Saturday, October 23, 2010
Move to new website and BLOG
After rebuilding my website, I have moved my blog to the Wordpress format. Please reroute your RSS feeds to www.drkkesler.com/blog and check out my website. Give me feedback as criticism (gentle) is always appreciated!
Tuesday, February 2, 2010
Small study indicates fish oil may stave off psychotic illness.
Small study indicates fish oil may stave off psychotic illness.
The AP (2/2, Johnson) reports that "fish oil pills may be able to save some young people with signs of mental illness from descending into schizophrenia," according to a study published in the February issue of Archives of General Psychiatry. For the study, investigators "identified 81 people, ages 13 to 25, with warning signs of psychosis," then randomized 41 of them "to take four fish oil pills a day for three months" at a "daily dose of 1,200 milligrams."
The Los Angeles Times (2/1, Healy) "Booster Shots" blog reported that "for a year after" the study "was completed,12 weeks of dietary supplementation with omega-3 fish oil reduced progression to full-blown psychosis in a large group of adolescents and young adults," while simultaneously improving "many of the symptoms that identified these young patients as likely schizophrenics and bipolar disorder sufferers." In fact, "roughly 5% of those on fish oil went on to develop full-blown psychosis during the study period, versus 28% of those who got psychotherapy alone."
WebMD (2/1, DeNoon) reported, "No other intervention, including psychiatric" medications, "has achieved as much for so long after treatment stopped." Unlike antipsychotic medications, "fish oil pills have no serious side effects."
Reuters (2/2, Harding) noted that fish oils may be used someday to stave off or even prevent psychotic or bipolar illness as well as substance abuse disorder and depression. BBC News (2/2) and the UK's Press Association (2/2) also cover the story.
Thursday, October 29, 2009
Anxiety: Prevention and Complementary Therapies
Taken from some online continuing education material on Medscape, I think that this is a great summary of therapies for anxiety that can be utilized at home.
From MedscapeCME Pediatrics
Anxiety: Prevention and Complementary Therapies for Children and Adolescents
Kathi J. Kemper, MD, MPH
Prevalence
Anxiety disorders, including panic attacks, phobias, separation anxiety, social anxiety, obsessive-compulsive disorder, generalized anxiety disorder, and PTSD, affect about 1 in 10 children and nearly 1 in 3 adults. The annual adult prevalence is 13% to 18%, with rates in women twice as high as rates in men. Anxiety is more common than attention-deficit/hyperactivity disorder, autism, or schizophrenia.
Definition
Fear occurs in response to a specific threat, whereas anxiety is a general feeling or a response to an uncontrollable or unavoidable stress. Anxiety is an unpleasant emotional, cognitive, and physiologic state. Physical symptoms include stomach aches, headaches, sweating, jitteriness, trembling, restlessness, dizziness, palpitations, dry mouth, lump in the throat, shortness of breath, chest pain, nausea, aches and pains, numbness or tingling in the fingers or toes, hot flushes, and cold sweats; anxious people may tire easily or feel fatigued, sleep poorly, have trouble concentrating, or feel restless, tense, or irritable. Some have trouble concentrating or remembering things, while others cannot stop thinking about their worries. No specific brain imaging, blood tests, assays, or other objective physiologic measures are diagnostic for anxiety. Medical evaluations help rule out other conditions that mimic anxiety such as hypoglycemia, thyroid conditions, asthma, hypoxia, cardiac arrhythmias or other cardiac problems, cancer, autoimmune disorders, allergies, reflux, gluten-sensitive enteropathy, and seizure disorders.
Consequences of Anxiety
Anxiety is not only uncomfortable; it can be disabling. Social anxiety can prevent people from attending social events or even venturing out to work or school. The unpleasant sensations associated with anxiety may mimic serious medical disorders and lead to costly and invasive evaluations. Trying to dull the pain of anxiety can lead to smoking, drinking, and drug abuse. Using prescription anxiety medications chronically can result in addiction or dependence.
Treatments
Medications
Medications and cognitive-behavioral therapies can be effective treatments for anxiety disorders. However, the focus of this review is complementary therapies because they are so commonly used and because clinicians have often not received formal training about them. The most commonly used lifestyle and complementary therapies reported by patients suffering from anxiety include:
• Stress management practices;
• Exercise;
• Nutrition;
• Dietary supplements, including vitamins, minerals, and herbs;
• Environment -- more music and nature, less upsetting TV and radio;
• Eye movement desensitization and reprocessing (EMDR; this has become a fairly mainstream therapy and will be covered only briefly here);
• Cranial electrostimulation;
• Massage;
• Therapeutic touch, healing touch, and Reiki; and
• Acupuncture.
To counsel patients responsibly about the potential benefits and risks of these therapies, clinicians need evidence-based information.
Managing Stress
Because stress is the most common trigger for anxiety, stress management practices provide an important foundation for effective lifestyle interventions to help manage anxiety. No single stress management technique works for all people. A large repertoire of effective stress management techniques are available to assist in lowering baseline stress and recovering from stressful events quickly and skillfully. Regular exercise, restful sleep, a calm, supportive environment, and optimal nutrition can help decrease stress and are discussed separately. This section focuses on emotional, mental, and spiritual stress management practices. Meditation, relaxation exercises, guided imagery, self-hypnosis, autogenic training, biofeedback, journaling, and prayer have all proven helpful.
Practice, warm-up, and coaching are important elements of all stress management programs, just as they are with athletic or musical training. Developing and strengthening any kind of skill takes practice. Practice means that these techniques are most effective if used on a regular basis, not just when stress occurs. Similarly, warming up or using a stress management skill in anticipation of a stressful event is usually more effective than waiting until a stress has occurred. Finally, as with musical or athletic skills, performance can be enhanced with good coaching. In the case of stress management skills, coaches could be meditation teachers, pastoral counselors, psychologists, social workers, or primary care clinicians.
Meditation
The word "meditation" comes from the same root as the word medicine. There are many kinds of meditation practice, but they can be summed up as: paying attention on purpose (or intentional attention). Recent studies have demonstrated that meditation practice may have profound and sustained benefits for children, teens, and adults. The 2 major kinds of meditation are:
• Concentration (focusing on a thought, word, phrase, emotion, action. or object); and
• Mindfulness (nonjudgmental moment-to-moment awareness of sensations, emotions, and thoughts).
Concentration and mindfulness may ease anxiety when practiced regularly.[1-5] The usual practice is 10-30 minutes once or twice daily. Many major medical centers offer training in concentration-type (such as Harvard's Benson-Henry Institute for Mind-Body Medicine) or mindfulness-type (such as the University of Massachusetts Center for Mindfulness in Medicine, Healthcare and Society) meditation. These programs and Dr. Jim Gordon's Center for Mind-Body Medicine also offer books, CDs, and other resources for clinicians and patients interested in meditation as a stress management skill.
Relaxation Training
Progressive muscle relaxation is a technique in which muscle groups are intentionally tensed and then relaxed. Intentionally contracting muscles and then relaxing them leads to greater relaxation than simply telling oneself to relax. Regular practice can reduce anxiety.[6,7] Training and videos on this stress management technique are available through groups such as the Mayo Clinic, which offers several DVDs in conjunction with Gaiam.
Guided Imagery/Self-Hypnosis
Three particular guided imagery techniques are particularly helpful for enhancing a sense of safety, security, and greater calm: Safe Place, Wise Guide, and Caring Circle. The Safe Place guided imagery helps patients experience a real or imagined place in which they are completely safe, either alone or with real or imagined characters who are reassuring. The Wise Guide technique encourages patients to access inner sources of wisdom and strength through an imagined wise guide. The Caring Circle technique helps a patient imagine they are surrounded by caring, supportive beings that have their best interest at heart. Clinicians can learn to provide these kinds of guided images through workshops sponsored by the American Society for Clinical Hypnosis or the Society for Developmental and Behavioral Pediatrics. Patients may also be referred to psychologists, social workers, or other health professionals skilled in teaching these techniques. Guided imagery CDs and MP3 files to help manage stress and anxiety are available through several companies.
Autogenic Training
Autogenic training is a self-hypnosis technique developed by the German psychiatrist Johannes Schultz in 1932. The training consists of learning to repeat a set series of phrases such as: "My arms and hands are heavy and warm; my legs are heavy and warm; my heartbeat is calm and regular; my forehead is cool; my breathing is easy." Typically, each phrase is slowly repeated 3 times before going to the next phrase.
Repeating these phrases for 10-15 minutes can lead to a profound sense of calm and relaxation, improve sleep, and reduce reactivity to stress.[8-10]
Biofeedback
Biofeedback can help reduce anxiety and enhance sleep.[11] A variety of devices are available for home use. Devices can give feedback about temperature (raising hand or finger temperature promotes relaxation), breathing (slower is more peaceful), muscle tension (relaxing muscles leads to a sense of calm), and heart rate variability (certain patterns are associated with greater calm and even serenity). Computer-based biofeedback programs (such as Healing Rhythms® [Wild Divine, San Diego, California] and emWave® PC [HeartMath LLC, Boulder Creek, California]) are available for home use by both children and adults. Newer portable devices (emWave® PSR, HeartMath LLC) are also available.
Prayer and Participation in Religious Community
Prayer for help, guidance, direction, and support or even simple prayerful repetitions of a spiritually significant word can offer tremendous comfort and effectively ease anxiety.[12] Prayers of gratitude promote a sense of security and trust. Participation in a spiritual or religious community and pastoral counseling can also offer solace and support.[13-16] The type of religion appears to be less important than regular activity and participation.
