Anti-Psychiatry, Anti-medication; Thinking Critically about "Antidotes"

I suppose my post today is about thinking critically about any medical treatment you choose, or do not choose. It is about deciding for yourself, maybe with or without someones help, what you are willing to try to achieve your mental health goals. Please do not decide not to follow your psychiatrists treatment plan simply because someone told you someone, somewhere, but they can't remember who or where, had a bad reaction to a particular treatment. Some people have bad reactions to aspirin, it doesn't mean everyone should stop taking, or never take aspirin.

I've noticed more than average antimedication, antitreatment, antipsychiatry comments on my posts lately. Generall,y my first reaction when I read these comments is to become annoyed and brush off the comments as antipsychiatry propaganda or unbalanced, undereducated opinion, or opinions not informed by facts.

I am aware that some of my reaction is a reflection of my own irritation that the treatments I try aren't working. Some of my reaction though is worry that someone, who may really need help for their mental illness, may read the comment and without thinking critically about the other side of the information, might decide they are too afraid to seek treatment, or try a particular treatment.

Today I began thinking that the people/person writing the comments may have had some very bad/awful experiences of there own in psychiatric treatments,; either with the treatments themselves, or the medications. I suppose if I were not completely confident that I was being treated in the best manner possible I might feel that way too. I hope, if people have had bad experiences with their treatment for mental illness, that they find the power inside themselves to find a therapist or psychiatrist that they feel they can trust. I know for me, when nothing seems to help, just having a psychiatrist I connect with on a very deep level helps me keep trying to get better.

I am sorry to see people are having/or have had such negative experiences with their doctors, or medications, or other aspects of psychiatric treatment. It is ironic that although I do not seem to get better, I feel absolutely no anger, or annoyance or fear that I am not receiving the best care possible. You would think after so many failed treatments I might be anti-medication, or anti-ECT, or anti-therapy. I am not. In fact I feel that being treated with so many things has helped me learn about all the treatments available to people. It has also taught me I am very blessed to have Dr. X as my therapist/psychiatrist: very, very blessed.

I read somewhere (Maybe in a book called "Bipolar Disorder: A guide For Patient's and Families", by Francis Mark Mondimore, M.D....great book by the way IMO) that people used to die from being manic. Given there were no mood stabilizer to slow them down they would sometimes just collapse from exhaustion. Given how little was available to help people with mental illnesses even 30 or 40 years ago, I find it remarkable how much has been, and is being developed to help people now.

Some of the comments lately (and in the past) focus on how dangerous the side effects of a particular medication or treatment can be. Part of my difficulty with some of these comments is that they often relay unbalanced, inaccurate, or highly subjective "knowledge". For example, one commenter wrote:

"Antipsychotics are very dangerous drugs and can even cause Parkinson's disease and Tardive Dyskinesia...Many psyche drugs can cause permanent damage to the brain and nervous system...ECT causes memory loss - BRAIN DAMAGE....It has been my experience that most people are depressed for a valid reason...It sometimes goes all the way back to childhood. For someone who is considering incurring brain damage to rid themselves of a problem, I would ask this: What unpleasant truth are you willing to damage yourself in order to hide?" (from, ECT Media Portrayals of Depression comment)

(Note: I am using this particular comment as an example because it covers a range of concerns similar to many of the comments other people, who suggest psychiatry/psychiatric treatments don't work, are dangerous etc., often make,)

My understanding of some of the above treatments considers some of what this commenter has suggested. Yes, I believe use of antipsychotics should be carefully considered, because there is a potential for side effects such as Tardive Dyskinesia, and other unwelcome/dangerous side effects. As a patient I need to decide if my illness warrants taking the chance with the side effects of the medications I try. I have decided that for me, the pain of my continued depression, is far worse than my fear of a side effect that I may, "potentially", (not "necessarily"), experience.

As for "ECT caus[ing] memory loss- brain damage": I understand that memory loss is a fear, and sometimes. or for some, a side effect of ECT. I have had ECT though, and while I did experience some memory loss around the time I was receiving the treatments, I don't believe I permanently lost any memory. I could be mistaken, given that even when I was experiencing short term memory loss while being treated with ECT, it was not me who was noticing it. It was my family members. I couldn't remember, what I couldn't remember(...ha, ha.) Regardless, my choice to try ECT was informed and in fact it was my idea to try it. People underestimate how severe depression can be, and how hard it can be to treat sometimes. My depression was severe enough, and treatment resistant enough for me to decide that even if I had memory loss from ECT, it was worth trying a treatment that was shown to be highly effective in treating depression. I was willing to lose a few memories for the hope of feeling better mentally.

Last, but not least, this commenter, and others with similar concerns, has suggested my depression continues because of some "hidden", or unresolved "truth" from childhood. The truth is I had parents who were at times imperfect...imagine! Like everyone mine childhood was not perfect. Maybe at times my childhood experiences were devastatingly awful, but at times, in fact I'd say most times I had it pretty good. My parents loved me and tried to be good parents. I do have difficulty accepting and understanding some of my experiences in childhood, but I have worked hard in therapy to learn to manage, understand and for the most part accept and forgive some of the bad things. While sometimes I wonder if I have some deep dark hidden secret in my brain somewhere...locked away so deep that I cannot remember...I feel pretty confident that is not the case.

