depression

21
FEB
2014

On Loneliness

There’s an emptiness that many of us feel every day. Sometimes we feel it when we’re away from someone. Sometimes we feel it when we’re surrounded by people.  It isn’t depression, per se. We have all experienced it. Unless you’re schizoid, of course.

Loneliness is a want. When we want, we create a gap between what we have, and what we don’t. That gap hurts. Commonly we try to distract ourselves so we don’t have to pay attention to that pain. We don’t want to feel it. We have this deep fear it will consume us. It is almost as if we feel a need to find another person to verify that we’re really here.

As I sit and contemplate this state, there’s even guilt over feeling this way. Why should there be guilt over feelings? You feel what you feel. Unless you start thinking about expectations (from society, on yourself), about what you’re “supposed” to feel. We’re supposed to be happy and buoyant and “perfect.” Wouldn’t that be nice.

Of course we can examine if there are things we do that perpetuate these feelings, which keep us stuck. That’s the process of psychotherapy, and becomes especially important when we start to take ownership over our own participation in our feelings. While I understand the explanation of the brain as a “chemical state,” and bad feelings as “brain chemistry,” it’s an explanatory model that lessens the idea of free will. Brain chemistry exists. When I eat something, or think something, or close my eyes, I’m changing my brain chemistry. So maybe there is a way that we perpetuate loneliness as well.

When we idealize the individual and celebrate “I,” we are celebrating the disconnect of that person, what makes them unique, what distinguishes them from everyone else. When we cherish our own uniqueness, we are isolating ourselves. Thus our American culture of rugged individuality and championing the loner, who is dependent on no one, leaves the next generation very alone when they try to embody such an ideal. The more we want to be unique and important, the more alone we feel. We want to be important, which requires other people recognizing us as unique. Paradoxically trying to be independent and important makes our self-esteem dependent on the attention of others. In our culture where narcissism is on the rise (google Narcissism america), perhaps the consequence of cultivating some amazing individuals is the emptiness of some achievements, and an epidemic of loneliness.

The alternatives to the individual have their own stigma and problems. There’s the group identity, whether that’s as part of a team or an organization. There can become camaraderie amongst members, which is a definite antidote to loneliness. Fear can set in though, fear of dependence. Really this is true for any relationship. We play with the romanticization of love as something that absorbs a whole person, ultimately. As beautiful of an image as that can be, it also leads to the risk of betrayal, co-dependence and loss of any ultimate purpose. I’m sure members of any group that went down a dark path (think of cults, nazis, etc.) at first felt a true sense of purpose when they joined. It gave them an identity, a sense of belonging, and thus lessened loneliness. Social psychologists discuss that this group mentality leads to loss of humanity and performing acts that go against the morals of the individuals (see the work of Phil Zimbardo). But that person doesn’t think about them because at that time they aren’t themselves — they’re just a member of the group.

Co-dependence isn’t any more healthy, though it has the temptation of escape, and the romanticization by our culture. As much of a fan as I am, Shakespeare didn’t help this idealization of collectively losing ourselves in love. It’s beautiful to lose ourselves in another, to need and be needed completely and wholly. Depending on your belief in the idea of a soul mate, you may have convinced yourself that this is meant to be one person. And maybe it is. But if that dynamic of needing and being needed by the world could be diffused, spread out to the world, maybe we’d realize that loneliness could be an illusion.

J Krishnamurti, an Indian philosopher, believed that we’re all inherently connected. He believed that we’re all made up of the same substance. He was probably referring to a spiritual belief within Eastern philosophies that we all come from a God, and made of God. Within that framework, we’re all connected, since we’re all part of the same network. In the belief system, loneliness is an illusion, based on the false idea that we are all separate. If you could let go of the idea of having to be separate, without losing a sense of self, and feel that we are all connected, then loneliness could fade away.

Or maybe not.

I’m online right now, looking over facebook and twitter. I feel the impulse to reach out and find connection to other people. The more I feel alone, the more I feel I have to reach out to find someone and get any validation I’m real or alive. It’s hard to be alone. There’s an emptiness to it, as if I might collapse. These “social media” sites feed an illusion of connection through technology, which can make us feel more alone.