Journaling
Regularly writing about the day's events and concerns is another helpful and inexpensive stress management strategy. There is some controversy about whether it is more helpful to write about positive events (a gratitude journal) or negative events, and there is likely to be some individual variability in response to this exercise.[17] Some psychologists recommend combining journaling with creative writing, encouraging patients to develop a "new ending" for fearful situations.[18]
Exercise
Regular exercise lowers stress hormone levels. Studies indicate that exercise may help reduce anxiety and panic attacks.[19,20] Both aerobic conditioning and weight training are helpful. Exercise combined with breathing exercises and meditation, such as Tai Chi, Qigong, and yoga, seem to be particularly effective in reducing stress and anxiety.[21-23]
Nutrition
Clinicians should encourage patients to eat breakfast and avoid skipping meals to ensure stable blood sugar. Avoid high glycemic index foods, focusing instead on whole grains, fruits, vegetables, and healthy proteins and fats. For some sensitive people, artificial flavorings (MSG), colorings, and sweeteners may be linked to anxiety. A careful dietary and symptom diary can help sort out dietary triggers. For people who seem to be sensitive to more than one food, a short trial (2-4 weeks) of a diet eliminating foods that commonly cause trouble (such as gluten, dairy, soy, seafood, eggs, and nuts) may be worthwhile to see how well symptoms abate without them, gradually adding them back as tolerated.[24]
Counsel patients to avoid using toxins such as tobacco and alcohol; both are common self-management strategies for anxiety, but both can lead to devastating physical, mental, and social consequences.
For patients who take vitamins, counsel against taking large doses of niacin without other B vitamins; niacin can lead to flushing and feeling anxious. For patients who use niacin to help manage cholesterol, slow-release forms can offer similar effectiveness without the flushing.
Advise patients to reduce caffeine intake because caffeine can mimic symptoms of anxiety. A good substitute is decaffeinated green tea, which contains theanine; theanine may help promote a sense of calm and may also reduces stress.[25,26]
Vitamins, Minerals, and Other Dietary Supplements
Before entering a discussion about vitamins, minerals, fish oils, and herbal products, healthcare providers should impress on patients and caregivers that the quality of supplements can often vary from manufacturer to manufacturer and even from batch to batch.
When patients and caregivers do ask about the products, the following information can help the healthcare provider respond.
Vitamins. Multivitamins may reduce anxiety and stress, even in healthy young adults who appear to be well-nourished.[27,28] B vitamins are often marketed to help reduce stress, and several are important cofactors in the production of neurotransmitters that are essential to maintaining a sense of calm. For example, vitamin B6 is essential in metabolizing tryptophan to serotonin. Inositol in doses of 12-18 g daily has been helpful in several preliminary studies for people suffering from obsessive-compulsive disorder and panic attacks.[29-31] Vitamin C may also help reduce the subjective sense of stress[32]; adult supplements generally range from 500 to 1000 mg daily. Vitamins B and C are water soluble and readily excreted; toxicity is uncommon. Excessive vitamin C can cause diarrhea.
Minerals. Deficiencies of calcium, magnesium, iodine, selenium, and iron are associated with stress, insomnia, and anxiety.[33] Approximately half to two thirds of American children and adolescents do not meet their recommended intake for calcium.
• Many anxiety sufferers have low magnesium levels. At least 1 study has suggested that supplemental magnesium can help ease anxiety.[34] Magnesium-rich foods include dark green leafy vegetables, beans and bean products, seeds, soybeans, nuts, whole grains, shellfish, and citrus fruits. Although some patients take a calcium/magnesium combination, absorption is improved if magnesium is not taken at the same time as iron or zinc supplements. Magnesium supplements are generally safe; excessive doses can cause diarrhea.
• Iodine deficiency and selenium deficiency can impair thyroid function, which is associated with anxiety.[35-37] Advise patients to ensure that the salt they use at their own table is iodized and that they regularly eat ocean fish or ocean vegetables (seaweed) and garlic to prevent deficiencies.
• Iron deficiency can contribute to a sense of stress and feeling overwhelmed.[38] Iron deficiencies are most common in young children, vegetarians, and women who lose iron in their monthly menstrual cycles. Excessive iron is not helpful in reducing anxiety and can cause cardiac and hepatic toxicity.
Clinically, it is prudent to ensure that patients consume a diet rich in vitamins and minerals and, if they are deficient, that deficiencies be corrected through supplementation.
Other dietary supplements. Fish oil contains the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Fish oil supplementation is linked to decreased aggression and anxiety in people who are stressed and in those with alcohol and drug problems.[39,40] Fish oil supplements are generally well-tolerated, particularly the newer formulations that are molecularly distilled (minimizing the fishy taste and belching associated with older formulas). Testing of some products has revealed no significant contamination with mercury, dioxins, or other contaminants in molecularly distilled fish oil products. Clinicians can also consider encouraging patients to eat fish rich in omega-3 fatty acids and low in mercury, PCBs, and dioxin (such as sardines, herring, salmon, or mackerel) twice weekly,[1] or to consider a supplement containing between 500 and 3000 mg of omega-3 fatty acids.
GABA is an amino acid and an important neurotransmitter linked to feeling calm. Although we have historically believed that little GABA crosses the blood-brain barrier, some research suggests that GABA supplements may boost GABA levels in the brain, promoting relaxation and easing anxiety.[41] There is likely to be substantial individual variability in response to GABA supplements, but they generally appear to be safe.
Tryptophan and 5-HTP supplements are amino acid precursors to serotonin and melatonin. Supplementation with 200 mg of 5-HTP has effectively reduced symptoms for patients suffering from panic disorder.[42,43] For patients with obsessive-compulsive disorder whose symptoms had not improved with medications alone, tryptophan supplements have provided relief.[44,45] Side effects are uncommon, but some patients have more aggressive feelings and behavior when they start tryptophan supplements.
Herbs. Mildly sedative herbs such as chamomile, hops, lemon balm, passion flower, and valerian may help promote sleep, relaxation, and reduced stress.[46-53] These herbs are generally safe; allergies are possible but uncommon. However, because some of these herbs can cause sleepiness, advise patients not to take them just before driving, taking an exam, or working with dangerous devices.
Brahmi or bacopa monnieri is a traditional remedy from India used to treat anxiety. A few small studies support its benefits for calm and clarity[54]; serious side effects have not been reported. However, safe, reliable supplies of high-quality bacopa may be difficult to find in the United States.
While most people think of ginkgo as a memory enhancer, some research suggests 240-480 mg daily of the European ginkgo product EGb 761 can also help anxious adults feel more calm.[55] However, ginkgo may cause bleeding problems, particularly in patients taking medications that affect clotting; avoid ginkgo for patients taking anticoagulant medications and those who have a bleeding diathesis.
Kava kava (Piper methysticum) is a traditional Polynesian herb that has been used to treat anxiety and stress-related insomnia.[56,57] However, its severe hepatotoxic side effects (including liver failure and death) have curtailed recent use.[58-60] For patients who continue to use kava despite warnings about toxicity, it is prudent to monitor liver function closely.
Lavender is used mainly as aromatherapy to reduce agitation, restlessness, nervousness, or stress and to promote relaxation and sleep.[61-66] It is used in some hospitals and hospice centers as a safe, low-cost strategy to decrease anxiety and improve a sense of well-being.
Rhodiola or arctic root is a Russian remedy used to reduce anxiety, improve the ability to cope with stress, and as a general tonic. A UCLA study showed that 340 mg of rhodiola supplements daily helped reduce anxiety in patients diagnosed with general anxiety disorder.[67] Rhodiola is generally safe, but as with all herbal products, some people get an upset stomach and a few have allergic reactions.
St. John's wort is used to treat anxiety as well as depression. Results of clinical studies have been mixed; it appears to be more helpful for those with mild symptoms than those suffering from severe anxiety, obsessive-compulsive disorder, or panic attacks.[68-70] Typical adults doses are 900 mg daily. Although it generally has fewer side effects than medications, St. John's wort can negatively affect the effectiveness of many other medications, including oral contraceptive pills. St. John's wort can also trigger manic symptoms in patients with bipolar disorder.
Environment
Simple environmental measures such as listening to music, spending more time in nature, and minimizing exposure to upsetting media can also help reduce anxiety.
Music eases anxiety in people of all ages, including infants.[71,72] Music has been used in hospitals, surgery centers, dental offices, and airports to promote greater calm and confidence; it is also a part of most military traditions as an effective strategy to strengthen courage. Personal preference should generally guide musical choices; music designed to induce binaural beats, putting brain waves into delta or theta rhythms,[73-75] can be even more helpful in reducing anxiety than music without these tones. Nature sounds (waterfalls, ocean waves, crickets, bird song) can also be very soothing. Music is a safe, simple strategy to promote calm and courage; keep stress levels down (and ears safe) by keeping the volume down. Rousing marches and upbeat tunes are better choices for daytime, while soft, calm sounds are better for bedtime listening.
Few patients would invite a guest back into their home if he tried to induce terror, fear, or anxiety. Yet, the media do this daily. The "if it bleeds, it leads" philosophy has affected not only the evening news but also many dramatic shows. In the most extreme cases, PTSD can occur, not just in people who directly experience a life-threatening event, but those who watch such events repeatedly on TV.[76] Encourage patients to be as mindful of their use of media as they are of what they eat, drink, and breathe. It may be particularly useful to avoid watching upsetting news or programming within the hour before bed.