I work hard in therapy with Dr. X and I worked hard in therapy with every therapist I saw. I am open and able to articulate my feelings and work through my experiences. While my depression often makes me ashamed of things, when I am in therapy I work hard to ensure any shame about any memories or experiences is challenged and dealt with. It is not likely that my brain has hidden something from me, some deep dark secret that I cannot face. I feel pretty confident I could face any truth in therapy, especially with Dr. X. because I know he accepts me anyway I am.

For me there is no deep dark past that is keeping me depressed. My depression is keeping me depressed That's it, and I will do all I can, use any and all weapons available to me in the psychiatric arsenal to fight that depression. Of course I will learn about any of the medicines and treatments before I agree to try them. For me though, rejecting theses treatments outright because I am afraid of what I don't know, or because I hear bad things about them, or because I hear/read about other's bad experiences, is not my way of doing things. I try to check out all sides of the story, learn as much as I can, read balanced information, look for scientific information and then make a decision based on as much fact, and as little conjecture as possible.

I know no science is perfect. Mistakes are made. Drug and treatment side effects can be devastating ands sometimes permanent. Companies selling things like medication, treatments, help etc. sometimes lie and cheat. Pharmaceutical companies' studies are sometimes falsified or sometimes only positive drug trial outcomes are published. There are good and bad therapists/psychiatrists, and people in general, out there. It is not easy knowing what will or will not help or harm you.

I believe all we can do is try to find a psychiatrist/therapist whose education, knowledge and experience we trust, take the responsibility to look into treatments offered to us and try to understand the pros and cons, and decide for ourselves what we are willing to try to help ourselves become healthier. For some, they will decide no treatment is the best treatment for them, for others they will willingly try anything their psychiatrist suggests. For me, I will try any treatment that my psychiatrist thinks might help, if I feel is more likely to help me than harm me and I can see that the potential for benefits outweighs the potential for unacceptable side effects. We (my pdoc and I) may not always make the right choices, but they are well thought out choices and the choices I am willing to live with.

ECT & Media Portrayals of Depression Treatment Options

Dr Shock's blog is a wonderful mix of informative articles, videos and analysis of a variety of things from music, travel and art, to psychiatry and back. Of course, his focus is psychiatry, but the renaissance man in him shines through in his blog.

In one of his recent posts... "Illuminate Depression" he has posted a video about different treatments for depression. It is fascinating and talks about a variety of treatments. A big kudos to it for bothering to mention (unlike most overviews of depression treatments) some people's depression is treatment resistant.

I have pretty much given up hoping that main stream media will explain that depression is not always as "treatable" as they would have us believe. Nothing annoys me more than the statement "Depression is a treatable illness". It's the opening line of so many self help and depression information books...and for many of us it sounds like a lie. For me it creates an intense internal struggle within me about whether or not it is my fault I remain depressed despite trying several different kinds of treatments.

While the video is informative and interesting I found it very curious...and annoying...that the makers of the video included talks about all kinds of different treatments, some common, and some in the early stages of development, including rTMS, (which from what I understand has not been shown to be any better than a placebo***), yet it neglects to even mention Electroconvulsive Therapy (ECT); even though ECT is a well-studied, scientifically proven, highly effective treatment for resistant depression. (***see this recent post in the blog "Clinical Psychology and Psychiatry: A Closer Look" for a scathing look at the FDA's approval of rTMS and you will wonder how it was possibly approved)

It irritates me, (and does not help me explain potential treatments to concerned family members), when the media, either by negative portrayal or by leaving positive and informative information about ECT out of stories about depression treatments, subtly dismisses or devalues an effective and proven helpful treatment for resistant/refractory depression.

I feel confident I have informed myself about ECT as an option. What though of others who have not had access to any information about ECT except what they see, or don't see, portrayed in mainstream media? What about those who only ever hear negative information, or who trust that the books and videos the media are promoting and showing them the best, or the only, options available?

Will some people with resistant depression, some who might be helped with ECT, miss out on the chance to become well because popular media at best has failed to share balanced, scientific information about ECT, or at worst is colluding with naysayers to portray ECT as either a dangerous choice, or a barbaric one?

I worry also that the lack of accessible and scientific information in the media about ECT perpetuates the fears and myths that exist about the treatment. In effect this may (and I am certain does) lead fewer people to see it as an option...even if they have tried many, many other unsuccessful treatments for their mood disorder. I also think the negative media, and lack of media, and especially lack of an unbiased media about ECT affects how willing partners, family members and friends are when it comes to supporting a patient's decision to try ECT.

The media, when they discuss and examine depression treatment options and leave out, dismiss, or malign ECT as a valid and valuable treatment option, is not doing anyone with treatment resistant depression a favour. In doing so the media perpetuates ECT myths, hysteria and misinformation.

"It is the Relationship That Heals"

If this is your psychiatrist or therapist run...

I am always struck by how much support I get in my comments and how many thoughtful people comment. This was going to be a response to the comments in my last post, but it has turned into its own post instead...