But let’s just pretend I don’t have any internet. Let’s pretend I don’t have a phone. Let’s pretend there’s no way to distract myself. I’m stuck with just me. I could fight to find another way to distract myself. Or I could stay with the feeling. I might even feel like I’m collapsing. In the strangest way, staying with that feeling of collapsing (in Gestalt therapy called the implosive layer), can lead to a breakthrough. All the energy invested in holding back the fear [of being alone, etc] can be freed up.

Then we can see the world with new eyes. That’s a whole process (going through the Gestalt layers) that we’ll touch on in another post.

Until then, consider the possibility that you’ve never been alone.

07
OCT
2013

Not a Lab Rat

Minnie was forty years old, and came to see me in my office to discuss being depressed. She had felt depressed off and on for many years, but had rarely told anyone about it. It was like dragging a weight around. She could still get things done in her, just not quite as well as she’d like.

At one point she had told her family physician about this, and she was offered an antidepressant, lexapro. She took it for a few days, didn’t like how it made her feel, and stopped it. Her physician told her they could try something else, which might work better. She responded: “I don’t want to be a lab rat.”

Now of course the first thing I would tell her is that the first few days on antidepressants are not a good indication of whether it will work or not. There are potential early side effects that will go away, often within the first week. That isn’t the issue I wanted to address here, though.

I hear from people that they don’t want to be “experimented on,” or “feel like a lab rat.” As if doctors are purposely sitting in labs running experiments on their patients, for some other endgame. The only purpose of trying out different medications is to find what works for YOU. This seems to come from the expectation that the psychiatrist has to “try” different medications in an effort to find one that works.

It’s absolutely true that we do not know that a certain medication works. I tell this to people all the time. The current state of the science in medicine cannot predict if a medicine will work for you. What the research says, for example, is that in a group of a 1000 people somewhat like you, 30% got better on this. Which means 70% didn’t. We don’t have the science, quite yet, to be able to say which group you will fall into. So it comes back to trial and error. Even with a blood pressure medication, where we understand just about all the physiological changes occurring from the medication, only has the desired effect in 20% of individuals. And again, we don’t know which 20%. So meds are often combined to get the desired change in blood pressure.

“Personalized medicine” is an emerging approach, where factors like genetics can be used to predict if someone will respond to a medication. We’re juuuuust beginning to crack this area, such as with tests for the blood thinner warfarin. We can identify who might be sensitive to it, and who might not respond. We’re still some steps away from being able to reliably do this in the field of psychiatry, but it’s well on the way. Ideally, a finger-prick blood test will be able to tell us whether a medication will benefit you or not. That will still be a far distance away from understanding and treating all aspects of depression, but maybe it’ll help people stop believing their doctor is experimenting on them.

16
AUG
2013

Chemicals, Depression, and the Mythos of Natural

Usually by the time a depressed person comes in to see me, it’s because what they’re doing hasn’t been working.  Therapy hasn’t been helping, or they don’t have the time or finances to do therapy.  So as a psychiatrist, I offer an antidepressant.  And almost every day, people hesitate.  They don’t hesitate because they doubt whether the medications work (a separate debate).  They hesitate because they want to follow a “natural” lifestyle or philosophy.

Now I follow a principle of using as little medication as needed, recognizing a propensity in many colleagues to use more and chase every symptom with another medication.  But I disagree that “natural” means better in healthcare, as the foundation of a lifestyle of “natural” and “organic” is at its core shaky, particularly when it comes to depression.

Behind this lifestyle lies a bias against “chemicals,” as if all “chemicals” = “poison.”  As if there exists a homeostatic mechanism in humans that will protect them from disease if they remain “pure” enough.  This demonizes medicine and perpetuates a false model that the human system (body/mind) is inherently self-healing and self-correcting (a philosophy perpetuated in many alternative health models).  Disease occurs because the system isn’t working anymore, often despite a “natural” lifestyle.  And yet like anyone entrenched in a belief system, when something isn’t working anymore, rather than doing something else people just do more of the same.  More extreme of the same.