Eye Movement Desensitization and Reprocessing
Another effective therapy for anxiety, particularly PTSD, is called eye movement desensitization and reprocessing (EMDR). EMDR has become fairly widespread based on the results of a handful of controlled trials.[77-79] For example, one study showed that EMDR had better lasting benefits than medications in treating PTSD.[80] It is usually covered by insurance when provided by a psychologist, physician, or licensed professional counselor.
Cranial Electrotherapy Stimulation
Cranial electrotherapy stimulation (or "electrosleep"; CES) was originally developed in Russia in the mid-20th century to promote sleep and relieve anxiety. CES devices provide very-low-intensity currents via electrodes attached to the skin of the earlobes or just behind the ears. They do not require surgery and do not send the kind of strong current used in electroconvulsive shock therapy or transcranial magnetic stimulation. The device is used 20-30 minutes daily for several days or weeks. Controlled studies from Russia and France, primarily done in the 1970s, linked CES stimulation to anxiety relief and better sleep.[81-86] Although CES has not caught on as a mainstream approach to managing anxiety in the United States, devices such as the Alpha-Stim® (Electromedical Products International, Inc., Mineral Wells, Texas) are available, although they require a prescription from a health professional. They cost several hundred dollars and are not typically covered by insurance plans. No serious adverse effects have been reported from using CES, but patients who have implanted pacemakers, defibrillators, or insulin pumps should avoid using them.
Massage
Therapeutic massage contributes to increased blood flow and lymphatic drainage, muscle relaxation, and stress reduction. Physiologically, massage seems to decrease cortisol levels and increase levels of serotonin and dopamine. Research supports the benefits of massage on sleep and reducing stress and anxiety.[86-92] Therapeutic massage is safe, even for small infants. Massage is generally safe if care is taken to avoid wounds, burns, intravenous lines, pumps, or other subcutaneous devices and vigorous strokes in patients with low platelet counts. Careful discussion and respect for individual patients is extremely important for patients with a history of physical or sexual abuse. Massage therapists are licensed as health professionals in most states, with strict requirements for training and continuing education. Although it can be very helpful, ongoing professional massage therapy can be costly and may not be reimbursed by insurance. Training a trusted family member or friend can enable patients to receive the benefits of regular massage within a budget.
Therapeutic Touch, Healing Touch, and Reiki
Therapeutic touch, healing touch, and Reiki are classified as biofield therapies by the National Institutes of Health's National Center for Complementary and Alternative Medicine. Although the mechanism for their effects remains a matter of speculation and dispute, research suggests that many patients find these therapies comforting and calming. Most of the studies evaluating them have been conducted in medical rather than psychiatric settings and have shown that they can help relieve anxiety and promote a sense of calm and well-being among patients with serious or life-threatening illnesses.[93-99] They are safe. When provided by licensed healthcare providers, these services may be covered by insurance.
Acupuncture
Although many people think of acupuncture as anxiety-provoking, it has actually proved to be a useful therapy in decreasing anxiety in both adults and children.[100-104] For example, acupressure and acupuncture are used to reduce the fear of dental, medical, and surgical procedures.[91,105-107] In one study, acupuncture also proved useful in treating PTSD.[108]
Acupuncture is generally safe, though minor bleeding and bruising are possible with any treatment involving needles. Acupuncture can cause sleepiness or deep relaxation; this may be of benefit for patients suffering from insomnia secondary to their anxiety.[109-115] Acupuncture needles are regulated by the US Food and Drug Administration, and most practitioners use disposable needles; this means that needles used in the United States must meet certain manufacturing and labeling standards, and that the risk of acquiring an infection from treatment are exceedingly low. In 2 studies that each examined over 30,000 acupuncture treatments, no serious adverse events were reported[116,117]; serious side effects are possible, but they are extremely rare.
Summary
Anxiety is common and can lead to significant disability, expensive medical evaluations, and long-term addictions to alcohol, tobacco, and drugs. Although the primary mainstream therapies are cognitive-behavioral therapy and medications, a number of natural therapies have both common sense and evidence-based benefits. Among the most helpful are mind-body stress management practices such as meditation and biofeedback, optimizing exercise and nutritional patterns, selective use of dietary supplements, attention to environment (more uplifting and calming music and nature and less frightening media exposure), cranial electrostimulation, and professionally provided therapies such as EMDR, massage, and acupuncture. Many families are already using these therapies to prevent or treat anxiety. Armed with this information, clinicians can provide appropriate, evidence-based advice, and researchers can evaluate those therapies of great public health importance.
From MedscapeCME Pediatrics
Anxiety: Prevention and Complementary Therapies for Children and Adolescents
Kathi J. Kemper, MD, MPH
Prevalence
Anxiety disorders, including panic attacks, phobias, separation anxiety, social anxiety, obsessive-compulsive disorder, generalized anxiety disorder, and PTSD, affect about 1 in 10 children and nearly 1 in 3 adults. The annual adult prevalence is 13% to 18%, with rates in women twice as high as rates in men. Anxiety is more common than attention-deficit/hyperactivity disorder, autism, or schizophrenia.
Definition
Fear occurs in response to a specific threat, whereas anxiety is a general feeling or a response to an uncontrollable or unavoidable stress. Anxiety is an unpleasant emotional, cognitive, and physiologic state. Physical symptoms include stomach aches, headaches, sweating, jitteriness, trembling, restlessness, dizziness, palpitations, dry mouth, lump in the throat, shortness of breath, chest pain, nausea, aches and pains, numbness or tingling in the fingers or toes, hot flushes, and cold sweats; anxious people may tire easily or feel fatigued, sleep poorly, have trouble concentrating, or feel restless, tense, or irritable. Some have trouble concentrating or remembering things, while others cannot stop thinking about their worries. No specific brain imaging, blood tests, assays, or other objective physiologic measures are diagnostic for anxiety. Medical evaluations help rule out other conditions that mimic anxiety such as hypoglycemia, thyroid conditions, asthma, hypoxia, cardiac arrhythmias or other cardiac problems, cancer, autoimmune disorders, allergies, reflux, gluten-sensitive enteropathy, and seizure disorders.
Consequences of Anxiety
Anxiety is not only uncomfortable; it can be disabling. Social anxiety can prevent people from attending social events or even venturing out to work or school. The unpleasant sensations associated with anxiety may mimic serious medical disorders and lead to costly and invasive evaluations. Trying to dull the pain of anxiety can lead to smoking, drinking, and drug abuse. Using prescription anxiety medications chronically can result in addiction or dependence.
Treatments
Medications
Medications and cognitive-behavioral therapies can be effective treatments for anxiety disorders. However, the focus of this review is complementary therapies because they are so commonly used and because clinicians have often not received formal training about them. The most commonly used lifestyle and complementary therapies reported by patients suffering from anxiety include:
• Stress management practices;
• Exercise;
• Nutrition;
• Dietary supplements, including vitamins, minerals, and herbs;
• Environment -- more music and nature, less upsetting TV and radio;
• Eye movement desensitization and reprocessing (EMDR; this has become a fairly mainstream therapy and will be covered only briefly here);
• Cranial electrostimulation;
• Massage;
• Therapeutic touch, healing touch, and Reiki; and
• Acupuncture.
To counsel patients responsibly about the potential benefits and risks of these therapies, clinicians need evidence-based information.
Managing Stress
Because stress is the most common trigger for anxiety, stress management practices provide an important foundation for effective lifestyle interventions to help manage anxiety. No single stress management technique works for all people. A large repertoire of effective stress management techniques are available to assist in lowering baseline stress and recovering from stressful events quickly and skillfully. Regular exercise, restful sleep, a calm, supportive environment, and optimal nutrition can help decrease stress and are discussed separately. This section focuses on emotional, mental, and spiritual stress management practices. Meditation, relaxation exercises, guided imagery, self-hypnosis, autogenic training, biofeedback, journaling, and prayer have all proven helpful.
Practice, warm-up, and coaching are important elements of all stress management programs, just as they are with athletic or musical training. Developing and strengthening any kind of skill takes practice. Practice means that these techniques are most effective if used on a regular basis, not just when stress occurs. Similarly, warming up or using a stress management skill in anticipation of a stressful event is usually more effective than waiting until a stress has occurred. Finally, as with musical or athletic skills, performance can be enhanced with good coaching. In the case of stress management skills, coaches could be meditation teachers, pastoral counselors, psychologists, social workers, or primary care clinicians.
Meditation
The word "meditation" comes from the same root as the word medicine. There are many kinds of meditation practice, but they can be summed up as: paying attention on purpose (or intentional attention). Recent studies have demonstrated that meditation practice may have profound and sustained benefits for children, teens, and adults. The 2 major kinds of meditation are:
• Concentration (focusing on a thought, word, phrase, emotion, action. or object); and
• Mindfulness (nonjudgmental moment-to-moment awareness of sensations, emotions, and thoughts).
Concentration and mindfulness may ease anxiety when practiced regularly.[1-5] The usual practice is 10-30 minutes once or twice daily. Many major medical centers offer training in concentration-type (such as Harvard's Benson-Henry Institute for Mind-Body Medicine) or mindfulness-type (such as the University of Massachusetts Center for Mindfulness in Medicine, Healthcare and Society) meditation. These programs and Dr. Jim Gordon's Center for Mind-Body Medicine also offer books, CDs, and other resources for clinicians and patients interested in meditation as a stress management skill.
Relaxation Training
Progressive muscle relaxation is a technique in which muscle groups are intentionally tensed and then relaxed. Intentionally contracting muscles and then relaxing them leads to greater relaxation than simply telling oneself to relax. Regular practice can reduce anxiety.[6,7] Training and videos on this stress management technique are available through groups such as the Mayo Clinic, which offers several DVDs in conjunction with Gaiam.