I love to hear from people who comment on a regular basis. I feel like over the years I have developed relationships/friendships with many of these people. I also feel really good when I hear from those who rarely or never write. It feels like the beginning of a mutual support system. I am glad my writing reaches out to people. I hope it continues to do so. Your comments often inspire posts...like this one, so comment away.

I write this blog, not just for myself, but also for others trying to work through and battle the same or similar issues and demons. People sometimes comment about how open I am. My original intent for my blog was to try really hard to make this as close to therapy as possible. I wanted to push myself to be open and as completely honest as I thought I needed to be for therapy to work for me.

I also planned to use it to prepare for my therapy sessions, to debrief after my sessions, and to push myself to become brave enough to talk about deeply personal, and often scary thoughts I have. In writing I hoped I am able to show others that therapy is a rewarding, and helpful process, even if it is sometimes really, really hard to fully participate in.

I was hoping that if others could be "insiders" in another person's therapy sessions, if they could see my process, my difficulties, my struggles, my successes, my cycling, my wingbat thoughts and ideas, my creativity, my attempts to get better, and even my failures: I was hoping others might take a chance with their therapist; try hard to open up in therapy, to go to therapy if they never have, to address there darkest secrets, to address any patient/therapist disconnects in therapy, and to find the therapist or psychiatrist that truly fits their needs.

Before I met Dr. X. I had already been to therapy numerous other times each with varying degrees of success, and sadly often failure. With most of the therapists I saw there was either a complete disconnect between myself and them, or if it worked I was in need of a longer course of therapy, and I believe medication which no therapist ever mentioned was available.

I now believe I needed to somehow muster up enough energy to be more of an advocate for myself...Though I know, when severely depressed that may not be possible. If I were to have a second chance to be start at 19 again, if I needed to see a new psychiatrist/therapist, I would approach it as a customer trying to find the best "product"/"service"/treatment for me.

I would be more assertive, have greater expectations, ask more questions and not settle for the first person who comes along. I would have looked for someone like Dr. X from the start. Of course, that is easier said than done.

Below are some of the things I would look for in a psychiatrist/therapist if I had to look again:

When meeting a new psychiatrist or therapist, make a list of the types of behaviours that are important to you in someone you are seeking help from.

Be open to new ideas and approaches.

Ask them questions.

Listen to how they answer your questions. Are they welcoming? Do they sound put off by your questions? Are they caring?, or pushy?, or short?

Do they have time for you?

Are they just medication oriented?

or Do they provide therapy? (I find it really helpful to have a psychiatrist who does both).

Do they LISTEN?

What are there credentials?

What kind of experience do they have treating people like you?

What type of therapy do they practice? I find the less dogmatic about a particular therapy style the better....Use whatever works!

How flexible are they?

Do you feel comfortable around them?

The last sentence...Do you feel comfortable around them? ...is tricky, because many many times, probably during each of my sessions, there is some degree of feeling uncomfortable around Dr. X. Even 8 years into therapy I feel guilty, or ashamed, or afraid, or even angry at him periodically. The test of being comfortable lays in whether I can talk about my uncomfortableness...even if it takes a few sessions.

If I feel he has said or done something I am uncomfortable with, and I can safely work through and see this as an opportunity to discover something about myself and others...then it is indeed a powerful and psychically "comfortable" relationship.

The question I try to ask myself when this happens is whether these feelings are coming from me and my mood or experiences, or whether the psychiatrist or therapist is doing or saying something, that promotes my feeling ashamed, afraid, intimidated etc

I "understand" (in my rational mind) Dr X. is NEVER judgemental, or angry, or pushy, or authoritative, or any other way that might increase or promote my feeling bad in therapy. That does not mean I do not ever feel these things. Who I am, what I have experienced etc. impact my reactions towards all my relationships' experiences and interactions

Some Psychiatrists/Therapists (like some people of every persuasion or occupation) are pushy, or arrogant, or sure whatever they say is right, and the patient knows nothing about helping themselves. They tell the patient to just do whatever they tell them to do etc. This is the kind of therapy/doctor, that I always found did not work for me. For me a good therapist and/or psychiatrist forms a partnership with their patient, values their patients ideas and lets the patient know they are valued

Some of my readers have expressed difficulties, or difficult relationships with, with their psychiatrists and/or therapists. I believe it is important to delving into into why I might feel that way. What kinds of behaviours, exchanges, actions, thoughts are taking place both in and out of therapy that are leading to your feeling a disconnect?

In his book, "Love's Executioner" and in his novels and psychotherapy textbooks, Psychiatrist Irvin Yalom writes and expands upon the idea that, "it is the relationship [between patient & psychiatrist or therapist] that heals". My experiences in therapy with Dr. X have reinforced and proven this to be the case for me.

I try to remember therapy is sometimes difficult. During some phases it can see impossible a lot of the time. As people with depression, or other mental illnesses, (really as people even with no mental illness)... as people period, we may have difficulties with some relationships in the first place; maybe that is even why we are in therapy.

If I find something happening in my sessions that disturbs or perturbs me I always ask myself is the difficulty in therapy the therapist, or have I not opened up and taken the chances I need to take in therapy.

