external site.)
http://mentalhealth.samhsa.gov/publications/allpubs/ken98-0049/default.asp(Links to an external site.)
Please read this post and make a comment on anything you may find interesting.
Ok, this week we are considering the issue of depression. Depression is a very common occurrence; in fact it is called the “common cold” of mental illness. Most of us will experience at least one episode of depression in our lifetime, but even if it does not raise to the level of clinical depression, we all are and will be acquainted with depressed mood as part of our regular, everyday life and experience.
There is some controversy as to what is the real core of depression, but it is safe to assume that involves physiological, psychological and behavioral factors, which they don’t need to be mutually exclusive. One obvious factor or symptom of depression is “depressed mood”, but there may be a depression without the person expressing awareness of depressed mood;
this is actually fairly typical in children
, in which angry mood takes the place of sadness. In adults, it has been called “depression sine depressione” or smiling depression. Those cases will have the characteristic symptoms of depression without the reported depressed mood; this is also more typical of men. With the population of male soldiers, especially those in combat roles and very strong traditional male attitudes and behaviors, depression may take the form of intense anger. This is also often associated to anxiety, poor sleep, difficulties concentrating, hopelessness, etc. Some are surprised when I have told them they are dealing with unacknowledged depression and they don’t understand it at all (see A warrior’s tale in Fernandez’s book, page 115). Also, another important concept to know is melancholia. Some of you may notice this is the word linked to Hippocrates theory of humors, melancholia being “black bile”. This is a severe condition in which life seems to have been pulled out of a person, who experiences himself as “robot like” going through the motions with lethargy, confusion, anhedonia, insomnia with early morning awakenings, psychomotor retardation, loss of appetite, and excessive or inappropriate guilt; the “tempest of the Mind” as it has been referred to before.
From reading your textbook, you will be familiar with the current and popular understanding of the “etiology” of depression. Cognitive views, with the famous “Cognitive Triad” made popular by Beck and associates, has been carrying the filed, so to speak for several years now. However, the big question is whether the typical information-processing failures in depression are the genesis OR the consequences of having depression. I tend to see it mostly as a consequence of having depression. In other words, we don’t get depressed because we think screwie or irrationally, but we think
irrationally because we are depressed.
Certainly, once the depression sets in, this particular way of thinking about one’s experience, others and the world, makes it much more difficult to get over the depression. I must add however, that people who tend to think in negative terms and display a pessimistic personality style, are more vulnerable to develop depression. Seligman’s “Learned Helplessness” model is a very good one when applied to stress-related depressions. Finally, the Psychoanalytic view of depression as resulting from “
real or symbolic loss”
is also a very useful perspective for many cases. I see Depression as the final outcome of various influences including of course, biological vulnerabilities. Another brief point I want to make here is the issue of medications. There have been lots of controversies pro and con for the use of medication, especially when used in children and adolescents. As far as the last group, I almost never use or recommend using anti-depressant medication. Many adults, especially those with melancholic type of depression do respond well to medications and are helped by these drugs. But keep in mind that these drugs are not without side-effects and getting off of them is difficult. The decision should always be a frank discussion between the doctor and the patient with true understanding of benefits versus risks. Finally, and I have not checked the most recent stats on this issue, but in my experience, nearly 40-50% of all new cases of depressed patients recover within 6-10 months of onset of symptoms
even without treatment (medication or therapy).
If to this you add exercise, this number approaches, and in some studies exceeds those by medications. This number could in fact be much higher if anything because many patients who suffer an episode of depression do not seek help, and so we never know the total number of patients. However, we could persuasively argue that treatment for depression helps patients to recover faster than without treatment, providing them a context for a psychological safe environment. To that I would add that treatment, mostly via Psychotherapy, helps patients to
understand their lives and their experience
much better. That means the process of treatment will help them with relapse prevention and in addition, it will help them by enhancing and enriching their lives. I want to add that has been the case with many chronic depressive patients have treated. Once they have been in therapy and have recovered, the next episode of depression (unfortunately for a subset of patients in which depression seems to be cyclical part of their lives experience), tend to be less intense and the recovery also tend to be faster, once they began to engage in therapy once again.
IN addition to the fundamental symptoms of depression, anxiety is a quite common feature of depression. In some studies, as high as 90% of patient with depression also have anxiety and in the DSM5 is now coded as one of the “specifiers”. Also, the sense of reality, while clearly affected by the depressed mood (ie; the world is perceived as different), there may be delusion and other psychotic features. One especially important associate feature of depression is the risk of suicide. Studies looking at this tragic aspect of human behavior have pointed to the concept of “Psychic Pain” and the person’s need who acts on it as trying to get rid of unbearable pain. In old psychoanalytic literature, they referred to suicide as “self-murder”, as there are often intense feelings of anger and guilt associated with and against the self. In some cases, this may also lead to the murder-suicide events, so frequently reported in the press these days. On a side note, this theme is prominent in myths and legends. The well-known case is the one of Medea, a wife abandoned by the hero husband Jason, who in retaliation, kills their children and the future wife-to-be of her husband Jason. In this case, she does not kill herself or Jason, as her purpose is to make him suffer as she has suffered. By the way, the act of killing your own children is called Filicide. This Myth is part of the Greek Tragedy Medea by the Athenian poet Euripides. Other variation of the same them (what we would call psychological dynamics) is also found in the case of Clytemnestra who is driven to murder Agamemnon (her husband) partly to avenge the death of her daughter Iphigeneia, whom Agamemnon had sacrificed for the sake of success in the Trojan war.