Guided Imagery/Self-Hypnosis
Three particular guided imagery techniques are particularly helpful for enhancing a sense of safety, security, and greater calm: Safe Place, Wise Guide, and Caring Circle. The Safe Place guided imagery helps patients experience a real or imagined place in which they are completely safe, either alone or with real or imagined characters who are reassuring. The Wise Guide technique encourages patients to access inner sources of wisdom and strength through an imagined wise guide. The Caring Circle technique helps a patient imagine they are surrounded by caring, supportive beings that have their best interest at heart. Clinicians can learn to provide these kinds of guided images through workshops sponsored by the American Society for Clinical Hypnosis or the Society for Developmental and Behavioral Pediatrics. Patients may also be referred to psychologists, social workers, or other health professionals skilled in teaching these techniques. Guided imagery CDs and MP3 files to help manage stress and anxiety are available through several companies.
Autogenic Training
Autogenic training is a self-hypnosis technique developed by the German psychiatrist Johannes Schultz in 1932. The training consists of learning to repeat a set series of phrases such as: "My arms and hands are heavy and warm; my legs are heavy and warm; my heartbeat is calm and regular; my forehead is cool; my breathing is easy." Typically, each phrase is slowly repeated 3 times before going to the next phrase.
Repeating these phrases for 10-15 minutes can lead to a profound sense of calm and relaxation, improve sleep, and reduce reactivity to stress.[8-10]
Biofeedback
Biofeedback can help reduce anxiety and enhance sleep.[11] A variety of devices are available for home use. Devices can give feedback about temperature (raising hand or finger temperature promotes relaxation), breathing (slower is more peaceful), muscle tension (relaxing muscles leads to a sense of calm), and heart rate variability (certain patterns are associated with greater calm and even serenity). Computer-based biofeedback programs (such as Healing Rhythms® [Wild Divine, San Diego, California] and emWave® PC [HeartMath LLC, Boulder Creek, California]) are available for home use by both children and adults. Newer portable devices (emWave® PSR, HeartMath LLC) are also available.
Prayer and Participation in Religious Community
Prayer for help, guidance, direction, and support or even simple prayerful repetitions of a spiritually significant word can offer tremendous comfort and effectively ease anxiety.[12] Prayers of gratitude promote a sense of security and trust. Participation in a spiritual or religious community and pastoral counseling can also offer solace and support.[13-16] The type of religion appears to be less important than regular activity and participation.
Journaling
Regularly writing about the day's events and concerns is another helpful and inexpensive stress management strategy. There is some controversy about whether it is more helpful to write about positive events (a gratitude journal) or negative events, and there is likely to be some individual variability in response to this exercise.[17] Some psychologists recommend combining journaling with creative writing, encouraging patients to develop a "new ending" for fearful situations.[18]
Exercise
Regular exercise lowers stress hormone levels. Studies indicate that exercise may help reduce anxiety and panic attacks.[19,20] Both aerobic conditioning and weight training are helpful. Exercise combined with breathing exercises and meditation, such as Tai Chi, Qigong, and yoga, seem to be particularly effective in reducing stress and anxiety.[21-23]
Nutrition
Clinicians should encourage patients to eat breakfast and avoid skipping meals to ensure stable blood sugar. Avoid high glycemic index foods, focusing instead on whole grains, fruits, vegetables, and healthy proteins and fats. For some sensitive people, artificial flavorings (MSG), colorings, and sweeteners may be linked to anxiety. A careful dietary and symptom diary can help sort out dietary triggers. For people who seem to be sensitive to more than one food, a short trial (2-4 weeks) of a diet eliminating foods that commonly cause trouble (such as gluten, dairy, soy, seafood, eggs, and nuts) may be worthwhile to see how well symptoms abate without them, gradually adding them back as tolerated.[24]
Counsel patients to avoid using toxins such as tobacco and alcohol; both are common self-management strategies for anxiety, but both can lead to devastating physical, mental, and social consequences.
For patients who take vitamins, counsel against taking large doses of niacin without other B vitamins; niacin can lead to flushing and feeling anxious. For patients who use niacin to help manage cholesterol, slow-release forms can offer similar effectiveness without the flushing.
Advise patients to reduce caffeine intake because caffeine can mimic symptoms of anxiety. A good substitute is decaffeinated green tea, which contains theanine; theanine may help promote a sense of calm and may also reduces stress.[25,26]
Vitamins, Minerals, and Other Dietary Supplements
Before entering a discussion about vitamins, minerals, fish oils, and herbal products, healthcare providers should impress on patients and caregivers that the quality of supplements can often vary from manufacturer to manufacturer and even from batch to batch.
When patients and caregivers do ask about the products, the following information can help the healthcare provider respond.
Vitamins. Multivitamins may reduce anxiety and stress, even in healthy young adults who appear to be well-nourished.[27,28] B vitamins are often marketed to help reduce stress, and several are important cofactors in the production of neurotransmitters that are essential to maintaining a sense of calm. For example, vitamin B6 is essential in metabolizing tryptophan to serotonin. Inositol in doses of 12-18 g daily has been helpful in several preliminary studies for people suffering from obsessive-compulsive disorder and panic attacks.[29-31] Vitamin C may also help reduce the subjective sense of stress[32]; adult supplements generally range from 500 to 1000 mg daily. Vitamins B and C are water soluble and readily excreted; toxicity is uncommon. Excessive vitamin C can cause diarrhea.
Minerals. Deficiencies of calcium, magnesium, iodine, selenium, and iron are associated with stress, insomnia, and anxiety.[33] Approximately half to two thirds of American children and adolescents do not meet their recommended intake for calcium.
• Many anxiety sufferers have low magnesium levels. At least 1 study has suggested that supplemental magnesium can help ease anxiety.[34] Magnesium-rich foods include dark green leafy vegetables, beans and bean products, seeds, soybeans, nuts, whole grains, shellfish, and citrus fruits. Although some patients take a calcium/magnesium combination, absorption is improved if magnesium is not taken at the same time as iron or zinc supplements. Magnesium supplements are generally safe; excessive doses can cause diarrhea.
• Iodine deficiency and selenium deficiency can impair thyroid function, which is associated with anxiety.[35-37] Advise patients to ensure that the salt they use at their own table is iodized and that they regularly eat ocean fish or ocean vegetables (seaweed) and garlic to prevent deficiencies.
• Iron deficiency can contribute to a sense of stress and feeling overwhelmed.[38] Iron deficiencies are most common in young children, vegetarians, and women who lose iron in their monthly menstrual cycles. Excessive iron is not helpful in reducing anxiety and can cause cardiac and hepatic toxicity.
Clinically, it is prudent to ensure that patients consume a diet rich in vitamins and minerals and, if they are deficient, that deficiencies be corrected through supplementation.
Other dietary supplements. Fish oil contains the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Fish oil supplementation is linked to decreased aggression and anxiety in people who are stressed and in those with alcohol and drug problems.[39,40] Fish oil supplements are generally well-tolerated, particularly the newer formulations that are molecularly distilled (minimizing the fishy taste and belching associated with older formulas). Testing of some products has revealed no significant contamination with mercury, dioxins, or other contaminants in molecularly distilled fish oil products. Clinicians can also consider encouraging patients to eat fish rich in omega-3 fatty acids and low in mercury, PCBs, and dioxin (such as sardines, herring, salmon, or mackerel) twice weekly,[1] or to consider a supplement containing between 500 and 3000 mg of omega-3 fatty acids.
GABA is an amino acid and an important neurotransmitter linked to feeling calm. Although we have historically believed that little GABA crosses the blood-brain barrier, some research suggests that GABA supplements may boost GABA levels in the brain, promoting relaxation and easing anxiety.[41] There is likely to be substantial individual variability in response to GABA supplements, but they generally appear to be safe.
Tryptophan and 5-HTP supplements are amino acid precursors to serotonin and melatonin. Supplementation with 200 mg of 5-HTP has effectively reduced symptoms for patients suffering from panic disorder.[42,43] For patients with obsessive-compulsive disorder whose symptoms had not improved with medications alone, tryptophan supplements have provided relief.[44,45] Side effects are uncommon, but some patients have more aggressive feelings and behavior when they start tryptophan supplements.
Herbs. Mildly sedative herbs such as chamomile, hops, lemon balm, passion flower, and valerian may help promote sleep, relaxation, and reduced stress.[46-53] These herbs are generally safe; allergies are possible but uncommon. However, because some of these herbs can cause sleepiness, advise patients not to take them just before driving, taking an exam, or working with dangerous devices.
Brahmi or bacopa monnieri is a traditional remedy from India used to treat anxiety. A few small studies support its benefits for calm and clarity[54]; serious side effects have not been reported. However, safe, reliable supplies of high-quality bacopa may be difficult to find in the United States.
While most people think of ginkgo as a memory enhancer, some research suggests 240-480 mg daily of the European ginkgo product EGb 761 can also help anxious adults feel more calm.[55] However, ginkgo may cause bleeding problems, particularly in patients taking medications that affect clotting; avoid ginkgo for patients taking anticoagulant medications and those who have a bleeding diathesis.
Kava kava (Piper methysticum) is a traditional Polynesian herb that has been used to treat anxiety and stress-related insomnia.[56,57] However, its severe hepatotoxic side effects (including liver failure and death) have curtailed recent use.[58-60] For patients who continue to use kava despite warnings about toxicity, it is prudent to monitor liver function closely.