• Is it my issue clouding the session,
• Are my symptoms such that they are affecting my judgement (not always easy to know)
• or is the therapist doing something hurtful that negatively impacts my ability to open up?
• Is my therapist a good therapist?
• Did they just make a mistake,
• or is their attitude always this way?
• Is it my approach to therapy?
• or is it the therapists approach that is making it not work?

The most important thing I can do as a patient is talk to my psychiatrist or therapist if I am feeling uncomfortable, or hurt, or diminished or disconnected in any way. I may not have the courage to bring it up while it is happening, or even during the next session, but if something about my therapy is festering inside me...I always bring it up.

Everytime I have brought difficulties up he is completely open to discussing what went on. He apologizes if a mistake was made on his part, or we discuss my reaction if we discover my perception might be coloured by other things. He accepts and encourages my feedback no matter what. This is part of what makes our relationship so important and the bond so strong.

I guess what I am trying to say here is that the first therapist you see, even the fifth and sixth therapist you see, may not be right for you . Don't give up because your therapy does not seem to be working for you.

Therapy, and good relationships in therapy, is/are hard work. If the relationship between you and your psychiatrist or therapist does not seem to have a positive impact on you maybe try approaching your therapy a different way, or try a different kind of therapy, tell your therapist how you feel. If it still is not working perhaps trying a different therapist or psychiatrist would be the positive change you need.

Something is Wrong With This Picture

When I was talking at the family support group last night and I came to the part about the psychiatrist needing to fill out a portion of the tax credit form one of the family members participating in the meeting said: "How is my son's psychiatrist going to fill this section out. They barely know him. They have hardly met with him".

I had a few thoughts in that moment:

1. Something is wrong with this picture. Given how ill it sounded like her son was it does not seem right that the psychiatrists have not met much with him. He isn't even at the point where he has the insight that he has a mental illness. When I mentioned I was in therapy with my pdoc, and that it was a very important (I think the MOST important), aspect of my treatment...the lady looked incredulously at me and could not believe my pdoc participated in therapy with me.
2. I felt guilty. Guilty that her son was so ill and needed help and here I was 7.5 years into therapy, once, and for extended periods twice, a week. I am taking up important resources that others need too. Maybe I need to leave therapy so others can receive the help and support they need to get better.
3. I really think therapy needs to be a part of the healing process. People need human support, they need professional psychiatric support, not just medication. What if this had been me? No medications seemed to help until recently...and I am not even sure about them helping now, as I am still taking them and I feel extremely depressed again. I am sure I would not be here if my pdoc simply prescribed me medication and sent me on my way. My way would not have been merry and I would have given up.
4. I am so extremely lucky that I am cared for by Dr. X. When I first met him I thought it was the norm in psychiatry to treat patients with both therapy and medication. I recognised fairly quickly that Dr X. and his psychiatric style and approaches to treatment were/are far above the norm. I recognised, and still do recognize, meeting him, and having his unflagging support is the biggest blessing I have ever received in my life.

It is so Difficult Most of the Time

Two incredible bloggers, Lola, from "Marine Snow" , and Hannah, from "Becoming Hannah" posted a comment on my post titled, "Benevolent Structure".

Hannah's blog reflects upon her struggles with Borderline Personality Disorder, and Lola writes about her challenges living with an eating disorder; both work through the blackness of depression on a regular basis. I feel so much in common with both these bloggers. There comments reverberated a common difficulty I am sure many people with mental illnesses encounter: Motivation difficulties.

Hannah writes that with the people around to encourage her to create she creates. Home alone, with all the tools, materials etc. to create she has a difficult time getting going. In her words: "I need someone to nudge me along otherwise I scrabble back under the duvet and curse myself.".

Lola's comment is different, but I think is a similar problem. She writes that the more she stays in bed, the more she wants to, and does, stay in bed. She writes, "If I don't get up with a purpose on a Saturday then i spend all weekend in bed moping, sort of like this weekend. Trouble is I am so exhausted by a Friday, that the only thing which gets me through is the thought of a lie in on the Saturday!!!"

I relate so much to both comments it is frightening. I have pretty much stayed in bed since Friday at 4:30, only getting up to walk the dog, blog and go to a Flamenco show I had committed to seeing on Saturday Night. Like Hannah, I need a pull, a tug, a commitment to get going...that's okay, many people who are well need that too.

Like Lola's experiences...the more I slept, the more I NEEDED to sleep. In fact right now I want so badly to crawl back into bed. I have already given up trying to paint this morning (I managed for about 15 minutes and simply couldn't do it)

To top it all off last night at the Flamenco show I had huge problems with "disappearing" and "disconnecting" at the Flamenco show last night. I found myself unable to talk, or feel like I belonged during the wine and cheese reception afterwards, and during the show I kept dissociating.

However...had I not gone to the show I would have missed two of the most incredible Flamenco dances I have ever seen. Both were by the same dancer and I have NEVER seen so much passion in flamenco before. It is always passionate, sensual and outright sexual, but this dancer had the ability to drag me out of my dissociative state, to hold my interest.