There are some interesting changes in the DSM5 as far as diagnoses are concerned. Among those, and one which has been the object of much controversy is the “Disruptive Mood Dysregulation Disorder”, which is essentially very frequent “temper tantrums” (and this is the core of the controversy). For this diagnosis can only be made on individuals between 6 and 18 years of age (just very recent, I diagnosed my first patient with this diagnosis). Another controversial addition is the Premenstrual Mood Disorder, which as the name implies refers to the changes in mood prior and during the menses with recovery afterwards. Finally, we are not having anymore the diagnoses of dysthymia and chronic depression, but they are subsumed under
Persistent depression disorder
Here is from the American Psychiatry Association:
DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. An inability to find scientifically meaningful differences between these two conditions led to their combination with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.
How do we assess depression? As always, a careful clinical interview of the patient and family members if available, is essential, along with careful observation of the patient as he/she presents to you. Doing a Mental Status exam will also give you good information and baseline of the current mental functioning. There are a series of short testing instruments which are also helpful such as the Beck Depression inventory and the Hamilton Scales, but there are many other good ones as well. If you think other issues are also present you may want to use a more comprehensive psychopathological test instrument such as the MMPI or PAI. For children there are various instruments such as the BASC or the DAP as well as the Child Depression Inventory and many others. In children, in addition to the above, it is especially important to interview the adults in the family and if time/resources permit, school or playground observation. I am always amazed how children tend to behave “differently’ on different contexts.
I want to add that these days, schools, and current textbooks emphasize the use of instruments (Psychological Tests) to assess depression or other mood disorders. Somehow, we have come to believe we diagnose only if the so-called objective data is available. That is a mistake, and a major one. Testing has an important role in assessment as I have already shared with you before, but it will never substitute for sharp clinical skills, accurate patient observation and proper questioning. These days, as I have begun to interact with new graduates from even very prestigious programs, I keep getting the feeling that they have become highly trained “technicians” rather than scholars and healers: good at crunching numbers, but totally incapable of being at ease (“being there”) with a regressed schizophrenic patient, or melancholically depressed person. Similarly, they seem to learn the now famous ABC formula made notorious by Albert Ellis and his RET approach, and other CBT approaches, but have absolutely no idea how to treat someone who does not fit that “cookbook” approach. This is one of the reasons why I wrote my book, but I am digressing…
How do we treat depression? There are many anti-depressant choices in the market these days with the SSRis and NSRIs the more popular. There are also the concerns regarding side-effects and other issues that may need to be taken into consideration, but the patient needs to know what the therapeutic options are. Regarding children my own preference is not to medicate, unless not medicating puts the child at higher risk. There are some serious concerns regarding the use of anti-depressants, especially SSRIs and children’s increase risk for suicide. Although the findings have been weak, it is still a risk. Psychotherapy is also a highly effective option with some therapies being more empirically validated such as Cognitive therapy and Interpersonal Therapy, but other approaches may be as effective. The important point is the depression is a treatable condition!
I have treated many patients with depressive disorders either primarily or secondarily to another condition, and almost always, if the patient stays in treatment, they are relieved. For many years I have had in my office a painting of a beautiful tree painted by a once very depressed patient. She was a young woman suffering from a profoundly serious melancholic depression, and through treatment, she had an amazing recovery (see the story below). For the astute student, who may have it figure it out already, the tree in the front cover of my book is the one she painted.
OK< I do not want to extend myself more and as I said above, I just need a reaction (class participation) to this week’s topic on any aspects of this discussion, which you may find useful or interesting. As always, you do this in response to this posting and you have 10-12 days to post it, then it will close. Thanks!! My Sad Tree. During my residence training a young military woman came to see me seeking help for depression. She had broken up with her boyfriend, and although this had happened a few months back, she was still depressed and hopeless. Depression is a very common human emotional condition, so much so that is often called the “common cold of Psychiatry”. The onset of depression is often (although not always) associated with a real or perceived loss. The focal point is that the loss is often tied to the self in ways not seen in other disorders. For example, the person may feel inadequate, guilty and often engages in significant self-deprecation or self-hate. Sigmund Freud wrote one of the most beautiful and incisive papers on depression called Mourning and Melancholia (Freud, 1964) indicating the process of loss, introjection and incorporation of the lost object into the self and a turning in of anger against the internalized object; this is the basis of the now famous concept of depression as anger turned inward. There is an existential loss of the future, and the person “feels” the world is a strange and cold place to live. Aaron Beck has also demonstrated, there is a simultaneous negative view of self, others and the world. The person withdraws into social isolation, becomes physically inactive and loses the pleasure of activities and interaction with others, furthering the sense of despair and hopelessness. While this is also a complex condition, and potentially very dangerous due to the risk for self-harm, the good news is that most people who undertake treatment do recover. This young lady was very depressed, had lost weight and was having a very difficult time with life in general. One day a conversation turned around art (which had been a former interest of hers) and I asked her to draw a Tree for me. Her tree was solid, with strong roots and a wide trunk with many braches. However, the branches were leafless and the tree itself was dark and gloomy. I engaged her in the possible ways in which a drawing may represent aspects of the self (something she was familiar with) and suggested that while she had a strong foundation in her life (roots and trunk) her Tree was sad as she was sad. She became very tearful and said the tree was her. Since this was one of our first sessions, I told her that perhaps one day, the tree will flourish again, Spring would come and with it a new hope for the future. As we continued to work in therapy, she began to improve, her depression began to lift and soon we made arrangements for our last session. When we met for our last time, she brought a present for me. The present was a colorful painting of a beautiful tree in spring time, and she said to me: “I never stopped believing that my life (like this tree) was going to flourish again” I kept that drawing in my office for many years and I often use it with my depressed patients as a symbol of hope and recovery.

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