Lavender is used mainly as aromatherapy to reduce agitation, restlessness, nervousness, or stress and to promote relaxation and sleep.[61-66] It is used in some hospitals and hospice centers as a safe, low-cost strategy to decrease anxiety and improve a sense of well-being.
Rhodiola or arctic root is a Russian remedy used to reduce anxiety, improve the ability to cope with stress, and as a general tonic. A UCLA study showed that 340 mg of rhodiola supplements daily helped reduce anxiety in patients diagnosed with general anxiety disorder.[67] Rhodiola is generally safe, but as with all herbal products, some people get an upset stomach and a few have allergic reactions.
St. John's wort is used to treat anxiety as well as depression. Results of clinical studies have been mixed; it appears to be more helpful for those with mild symptoms than those suffering from severe anxiety, obsessive-compulsive disorder, or panic attacks.[68-70] Typical adults doses are 900 mg daily. Although it generally has fewer side effects than medications, St. John's wort can negatively affect the effectiveness of many other medications, including oral contraceptive pills. St. John's wort can also trigger manic symptoms in patients with bipolar disorder.
Environment
Simple environmental measures such as listening to music, spending more time in nature, and minimizing exposure to upsetting media can also help reduce anxiety.
Music eases anxiety in people of all ages, including infants.[71,72] Music has been used in hospitals, surgery centers, dental offices, and airports to promote greater calm and confidence; it is also a part of most military traditions as an effective strategy to strengthen courage. Personal preference should generally guide musical choices; music designed to induce binaural beats, putting brain waves into delta or theta rhythms,[73-75] can be even more helpful in reducing anxiety than music without these tones. Nature sounds (waterfalls, ocean waves, crickets, bird song) can also be very soothing. Music is a safe, simple strategy to promote calm and courage; keep stress levels down (and ears safe) by keeping the volume down. Rousing marches and upbeat tunes are better choices for daytime, while soft, calm sounds are better for bedtime listening.
Few patients would invite a guest back into their home if he tried to induce terror, fear, or anxiety. Yet, the media do this daily. The "if it bleeds, it leads" philosophy has affected not only the evening news but also many dramatic shows. In the most extreme cases, PTSD can occur, not just in people who directly experience a life-threatening event, but those who watch such events repeatedly on TV.[76] Encourage patients to be as mindful of their use of media as they are of what they eat, drink, and breathe. It may be particularly useful to avoid watching upsetting news or programming within the hour before bed.
Eye Movement Desensitization and Reprocessing
Another effective therapy for anxiety, particularly PTSD, is called eye movement desensitization and reprocessing (EMDR). EMDR has become fairly widespread based on the results of a handful of controlled trials.[77-79] For example, one study showed that EMDR had better lasting benefits than medications in treating PTSD.[80] It is usually covered by insurance when provided by a psychologist, physician, or licensed professional counselor.
Cranial Electrotherapy Stimulation
Cranial electrotherapy stimulation (or "electrosleep"; CES) was originally developed in Russia in the mid-20th century to promote sleep and relieve anxiety. CES devices provide very-low-intensity currents via electrodes attached to the skin of the earlobes or just behind the ears. They do not require surgery and do not send the kind of strong current used in electroconvulsive shock therapy or transcranial magnetic stimulation. The device is used 20-30 minutes daily for several days or weeks. Controlled studies from Russia and France, primarily done in the 1970s, linked CES stimulation to anxiety relief and better sleep.[81-86] Although CES has not caught on as a mainstream approach to managing anxiety in the United States, devices such as the Alpha-Stim® (Electromedical Products International, Inc., Mineral Wells, Texas) are available, although they require a prescription from a health professional. They cost several hundred dollars and are not typically covered by insurance plans. No serious adverse effects have been reported from using CES, but patients who have implanted pacemakers, defibrillators, or insulin pumps should avoid using them.
Massage
Therapeutic massage contributes to increased blood flow and lymphatic drainage, muscle relaxation, and stress reduction. Physiologically, massage seems to decrease cortisol levels and increase levels of serotonin and dopamine. Research supports the benefits of massage on sleep and reducing stress and anxiety.[86-92] Therapeutic massage is safe, even for small infants. Massage is generally safe if care is taken to avoid wounds, burns, intravenous lines, pumps, or other subcutaneous devices and vigorous strokes in patients with low platelet counts. Careful discussion and respect for individual patients is extremely important for patients with a history of physical or sexual abuse. Massage therapists are licensed as health professionals in most states, with strict requirements for training and continuing education. Although it can be very helpful, ongoing professional massage therapy can be costly and may not be reimbursed by insurance. Training a trusted family member or friend can enable patients to receive the benefits of regular massage within a budget.
Therapeutic Touch, Healing Touch, and Reiki
Therapeutic touch, healing touch, and Reiki are classified as biofield therapies by the National Institutes of Health's National Center for Complementary and Alternative Medicine. Although the mechanism for their effects remains a matter of speculation and dispute, research suggests that many patients find these therapies comforting and calming. Most of the studies evaluating them have been conducted in medical rather than psychiatric settings and have shown that they can help relieve anxiety and promote a sense of calm and well-being among patients with serious or life-threatening illnesses.[93-99] They are safe. When provided by licensed healthcare providers, these services may be covered by insurance.
Acupuncture
Although many people think of acupuncture as anxiety-provoking, it has actually proved to be a useful therapy in decreasing anxiety in both adults and children.[100-104] For example, acupressure and acupuncture are used to reduce the fear of dental, medical, and surgical procedures.[91,105-107] In one study, acupuncture also proved useful in treating PTSD.[108]
Acupuncture is generally safe, though minor bleeding and bruising are possible with any treatment involving needles. Acupuncture can cause sleepiness or deep relaxation; this may be of benefit for patients suffering from insomnia secondary to their anxiety.[109-115] Acupuncture needles are regulated by the US Food and Drug Administration, and most practitioners use disposable needles; this means that needles used in the United States must meet certain manufacturing and labeling standards, and that the risk of acquiring an infection from treatment are exceedingly low. In 2 studies that each examined over 30,000 acupuncture treatments, no serious adverse events were reported[116,117]; serious side effects are possible, but they are extremely rare.
Summary
Anxiety is common and can lead to significant disability, expensive medical evaluations, and long-term addictions to alcohol, tobacco, and drugs. Although the primary mainstream therapies are cognitive-behavioral therapy and medications, a number of natural therapies have both common sense and evidence-based benefits. Among the most helpful are mind-body stress management practices such as meditation and biofeedback, optimizing exercise and nutritional patterns, selective use of dietary supplements, attention to environment (more uplifting and calming music and nature and less frightening media exposure), cranial electrostimulation, and professionally provided therapies such as EMDR, massage, and acupuncture. Many families are already using these therapies to prevent or treat anxiety. Armed with this information, clinicians can provide appropriate, evidence-based advice, and researchers can evaluate those therapies of great public health importance.
Friday, August 14, 2009
Depression and Smoking Carry Same Mortality Risks
This article was sent this am to me from Medscape. It drives home the need to accurately assess and aggressively treat depression.
August 14, 2009 — Depression is on a par with smoking when it comes to increasing risks for mortality, although anxiety may counteract some of this increased risk, according to a new study.
"We were a bit surprised to find that depression — and not necessarily at a severe level — is associated with mortality at the same strength as smoking," lead author Arnstein Mykletun, PhD, from the University of Bergen, Norway, told Medscape Psychiatry. "Perhaps one of the more important new findings is that depression is that strong, even taking into account a lot of potential confounding factors including health status," he added.
Whereas other studies have linked depression with mortality, Dr. Mykletun said this study is more comprehensive and also is large enough to be able to address all of these factors.
The study is published in the August issue of the British Journal of Psychiatry.
Strong Association
British and Norwegian researchers used information gathered in the Health Study of Nord-Trondelag County (HUNT-2). All residents of this Norwegian county aged 19 years or older were asked to fill out a detailed questionnaire. Of these participants, 66% (61,349) completed this self-report questionnaire. Study subjects were also asked to complete a
14-item survey covering symptoms of anxiety and depression during the last 2 weeks.
Using a cut-off score to screen for depression and anxiety according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, the researchers organized the respondents into 4 groups: case-level anxiety only, case-level depression only, case-level comorbid anxiety and depression, and a reference group scoring below
ase levels on both scales.
Patient reports provided information on smoking habits, level of physical activity, alcohol use, educational level, and socioeconomic status. Researchers used patient-reported physical health data that included asthma, angina, cancer, diabetes, and hypertension to create an index of somatic symptoms weighted for their associations with mortality. They also collected data on body mass index, blood pressure, and cholesterol levels.
The National Mortality Registry provided statistics on deaths from the date of screening to December 2000, which represented a mean follow-up of 4.4 years. During that time, there were 2309 deaths among the 61,349 residents. The study found that after adjusting for age and sex, depression was strongly associated with mortality with an odds ratio of 1.68, whereas anxiety had an odds ratio of 1.19, and comorbid anxiety and depression had an odds ratio of
1.44.
Depression remained a risk factor for mortality even after controlling for somatic symptoms and diagnoses. These factors accounted for less than a quarter of the association between depression and mortality. Even after adjusting for alcohol problems, educational level, socioeconomic status, body mass index, blood pressure, and cholesterol level, a substantial proportion of the association between depression and mortality remained unexplained.
"Smoking and mortality seems to be similar to depression and mortality," said Dr. Mykletun. "Both of them, of course, are attenuated when we take adjusting factors into account, but the striking thing is that this comparison seems hold up regardless of the level of adjustment."