I felt her dancing inside my body, in the way your body reacts to a sexual come on, or enticement. It was amazingly erotic. The only way I got out last night was by making a commitment to a friend to go. I would have missed two stunning dances, and would not have known of this dancer had I not known. I discovered she dances at different venues around the city...now I have something I enjoyed that I can experience again.

Sleep is a narcotic. It pulls you in and holds you hostage. The more sleep I get the more I want to sleep. Depression is like a drug too. The more you succumb to its power, the more you stop doing things because you don't have the motivation, or the energy, or the will, the more power depression gains on you. It is so difficult. It is not easy. It requires external help to both create and participate in a benevolent schedule of activities.

1. For me that external help is a little caring "pressure" from Dr. X...a few questions about what I am doing next week, a soft commitment to do them, and a desire to please him, is in part what keeps me mostly on track.
2. Commitments with friends to visit, to do activities, and sometimes a gentle competition between us to do the things we want to do, helps me too.
3. Commitments to others (like volunteering to teach art) keeps me getting out of bed, even if I don't want to.
4. A commitment and love for my dog gets me outside at least a few times a day, rain or shine

...and you get the picture. This benevolent structure only happens if I have a caring structure in place to get me moving, to get me out of bed, to make me want to be actively participating in my life. ...and no it isn't easy. It sucks sometimes and it is always hard work. I do however believe in the long run it will pay off for me.

How Long Should I Remain in Therapy?

In my the comments section of my previous post "Consciously Challenge My Thoughts" Kara asks:

..."how often and for how long have you met with Dr. X? I ask because I've been seeing my counselor weekly since beginning of January. And it's not that I "want" to stop; actually I'm a bit fearful because it's become a habit...it's in my routine..."

The short answer is I have been seeing Dr. X once a week for almost exactly 7 years. At least a couple years of that time (off and on) I saw him twice a week. Kara's question, and the subsequent worries attached to it, often swirl around in my head

I despise myself for feeling like I need the help. I rail against myself for feeling too dependent. I see it as a sign of weakness that every week I look forward to having 50 minutes of time with someone I care about, and someone I feel I can be free around.

I even think I am a bad person for caring about, thinking about, and actually "wanting" to see my psychiatrists. What kind of person wants to see there psychiatrist? Like in Kara's comment I often think I am habitualized to our meetings, too attached; that wanting to go to a psychiatric appointment each week is somehow a sign I should break the bond.

Dr. X and I have talked about my feeling this way numerous times. Before my Mom passed away she wanted to meet him, because she too feared I was too dependant on him. When she came to my appointment she asked him about this directly.

His response was (paraphrased): "In fact I encourage a type of maternal dependence. The type of dependence that allows the patient to feel supported, so they can eventually go out on their own". An example he gave me one time was (and he assured me the example was not meant to be paternal)...the example was that of a parent teaching a child to ride a bike. The child has to feel safe and feel they are completely supported and cared for before the child will feel safe telling the parent to let go of the bike.

For three of the 4 years before my Mom met Dr. X. she kept telling me how concerned she was about my dependency on him. The day we all met together; as we walked out of his office, she expressed an intense feeling of relief and told me she now felt confident I was both in good hands and in the right hands. She told me it was an immense relief to know I had Dr,. X to help after she passed away, and to know that he would continue to help me.

My Mom always loved, encouraged, supported and helped direct us. Even when she was depressed she was supportive, kind and loving. Now that Mom has passed away, I really miss her maternal love and support.

My Dad was a different story. I know he loved us, but he was unpredictable in his anger. He scared the hell out of me when he was mad and I never knew when that was going to be. He controlled me with fear, derision, dismissal and shame. For some reason his model stuck with me and looms large within, and runs through, my life.

His model of parenting led to my fear of authority figures; so much so that almost every day I worked, despite being constantly rated in my work performance as an employee who exceeds expectations, everyday I was afraid I would be fired, let go, or punished for making mistakes. The things I remember from work are the times I received negative feedback. I find it difficult to remember the feedback that was positive. I really need help relearning life in a safe environment.

Dr. X.'s support and unconditional regard is so similar to my Mom's when she was alive and well. I used to think I relied on my Mom too much, and she was family. It makes sense that I feel that way with Dr. X.

More and more I am starting to see that my depression as a chronic, lifelong illness. I will never be "cured". I have to live within the parametres of having a chronic illness, in the way that a person with heart problems, or diabetes, or MS must live within the parametres of their illnesses' symptoms, and with an eye towards reducing the symptoms as much as possible, but also accepting that they have whatever illness they have, and symptoms will come and go.

The previous paragraph is not meant to sound morose or hopeless. It is a way towards peace with myself. The more I FIGHT my illness, the less the symptoms seem to recede. If I can accept my life is different now than before I had so many Major Depressive Episodes, then maybe I can at least try to excel with my limitations.

Maybe I won't ever have a job like I had before. Maybe I am relegated to doing sporadic volunteering when I am well enough to do so. That is painful for me to even contemplate, but ironically the way up, might be to let the downs happen, and accept they create limitations.