The “natural” lifestyle could be partially a backlash against the overmedicalization and overmedication of every condition.  I understand that.  I can only blame my own field, where the trend of using medications exclusively causes a distorted view of chemistry as a solution for everything.  This comes at the expense of what many seek in therapy, which is someone to listen.

The backlash against overuse is underuse.  Antidepressants are all too often given out for mild complaints, or temporary depression and anxiety.  This leads to the myth that antidepressants are useless, and even that “depression is natural.”  People get concerned about getting treatment for their catastrophic depression because “it’s natural to feel this bad in these bad circumstances.”  They hesitate because maybe depression is adaptive.  And it is, to a point.

There may be an evolutionary basis to depression (see research by Keller and Nesse).  Crying may have been selected for as a mechanism to help a person get social support.  The low energy and interest of depression may have been selected for as mechanisms to conserve energy in the face of an impossible goal that can’t be relinquished.  In the way having sickle cell trait (a single copy of the gene) appears to protect against malaria, some genetic developments help support life in a milder form.  But when the development is in a more extreme, it isn’t adaptive.  Sickle cell disease (a more severe type with two copies of the gene) isn’t more helpful than sickle trait against malaria.  A sickle cell crisis can even kill a person.   Similarly severe depression may be an out-of-control version of something originally adaptive or beneficial.  To follow a model of statistical normal distribution (the bell shaped curve), it’s an outlier, where the mechanism is causing harm rather than helping.

Of course there may be conditions that are environmentally caused.  That is not in debate.  Some cancers are definitively caused by chemical exposure.  What is less clear is if “purification” leads to remission from environmentally caused problems.  If it’s “stress,” can we realistically avoid all stress?  Probably not.  Avoidance with stress is almost never helpful.  Just as “bed rest” for back pain is in fact harmful, not helpful.  An alternative to avoidance should be to utilize alternative ways to handle the environmental problems.

Physicians, as a profession, are inherently anti-evolution, in its traditional sense.  Evolution occurs through natural selection, where environmental stressors kill off the “unfit” or weak.  Our job is to help those that might not function as well without help.  We’re a modern social invention to assist more of humanity to survive.  In the first world of plenty, there’s fewer selective pressures.  So apparently people are constructing their own, letting their ideals get in the way of their lives.

Everything is chemical.  The state of being depressed is chemical, in that there’s a chemical process going on in the brain.  Medications change those chemicals.  Therapy changes those chemicals.  Food has chemicals.  Herbs, often touted as “natural,” are just weak medications that are less regulated (so you don’t know how much you’re getting), and less studied (so we know even less if they help or hurt).  The idea of ingesting “foreign” or unnatural chemicals ignores the reason medication exists.  Medication does something for your body that it can’t do on its own.  An antibiotic, which is a foreign, unnatural chemical, that gets through your entire body often into your brain as well (thus its utility), is necessary when your own body can’t fight off an infection on its own.  Few people think twice about that.  It’s acceptable, most likely because it’s temporary.

I hear all the time in passing people present the rationale “well if cave men didn’t do it, it must not be healthy.”  Paleo diets, organic air fresheners.  The evidence actually isn’t that good as to the life expectancy of ancient man, but we can be sure of one thing now:  we’re living longer.  So we’re doing something right.  Modern medicine helps people live longer.

In primary care, usually people are unable or unwilling to make the necessary lifestyle changes to keep themselves healthy.  They won’t exercise or quit smoking.  In psychiatry it can be about the same issue, that of getting someone to admit that what they’re doing isn’t working, and that doing more of the same isn’t really a solution.  This is an issue throughout all of life, not just medicine.  If telling a patient to exercise more isn’t getting them to exercise at all, telling them more often isn’t going to make them do it.

If it can be done “naturally,” terrific.  Therapy is great.  I treat with psychotherapy as much as I do with medications.  But if you’re waiting to see if being natural will help with depression or any other medical problem, determine where the “point of no return” is, where it’ll be too late to take advantage of the treatments right in front of you.  Is it when death is near?  Is it when you’re hurting those around you?  Consider the point when following a lifestyle comes at the cost of your life.

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