There were no sex differences in the association between depression and mortality.
A "conservative" estimate is that depression can account for a 40% increase in the risk of mortality, whereas a lessconservative estimate that adjusts for more of these factors would be closer to a 60% increase, he said.
The study should serve as a reminder to physicians to consider somatic symptoms in their depressed patients, said Dr. Mykletun. "We already know that depression is undertreated, and there's increasing attention to undertreatment of somatic illness in those with depression. This study might be additional evidence to back up the conclusion that we should take depression more seriously."
Depression, he said, is a multisystem disease that involves changes not only in the brain but also in blood vessels, heart, and bones. "Of the major common mental illnesses, depression really stands out as looking like ordinary disease across a number of body systems."
Dr. Kramer said the comparison with smoking was "a terrific metaphor" in that it gives people "a sense of the size of the contribution" of depression to mortality. He was also intrigued by the U-shaped curve found with anxiety. "It looks like there's some optimal level of anxiety. If you're depressed and have no anxiety, that might be a very bad set-up because you're doing very badly physically and you're not worried enough to take measures."
August 14, 2009 — Depression is on a par with smoking when it comes to increasing risks for mortality, although anxiety may counteract some of this increased risk, according to a new study.
"We were a bit surprised to find that depression — and not necessarily at a severe level — is associated with mortality at the same strength as smoking," lead author Arnstein Mykletun, PhD, from the University of Bergen, Norway, told Medscape Psychiatry. "Perhaps one of the more important new findings is that depression is that strong, even taking into account a lot of potential confounding factors including health status," he added.
Whereas other studies have linked depression with mortality, Dr. Mykletun said this study is more comprehensive and also is large enough to be able to address all of these factors.
The study is published in the August issue of the British Journal of Psychiatry.
Strong Association
British and Norwegian researchers used information gathered in the Health Study of Nord-Trondelag County (HUNT-2). All residents of this Norwegian county aged 19 years or older were asked to fill out a detailed questionnaire. Of these participants, 66% (61,349) completed this self-report questionnaire. Study subjects were also asked to complete a
14-item survey covering symptoms of anxiety and depression during the last 2 weeks.
Using a cut-off score to screen for depression and anxiety according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, the researchers organized the respondents into 4 groups: case-level anxiety only, case-level depression only, case-level comorbid anxiety and depression, and a reference group scoring below
ase levels on both scales.
Patient reports provided information on smoking habits, level of physical activity, alcohol use, educational level, and socioeconomic status. Researchers used patient-reported physical health data that included asthma, angina, cancer, diabetes, and hypertension to create an index of somatic symptoms weighted for their associations with mortality. They also collected data on body mass index, blood pressure, and cholesterol levels.
The National Mortality Registry provided statistics on deaths from the date of screening to December 2000, which represented a mean follow-up of 4.4 years. During that time, there were 2309 deaths among the 61,349 residents. The study found that after adjusting for age and sex, depression was strongly associated with mortality with an odds ratio of 1.68, whereas anxiety had an odds ratio of 1.19, and comorbid anxiety and depression had an odds ratio of
1.44.
Depression remained a risk factor for mortality even after controlling for somatic symptoms and diagnoses. These factors accounted for less than a quarter of the association between depression and mortality. Even after adjusting for alcohol problems, educational level, socioeconomic status, body mass index, blood pressure, and cholesterol level, a substantial proportion of the association between depression and mortality remained unexplained.
"Smoking and mortality seems to be similar to depression and mortality," said Dr. Mykletun. "Both of them, of course, are attenuated when we take adjusting factors into account, but the striking thing is that this comparison seems hold up regardless of the level of adjustment."
There were no sex differences in the association between depression and mortality.
A "conservative" estimate is that depression can account for a 40% increase in the risk of mortality, whereas a lessconservative estimate that adjusts for more of these factors would be closer to a 60% increase, he said.
The study should serve as a reminder to physicians to consider somatic symptoms in their depressed patients, said Dr. Mykletun. "We already know that depression is undertreated, and there's increasing attention to undertreatment of somatic illness in those with depression. This study might be additional evidence to back up the conclusion that we should take depression more seriously."
Depression, he said, is a multisystem disease that involves changes not only in the brain but also in blood vessels, heart, and bones. "Of the major common mental illnesses, depression really stands out as looking like ordinary disease across a number of body systems."
Dr. Kramer said the comparison with smoking was "a terrific metaphor" in that it gives people "a sense of the size of the contribution" of depression to mortality. He was also intrigued by the U-shaped curve found with anxiety. "It looks like there's some optimal level of anxiety. If you're depressed and have no anxiety, that might be a very bad set-up because you're doing very badly physically and you're not worried enough to take measures."
Sunday, June 21, 2009
A Physician's Personal Journey Through Depression
I found this account poignant and a reminder of that which connects us all- our humanity with it's frailties and strengths.
Keith Kesler
May 26, 2009
Psychiatric Times. Vol. 26 No. 6
Reflections
A Physician’s Personal Experience—The Gift of Depression
Jan Goddard-Finegold, MD
Depression is an insidious, ugly beast, creeping into the mind over time until one is engulfed and powerless, feeling only a sense of futility and heaviness. In my case it came some months after I had had to retire from a fruitful and enjoyable academic neurodevelopmental pediatrics practice, because of onset of a degenerative neuromuscular disease. My depression was manifested mainly by weight loss, poor affect, anger and irritability, fitful sleep, and thoughts of suicide. Luckily, my primary physician recognized the signs immediately and recommended both pharmacotherapy and psychotherapy. For both therapies and for this physician, I am extremely grateful. However, in this essay, I will speak of the ways I experienced psychodynamic psychotherapy and its ramifications into many parts of my life.
I am certain that with pharmacotherapy alone I would feel far less depressed today than I did 3 years ago. However, psychotherapy has provided me with new knowledge and an understanding of the underlying roots of and predispositions to my depression. In addition, I now understand more of the immature patterns of my behavior that remain parts of all of us and can lead to unwelcome consequences. More than this, I now know more clearly how the intimate sharing of thoughts between 2 people in a secure environment can heal. I appreciate even more that I can both give and receive love in my life despite being disabled physically.
Pharmacotherapy alone would not have given me these gifts. These understandings have provided me with a sense of strength and ease as I deal with aging and loss. I am better able to face further incapacitation and death, as well as to enjoy what time I have. In addition, the therapeutic relationship that I developed with my psychiatrist is sacred and confidential—a caring relationship that gives me time for discovery; critique; questioning; and emotional, spiritual, and intellectual freedom. I wish the process to continue until I have shaved off the top layers of consciousness and have reached more of the core below, so that unlike finding the treachery and danger of the lower four-fifths of an iceberg, I continue to understand more and more of my underlying motivations and unconscious will with awe and gratitude.
The work of 2 people
Everyone knows what a material gift is, but why should I call a process, and especially one that involves such personal vulnerability and hard work, a gift? What is the ultimate purpose of working to overcome depression, rather than only changing the serotonin, dopamine, or norepinephrine levels in the brain?
I believe that the process of 2 people working to overcome depression becomes a gift when the patient comes to find (1) success in the process; (2) previously undiscovered insights into the causes of depression; and (3) that one always has meaning in life and gifts to give to others, including one’s therapist. There is no serious therapist alive who has not learned from his or her patients. Part of this, of course, depends on there being a good intellectual and emotional fit between therapist and patient, and the desire of both parties to work toward understanding and healing.
Because of the challenge of this process and the feeling of hard-won reward when breakthroughs are made, as well as the positive effects on my life and my feelings about myself, I consider my work with my psychotherapist a supreme gift. Because my depression brought me to this, it was a gift. And because I am a conscientious student of the process, I believe I am a gift to my therapist, to others, and to myself.
Doing things well
I have learned that being a gift to anyone has always been a difficult thing for me to acknowledge. I have always felt that I have not given enough. The fact is, I have done things well, although imperfectly. And doing things well enough makes it possible to give many gifts—to love one’s husband and children well; to do one’s chosen profession well; to share one’s life with others well through understanding one’s own feelings well.
Doing things well does not mean being perfect, nor does it presuppose having a perfectly orchestrated life. Doing things well does not mean having perfect relationships. Likewise, doing things “perfectly”does not make life perfect. Perfection, after all, is an expensive illusion. Unfortunately, expecting perfection, of ourselves and of others (whatever our concept of it), contributes to feelings of being let down or of letting others down. These feelings can accelerate over time, leading to guilt and depression. Once the concept that doing things well enough can be good enough for a meaningful life is part of our inner being, we become better at accepting ourselves and being good to others.
A life of meaning—love and sacredness in relationships
Love has nothing to do with knowledge, education, or power; it is beyond behavior. It is also the only gift in life that is not lost. Ultimately it is the only thing we can really give. In a world of illusions, a world of dreams and emptiness, love is the source of truth.1
—Elisabeth Kubler-Ross
While I have always made it a point to share the most important parts of my psychotherapy with my husband, to make him aware both of my current thoughts and of my progress, there have also been other people in my life with whom I share meaningful aspects of my feelings and thinking.
People with whom I relate in this way give great meaning to my life and are gifts themselves. The sharing in these relationships is basically intimate and bilateral, full of meaning and involving trust and commonality of interests. These relationships are unguarded, truthful, safe, intellectually and emotionally intimate, and confidential when necessary. They are sacred relationships. What do such friendships offer? Why can having sacred friendships help prevent depression?