A few days ago I began reading Peter Kramer's book, "Against Depression". If I am reading it correctly (and I easily could be misunderstanding as I am having a hard time reading it) in it he surmises that people with depression do not simply need the symptoms of their depression taken care of (the depressive mood, suicidality, amotivation, fatigue, i.e. the psychiatric "markers" of depression). Peter Kramer seems to be saying that ridding a person of the symptoms that psychiatrists have defined as "depressive symptoms" may not be enough.

The person who is depressed may need to review and rebuild their entire "personality"; how they manage rejection, their ability to socialize, their perfectionism, their ability to accept and go with change, and so on.

If Kramer is right, and on some level I suspect he is, then therapy for a chronically depressed person would be expected to last a long time, and would probably be required periodically throughout a person's life. Even if a person's MDE symptoms seem to completely disappear, therapy may be needed to help the person successfully get through and manage life's changes and blips.

So Kara, in the scheme of things, I am saying you have been in therapy a relatively short period of time. It is up to you to determine if you feel comfortable with, and have confidence in, your therapist and the the value of the therapy you do together. I personally believe in quality over quantity.

I also believe there is evidence that supports long term therapies (both medication and psychotherapy). From what I have read, if your depression is chronic, or you have had more than one or two MDE's in your life, long term support can be really helpful and is probably crucial, given the more depressive episodes one has, the more likely one is to have another MDE inthe future. I believe the statistics show a person who has had three MDE's has a 90% chance of having another in the future. To me that indicates the value of taking a proactive approach towards staving off any indicators of depression and hopefully managing to be in the 10% whose deression does not return

For me, I am beginning to believe the "habit" of therapy might be a good coping strategy and a good habit to form; like cuddling your puppy throughout the day, or singing to your nieces and nephews, or enjoying a walk in the sun. Just because you habitually like doing does not mean it is wrong.

Sorry Dr. X...you may be stuck with me for a while;>)

Prozac and Bruxism or Tardive Dyskinesia, or both?

I am exhausted right now. It is the "witching hour", that wicked two hours everyday where someone sprinkles a magic potion over me and I fall into a deep sleep, like sleeping beauty. Hey, Where's my prince?

I get so tired everyday at this time that I feel sick, literally. The tiredness isn't "sleepy" tired, it's fatigued, "burnout" tired. So I will lay down and even though I'm not sleepy tired, will fall asleep for a few hours. I am trying hard to be okay with this. To accept that outside these few hours my mood is definitely better; so what if the trade of is a few hours extra of tiredness. At least I do not feel like this all day, like I do when I am depressed.

I am also having "mouth movement problems". At first my pdoc said it was bruxism, then three or four weeks ago he seemed to be really concerned about how my mouth was moving and took me off the Dexedrine as he said it was making the movement worse.

Last week he said they were not as bad as the previous week, but the night before I saw him I took extra Valium and two muscle relaxants because I had such a sore next from my teeth clenching and grinding. I got a bit mad at him, because I felt he was brushing off my concerns about Prozac and tardive dyskinesia. However, he told me he was aware Prozac has been seen to cause TD and he was concerned too.

Anyways, He suggested I see a neurologist to rule TD out. I told him I would like to see if it subsides over time first. In the mean time I want to come off Valium, because I think it is masking the movements. So I began cutting back slowly and already the movements are getting worse and I am not sleeping well. Argh!

I definately have Prozac induced bruxism; and I am increasingly certain I have TD as well. I have videotaped myself while I am involved in an activity (playing guitar, working on the computer) and the weird mouth movements are definitely there. Every once in a while my mouth makes really strange movements. This is freaking me out, I do not want to look strange to other people. What do I do if it is TD? When my current medication mix is the first thing to ever help me?

4000th visitor "My Psychiatrist Won't Give Me Counselling..."

Just a today I had my 4000th visitor to this site. Thanks for visiting everyone. I am always so interested to hear from others and to discover other people searching for some of the answers to the questions I ask. I feel less alone knowing other people exist and are trying to work through their lives while struggling with mental illness. I also appreciate those visitors who may not be mentally ill, but support and search for help for those of us with these illnesses.

I thought I'd address the question Visitor 4000 googled to get to my blog because I found it especially poignant given how much support I receive from my psychiatrist. It saddens me that people are being left to fend for themselves when they think they need more support.

Visitor # 4000 googled: "my psychiatris[t] wont give me counselling i need more than 20 sessions".

In my experience I have seen so many people whose psychiatrists offer no therapy, but are simply there to provide medication and biological treatment advice. In some cases, where a person takes an antidepressant, it works wonders and the person is off and returning back to a normal life, I think this might be a good approach.

My question is...and this is a big one...Does this EVER happen? I have met so many people in the last 10 years or so with depression and honestly, I cannot think of a single one whose illness was that easily treated.

I don't believe depression is simply a biological illness. There are so many factors involved in why someone becomes depressed and why one person gets better while another struggles. 15 years ago I would have told you all I needed was 5 or six therapy sessions when I was depressed and I got my life back and became well...but DID I BECOME WELL?

Would I have been in a better situation now if my depression had been taken more seriously when I was having short Major Depressive Episodes. I addressed this before in my post "Early Medical Intervention for Major Depression" . There are no easy answers, but I really believe I needed the support of a psychiatrist, and especially a psychiatrist who works longterm with his or her patients in therapy as well. Twenty therapy visits would not be enough for me, even before this episode.

Why do I believe this??

1. I believe Major Depression is complex and has complex triggers...environmental stressors, the person's family history, the individual's history, the individual's coping mechanisms. whether abuse has been involved, whether there are other psychiatric problems like anxiety disorders, or OCD problems, or alcohol or drug abuse problems, whether genetics is a factor, how much, or how little support the depressed person has, whether or not medication, or medications work....the list goes on. No one can convince me that all these things can be addressed in 20 sessions or less.
2. What if medications don't work, or work for a while and then stop, or are not optimal and as such are leaving the depressed person at risk of another depressive episode, or more problems in their life due to the side effects, or ineffectiveness of the medication. Long term support is crucial.
3. By long term support I mean a psychiatrist you have the opportunity to learn to trust. A psychiatrist who is there for you when it's black and dark and life is not worth living, a supportive psychiatrist who listens and cares and believes they can help you, a psychiatrist who does not falter when mistakes happen, or when the patient gives up hope, or even when the patient feels distrustful of the psychiatrist in spite of the doctor's consistency. My experiences in life have left me scared and scarred and afraid and distrusting of other people. No medication takes those fears away without a combination of therapy. Certainly, 20 therapy sessions cannot eradicate a lifetime of lessons in anxiety, fear, intimidation, helplessness, hopelessness and sadness.
4. I know the reason I have survived the last few years is because my psychiatrist offers therapy. Without his continuing support, without there being an understanding that I can see him until I am well, and even after I feel well, I would not have the courage to keep trying.

Dear 4000th visitor...there are psychiatrists who offer therapy. If that
is what you want, or think you need, please listen to yourself and look for a different doctor. You have one life and it is so important to get the care you need to make your life manageable, and, hopefully one day, delightful. I wish you all the luck in the world.

Reviewing Treatment Plans for TRD

This post is inspired by a recent post on the Dr Shock MD PhD blog. The post titled: "Management of Depression" brought up a number of issues that I generally discuss with my pdoc, but also a couple I avoid because I am scared. Each of the nine section titles below are taken directly from Dr. Shock's article.

He talks about: "...the components of a comprehensive management plan and factors associated with increased risk for recurrence of depression". I found the article very interesting and I'm bringing it to my therapy session tomorrow to thoroughly discuss my treatment plan with Dr. X.

Being the inquisitive person I am I have discussed much of this with him already, but I think the information Dr. Shock posted about the "[c]omponents of a comprehensive management plan for depression. Adapted from American Psychiatric Association and World Federation of Societies of Biological Psychiatry guidelines" is a really comprehensive list of discussion points.

I will try to relay how they relate to me, my treatment plan, and my continuing difficulties working to find a solution to not simply Treatment Resistant Depression, defined as resistance to at least two medication trials...but a depression that has consumed me for years and been resistant to more than 30 medications and years of therapy:

1)"Determine the pharmacological or psychosocial treatment":
I've tried (numerous times) different CBT therapy treatments, Group therapy (twice), individual therapy(with numerous different therapists). I think my current supportive therapy has "saved" my life. I believe it gives me the strength to keep trying in the face of continued failure.

I feel I have a very valuable therapeutic alliance with my pdoc, stronger than any I have ever had with any therapist I have seen. I do, however, often question the value of continuing as it really has not put a dent in my depression. I wonder sometimes if I should try another therapist, but I have seen at least 7 or 8 different therapists since I began having depressive episodes at 17 or 18.

The therapy I am involved in now is better than any of them and some of the therapists I saw were so awful I do not even know how they remained to do what they do. So I really feel like I am in a better situation right now despite not making much progress. I feel safe, can talk about anything, feel advocated for and supported by my pdoc 100%.

• Pharmacological treatments have been completely unsuccessful to date despite trying 30 plus medication alone, in combinations and using augmentation. This is so frustrating and I feel like it has to be my fault. Why do others get better, when I feel like I try so hard and never seem to succeed?

2) "Determine the treatment setting": I assume this means outpatient/inpatient/day program etc. My pdoc tried numerous times to get me into the hospital last spring/summer. I seemed to go into an up phase, just as I was about to concede so decided against it. He suggested maybe a hospital stay would allow a second opinion. Problem is I have had second opinions two other times before and both of them said I had Bipolar Disorder. My pdoc says I am somewhere in between Major Depression and BPII. I get what looks like hypomania, but it does not impacts my life in any negative way...so he believes I sit somewhere at the end of Major Depressive Disorder and at the beginning of BPII.

It doesn't really matter because our we have used treatment approaches for both illnesses and somewhere in between and still we have not had success. To me, and to my pdoc, diagnosis is a means by which we develop a treatment plan and I trust fully that that is being done. My pdoc has experience working in a mood disorders program, and I feel confident in his skills.3)

3) "Establish and maintain a therapeutic alliance": I feel this is perfect and could not be better.