First, these close relationships are sacred because they are accepting. Second, the communications in these relationships frequently simulate some of the aspects of psychotherapy by virtue of their intimacy, openness, and allowance of emotional expression.They differ from communications with a spouse by eliminating the caring spouse’s frequent need to “solve the problem.”
Often my sacred friends are available only to listen; but, in addition, my really observant friends notice changes in my mood and help to alleviate pain and suffering. My friends would most likely notice signs of suicidal intent. My good friends offer understanding, suggestions, and reassurance. These friends also enhance fun, recreation, laughter, and relief. Thus, the person without truly sacred friends is indeed bereft, and such loneliness inhibits recovery from depression.
Finding new joys
It might seem that a neuromuscular degenerative disease does not provide many avenues for laughter. I rarely laughed when I was depressed, but now I find that laughter is one of the best responses to otherwise annoying situations—long waits at doctors’ appointments, difficulties in managing basic physical needs, and requiring mechanical devices to do what I used to do effortlessly. I use a power wheelchair now, and some of my very best friends have given me a decorated bicycle helmet that is hilarious to look at, preposterous to wear, and always good for a laugh when shown off to family and visitors.
We have to remind ourselves that even in seemingly senseless and painful situations, there are ways to find fun as long as we are sentient and communicative. Art Buchwald, who died in 2007 at the age of 81, spent most of his life finding ways to make us all laugh. Interestingly, he and a number of his well-known colleagues suffered at various times from severe depression. He always managed to write and speak with wit and great feeling. In explaining why he was not invited to the wedding of Grace Kelly and Prince Ranier, Mr Buchwald responded that “the Buchwalds and the Grimaldis have not spoken since January 9th, 1297.”2 Furthermore, Mr Buchwald used his illness as a source of humor by managing to live longer than was predicted and to spend considerable time in a hospice without dying there. He is quoted as having said, “The National Hospice Association made me man of the year. I never realized dying was so much fun.”2
Depresssion with disability—learning acceptance, compromise, and dignity
It would not surprise most of us to think that people with severe, life-changing diseases and disabilities might become depressed. In essence, living with chronic disease means, as Blair Justice3 notes in A Different Kind of Health, a “shifting of identity.”He states, however, that “studies show that people can be both fully aware of the severity of their physical condition and retain a sense of well-being.”
For some of us, attaining this sense of well-being takes a long time and considerable effort. It is natural to define ourselves by our illness, especially when the illness involves many hospital visits, painful treatments, uncertain diagnoses, doctors who have differing opinions, and decreases in energy that make days short and opportunities for relief limited.
I have found that I can decrease illness as my identity and reduce my depressive feelings by making new friends in many venues and by inviting people with special talents in art, photography, music, and writing to join us in our home and at some of my longer visits for medication infusions. Examining new ideas gives me a sense of well-being and the ability to maintain my dignity while still accepting compromises in my daily life.
As one of my favorite teachers showed me, a major means of coping was eloquently stated by T. H. White4 in The Once and Future King:
“The best thing for being sad,”replied Merlyn, “is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins…There is only one thing for it then—to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting…"
Continuing creative projects
I have been a photographer for many years, exhibiting my black-and-white photos, and sharing ideas with other photographers. Therapy has had a remarkable influence on my concepts for my photography. I express my feelings and my insights metaphorically through my photos. Photography is challenging and a way to look toward the future during a time that is full of uncertainty and pain. Although my mobility is limited, I can make photos of objects of beauty and symbolism, such as this surreal window that, for me, suggests looking onward and forward, although the path to insight may have many layers.
I also write poetry, and even in my darkest moments when I write my poems, I find out more about myself and my “less conscious”person. This poem is an example of this process.
I Dream
I dream I am walking
walking and running
I dream I am running
until I am breathless
and I stop running.
I dream I am swimming
swimming and diving
First from the low boards,
then from the high.
I dream I am dancing
dancing and sweating,
dancing in time to the
music of fast dancers;
I dream I am sleeping
sleeping exhausted,
sleeping unaware
sleeping deeply,
sleeping until
I dream again,
dreaming I am floating
dreaming I am dreaming
knowing I am not dreaming. (2006)
Accepting help when needed
One of my largest losses has been foregoing driving because of the effects the disease has had on my eye muscles. My therapy has helped me accept both my limitations and having to have a caregiver take me where I need to go, as well as help me with daily needs. This care has made it possible for me to have the energy to continue to show my photographic work in different places and to experiment with new photographic processes.
Dealing with the past and unhelpful family relationships
We are all products of our past relationships and happenings, our reactions to them, our ways of coping, the degree to which we have held on to “immature reaction patterns,”and the amounts of affection or dysfunction we experienced in our growing years. It is certainly possible to find out, even as we age, that parents, siblings, or spouses have problems that prevent them from sharing love easily. This can be especially true for one’s elderly parents who suffer strokes or have dementia.
Having a loved family member reject us when we reach out to him or her, especially as we climb the ladder from depression to hope, is tremendously painful. Whether the causes involve old hurts or jealousies, lack of communication for long periods, or fear and guilt regarding the disease process, the result can be an even greater difficulty in communication and an increase in sadness for both people.
When this involves the relationship with an aged parent, both psychopharmacological and geriatric psychotherapy can be very helpful.
Anger and resolution
Regardless of our wish for equanimity, anger is also a natural part of life, a normal reaction to the bad things that happen to us, to things we cannot control, to the death of a loved one, to one’s own or another’s disease, and to other significant losses.
Anger is a normal response, but if allowed to become overwhelming, can be destructive, can be “turned inward”along with guilt and can contribute to depression.
In Harold S. Kushner’s5 book, Overcoming Life’s Disappointments, he writes of an interpretation of Moses’ striking of the rock to get water in the desert for his tired and hungry brethren. This interpretation is that Moses is not frustrated and angry at his people for being so demanding of him, but rather, that he is angry at God for having imposed an “impossible burden”on him. The result is that Moses does not live to see the promised land to which he has been leading his flock for 40 years.
We, like Moses, have reasons to be angry at our “impossible burdens”—our diseases, our losses, those who have slighted us. But as Harold Kushner5 points out, we can prevent our anger from becoming a major and self-defining issue. Psychotherapy can help us learn harmless ways to vent anger, other than subjecting our spouses and family members to our temper, our sarcasm, or our withdrawal.
Gaining empowerment
Forgiveness is a necessary part of coping and of becoming empowered. Forgiveness and letting go of old hurts and disagreements can help tremendously in relieving tension and decreasing depression. As I have learned in my therapy, this does not mean that earlier hurtful behavior is excused, or forgotten, but it can be looked on with perspective, and sorrow, rather than with revenge or guilt. The more loving I can be, the more empowered I then become. The more I let go of old sorrows and disappointments, the easier it is for me to look forward, without denying the realities I am facing.
Other ways I become empowered include (1) continuing to learn; (2) keeping in touch with friends and family to avoid isolation and to gain the perspectives of others; (3) learning new ways to communicate—both physically and emotionally (I have a voice enhancer to enable me to speak when my vocal cords and surrounding muscles weaken, as well as a voice-directed and eye-directed computer system); (4) continuing to find ways to both give and receive love and realizing that the possibilities for both are endless.
It is empowering, although sometimes difficult, to tell others how much we appreciate or love them, or how much they have influenced our lives. I am finding it extremely helpful to take the opportunity—to make the opportunity—to do this. I felt much better after I told a dear teacher and loving friend how much her mentoring influenced my career and my success, something she had not truly realized.
Dealing with the inevitability of losses and our own mortality
Acknowledging the people we care about while they are still alive helps alleviate the feelings of “I should have told her” that often occur after a beloved friend or relative has died. This leads to one of the most difficult parts of living, whether with disability, depression, or not—the deaths of colleagues, friends, and relatives. Realizing that death is a natural part of the life cycle is easy to say, but, in reality, we are all overwhelmed by its finality. This is true even though throughout my life death has been an accepted family event, not only in older members of the family, but in 5 boys affected by the genetic disease that I share. The finality and often the rapidity of death of a beloved friend or loved one causes grief, retrospection, and introspection for me. I remember the past life we shared and my feelings of what we still could have given each other. Of course, I find myself thinking of my own disease process and the probable lessening of the length of my own life.
It is said that we have to “move on,”after the death of a loved one has been integrated into our sense of reality . . . and we do move on. But do we move on completely? Or should we endeavor to recover and keep the love of lost relationships?6 Does the essence of a person that lingers with us and made possible such a relationship end at death? The death of a loved one remains a loss with us forever. Contemplating the permanence of death thoughtfully helps me become at ease with the truly indefinable concept of infinity, and makes this life, however limited, more valuable.
If death is a state of “nothingness,”then we should consider that we were in a state of nothingness before we were conceived. Likewise, in the deepest stage of sleep we are totally unaware of our own being and, as during anesthesia, we are not conscious, but we are not in an unpleasant state. This state is probably much like death. However, there is a basic difference between our deaths and our previous nothingness: we WILL HAVE BEEN alive, and we WILL HAVE left part of ourselves hereafter. Whether this part of us is a soul, our thoughts, or a memory in the mind of a child, it is real and increases the sacredness of the life we are permitted to have. It makes our life on earth precious and our deeds on earth meaningful.