4) "Monitor and reassess the patient’s psychiatric status in the course of treatment": This is a question I would like to ask my psychiatrist. How do you monitor and reassess my psychiatric status over the course of the treatments we try? I sometimes feel like we stop trying medications too soon, or that we may miss an opportunity for a combination to work even if a particular medication is not working. Eg. Now I am going off Tegretol...my concern is that I feel it has helped me a tiny bit "sometimes", and I understand the treatment of TRD and/or BP disorder generally utilizes a mood stabilizer. I have no side effects with Tegretol and really would like to keep trying to find something that works with it.

5) "Monitor the patient’s response to treatment"...this seems like the same as above. No?

6) "Reassess the adequacy of diagnosis when appropriate": This is a biggy for me. I have often asked my pdoc if maybe I have a personality disorder; especially Borderline Personality Disorder, given my fears of abandonment and all my suicidal thoughts. Dr. X has told me numerous times that he, "...has not even considered BPD as a diagnosis for [me]".

He is however, cryptic sometimes when I bring up the question of whether or not I have a personality disorder. For example, one time I asked him if I had a personality disorder and he asked me, "what would it mean to you to have a personality disorder?"

I am not a psychiatrist so I had no idea what to say, except maybe it means I have a pattern of behaviour that is embedded so deeply in who I am and that is why the medication is not working. I have asked him if he would be honest with me if I had a personality disorder. He said he believes that honesty is very important and that he would not hold back information from me. Given how trustworthy he has proven to be over the years I have to believe he is being upfront with me, but I have this niggling feeling that something beyond a mood disorder is impacting my ability to become well.

7) "Monitor possible side effects and physical condition": I used to keep a daily mood calendar tracking mood, irritability, anxiety, exercise, medications, side effects, etc. A couple years ago I began feeling like maybe my micromanaging of my symptoms what keeping me sick so I stopped doing it. I go into my appointments with less clear information than before, and I often forget to tell my pdoc things. So not sure if I should begin my mood charts again.

I did ask my pdoc last week if maybe we stop medications too early because of side effects and don't give my body enough time to work through the side effects. He said maybe sometimes we have done that, but many times it becomes really clear that the side effects are unmanageable, or that the small benefits the medications give me are not enough for me to suffer the side effects. I almost always want to keep trying a medication longer even if it isn't working, because I am afraid I might miss out on that time when they might begin helping me. Usually we decide together.

8) "Enhance treatment adherence": I always take the medications Dr. X. and I decide on. I am not one to just go off my medications and not tell him. I do understand that I have some problems that may impact the medications working as well:

• With Benzodiazepines I find they help with my anxiety at first, but then I sometimes (not always) begin increasing them slowly because they stop working. I recognize their is a fine line between controlling anxiety and perhaps inducing a worse depression because I am too fatigued to do anything. Recently I was told to increase my Diazepam to 20mg (from 10mg)...I tried it a couple days and decided I did not want a repeat of last summer where I came of a fairly high dose of Diazepam and ended up have severe rebound anxiety and insomnia (for 3 months last time). I always inform my pdoc when I increase or decide against our plan though. How can he treat me properly if he doesn't know what I am taking?


• This is so hard to write and for some reason I feel so ashamed for being weak like this...I rarely talk about it, except with my pdoc)...When my Mom was diagnosed with pancreatic cancer I moved in with her to help her. I was so depressed, and on top of that grieving, and I began to drink to help numb all my feelings. Honestly, with no medications working it was the only thing that helped. I recognize now that I have had alcohol problems intermittently throughout my life, since I was 13. I have gone years without drinking hardly anything, maybe a drink here or there, once in a blue moon, but there have also been years when I was stressed out that I have been a binge drinker, starting with my high school years. Anyways, since my mom's death I have struggled with alcohol and I know that has impacted my wellness and made my depression more difficult to treat. In the last year I am really trying hard to change that, and I believe slowly, I am getting there.

9) "Educate patients and their families about the nature of the illness (psychoeducation)": I feel I am very educated about my illness, but I still have not accepted it. I'm not sure if I ever will be able to. Despite believing others like me are ill, and have a bonafide illness I continue to feel intensely guilty for not being able to work, for having an almost impossible time getting motivated to do things, for many things that my pdoc has taught me are "symptoms" of depression.

I also know that it would really help me if my family, my husband, my sisters, and my dad, would learn more about Major Depression, and especially about Treatment Resistant, and/or Chronic Depression. My pdoc likens my husband's negativity to medications to a "negative placebo effect" My husband rails so much about medications hurting me as opposed to helping me, that his insistence in this area could very easily impact the ability of the medications to help me. I really believe in the medications, so I am pretty sure I override his negativity, but you never know. The rest of my family seems to think I should just go see a naturopath and I'd get better, or I'd miraculously get better if I just got a job. Wouldn't that be great? I find their being unsupportive of the therapy I have decided on to be so frustrating. I wish they would come to a few therapy sessions with me, but that just isn't going to happen.

I do not even want to think of the "[f]actors associated with increased risk for depression recurrence." as listed on Dr. Shock's blog, because I have every single one. I cannot afford to focus on whether my depression will recur, until I can manage to get rid of the episode I am currently in.