It seems imperative to me to enjoy my impermanence and to make the most of it. This is why it is important for me to relieve my depression and continue my processes of mental and emotional discovery. I am learning to gratefully accept help from others when I need it, and I am coming to grips with my feelings and ideas about mortality so I can achieve a death that is welcome, kind, and dignified. Accepting the certainty of physical decline seems to enhance the possibility of finding my soul while I am still alive, and sharing it, finding those parts of me that are most meaningful, and making my life more sacred to others. Even in my darkest moments, I am uplifted, and I feel fewer burdens from my losses when I read Pablo Neruda. Here is a portion from his poem, “Oblivion”7:
I shall go on marching, opening broad roads against the shadow, making the earth smooth, spreading the stars for those who come. Stay on the road. Night has fallen for you. Perhaps at dawn we shall see each other again.
References
1.Kubler-Ross E, Kessler D. Life Lessons.New York: Scribner; 2000:31.
2. Severo R. Art Buchwald, whose humor hit the powerful, is dead at 81. New York Times.January 10, 2007.
3. Justice B. A Different Kind of Health.New York: Peak Press; 1998:31.
4.White TH. The Once and Future King.>New York: GP Putnam and Sons; 1958:185-186.
5. Kushner HS. Overcoming Life’s Disappointments.New York: Alfred A. Knopf; 2006:157-158; 1-3.
6.Vaillant GE. Love. In: Spiritual Evolution: A Scientific Defense of Faith.2008:82-101. http://www.adm.monash.edu.au/community-services/counselling/positive-psychology/posemotionvaillant.pdf. Accessed May 14, 2009.
7.Neruda P. Oblivion. In: The Captain’s Verses.Walsh DD, trans. New York: New Directions; 1972:83.
Dedications
This essay is dedicated to my always loving husband, Milton; to the memory of the gentle questions of the late Dr Chris E. Sermas; to the joy of reality, wit, common sense, and knowledge of pharmacology of Dr Herbert I. Dorfan; and especially, to the caring thoughts, teaching, wisdom, and spirit of Dr James W. Lomax. I am grateful for the careful editing and reviews by Dr Earle Silber and Rabbi Roy Walter.
This essay has been shortened to fit the requirements of the Psychiatric Times.Please contact the author by e-mail (jgfinegold@aol.com) if you would like a copy of the original essay.
Keith Kesler
May 26, 2009
Psychiatric Times. Vol. 26 No. 6
Reflections
A Physician’s Personal Experience—The Gift of Depression
Jan Goddard-Finegold, MD
Depression is an insidious, ugly beast, creeping into the mind over time until one is engulfed and powerless, feeling only a sense of futility and heaviness. In my case it came some months after I had had to retire from a fruitful and enjoyable academic neurodevelopmental pediatrics practice, because of onset of a degenerative neuromuscular disease. My depression was manifested mainly by weight loss, poor affect, anger and irritability, fitful sleep, and thoughts of suicide. Luckily, my primary physician recognized the signs immediately and recommended both pharmacotherapy and psychotherapy. For both therapies and for this physician, I am extremely grateful. However, in this essay, I will speak of the ways I experienced psychodynamic psychotherapy and its ramifications into many parts of my life.
I am certain that with pharmacotherapy alone I would feel far less depressed today than I did 3 years ago. However, psychotherapy has provided me with new knowledge and an understanding of the underlying roots of and predispositions to my depression. In addition, I now understand more of the immature patterns of my behavior that remain parts of all of us and can lead to unwelcome consequences. More than this, I now know more clearly how the intimate sharing of thoughts between 2 people in a secure environment can heal. I appreciate even more that I can both give and receive love in my life despite being disabled physically.
Pharmacotherapy alone would not have given me these gifts. These understandings have provided me with a sense of strength and ease as I deal with aging and loss. I am better able to face further incapacitation and death, as well as to enjoy what time I have. In addition, the therapeutic relationship that I developed with my psychiatrist is sacred and confidential—a caring relationship that gives me time for discovery; critique; questioning; and emotional, spiritual, and intellectual freedom. I wish the process to continue until I have shaved off the top layers of consciousness and have reached more of the core below, so that unlike finding the treachery and danger of the lower four-fifths of an iceberg, I continue to understand more and more of my underlying motivations and unconscious will with awe and gratitude.
The work of 2 people
Everyone knows what a material gift is, but why should I call a process, and especially one that involves such personal vulnerability and hard work, a gift? What is the ultimate purpose of working to overcome depression, rather than only changing the serotonin, dopamine, or norepinephrine levels in the brain?
I believe that the process of 2 people working to overcome depression becomes a gift when the patient comes to find (1) success in the process; (2) previously undiscovered insights into the causes of depression; and (3) that one always has meaning in life and gifts to give to others, including one’s therapist. There is no serious therapist alive who has not learned from his or her patients. Part of this, of course, depends on there being a good intellectual and emotional fit between therapist and patient, and the desire of both parties to work toward understanding and healing.
Because of the challenge of this process and the feeling of hard-won reward when breakthroughs are made, as well as the positive effects on my life and my feelings about myself, I consider my work with my psychotherapist a supreme gift. Because my depression brought me to this, it was a gift. And because I am a conscientious student of the process, I believe I am a gift to my therapist, to others, and to myself.
Doing things well
I have learned that being a gift to anyone has always been a difficult thing for me to acknowledge. I have always felt that I have not given enough. The fact is, I have done things well, although imperfectly. And doing things well enough makes it possible to give many gifts—to love one’s husband and children well; to do one’s chosen profession well; to share one’s life with others well through understanding one’s own feelings well.
Doing things well does not mean being perfect, nor does it presuppose having a perfectly orchestrated life. Doing things well does not mean having perfect relationships. Likewise, doing things “perfectly”does not make life perfect. Perfection, after all, is an expensive illusion. Unfortunately, expecting perfection, of ourselves and of others (whatever our concept of it), contributes to feelings of being let down or of letting others down. These feelings can accelerate over time, leading to guilt and depression. Once the concept that doing things well enough can be good enough for a meaningful life is part of our inner being, we become better at accepting ourselves and being good to others.
A life of meaning—love and sacredness in relationships
Love has nothing to do with knowledge, education, or power; it is beyond behavior. It is also the only gift in life that is not lost. Ultimately it is the only thing we can really give. In a world of illusions, a world of dreams and emptiness, love is the source of truth.1
—Elisabeth Kubler-Ross
While I have always made it a point to share the most important parts of my psychotherapy with my husband, to make him aware both of my current thoughts and of my progress, there have also been other people in my life with whom I share meaningful aspects of my feelings and thinking.
People with whom I relate in this way give great meaning to my life and are gifts themselves. The sharing in these relationships is basically intimate and bilateral, full of meaning and involving trust and commonality of interests. These relationships are unguarded, truthful, safe, intellectually and emotionally intimate, and confidential when necessary. They are sacred relationships. What do such friendships offer? Why can having sacred friendships help prevent depression?
First, these close relationships are sacred because they are accepting. Second, the communications in these relationships frequently simulate some of the aspects of psychotherapy by virtue of their intimacy, openness, and allowance of emotional expression.They differ from communications with a spouse by eliminating the caring spouse’s frequent need to “solve the problem.”
Often my sacred friends are available only to listen; but, in addition, my really observant friends notice changes in my mood and help to alleviate pain and suffering. My friends would most likely notice signs of suicidal intent. My good friends offer understanding, suggestions, and reassurance. These friends also enhance fun, recreation, laughter, and relief. Thus, the person without truly sacred friends is indeed bereft, and such loneliness inhibits recovery from depression.
Finding new joys
It might seem that a neuromuscular degenerative disease does not provide many avenues for laughter. I rarely laughed when I was depressed, but now I find that laughter is one of the best responses to otherwise annoying situations—long waits at doctors’ appointments, difficulties in managing basic physical needs, and requiring mechanical devices to do what I used to do effortlessly. I use a power wheelchair now, and some of my very best friends have given me a decorated bicycle helmet that is hilarious to look at, preposterous to wear, and always good for a laugh when shown off to family and visitors.
We have to remind ourselves that even in seemingly senseless and painful situations, there are ways to find fun as long as we are sentient and communicative. Art Buchwald, who died in 2007 at the age of 81, spent most of his life finding ways to make us all laugh. Interestingly, he and a number of his well-known colleagues suffered at various times from severe depression. He always managed to write and speak with wit and great feeling. In explaining why he was not invited to the wedding of Grace Kelly and Prince Ranier, Mr Buchwald responded that “the Buchwalds and the Grimaldis have not spoken since January 9th, 1297.”2 Furthermore, Mr Buchwald used his illness as a source of humor by managing to live longer than was predicted and to spend considerable time in a hospice without dying there. He is quoted as having said, “The National Hospice Association made me man of the year. I never realized dying was so much fun.”2
Depresssion with disability—learning acceptance, compromise, and dignity
It would not surprise most of us to think that people with severe, life-changing diseases and disabilities might become depressed. In essence, living with chronic disease means, as Blair Justice3 notes in A Different Kind of Health, a “shifting of identity.”He states, however, that “studies show that people can be both fully aware of the severity of their physical condition and retain a sense of well-being.”
For some of us, attaining this sense of well-being takes a long time and considerable effort. It is natural to define ourselves by our illness, especially when the illness involves many hospital visits, painful treatments, uncertain diagnoses, doctors who have differing opinions, and decreases in energy that make days short and opportunities for relief limited.
I have found that I can decrease illness as my identity and reduce my depressive feelings by making new friends in many venues and by inviting people with special talents in art, photography, music, and writing to join us in our home and at some of my longer visits for medication infusions. Examining new ideas gives me a sense of well-being and the ability to maintain my dignity while still accepting compromises in my daily life.
As one of my favorite teachers showed me, a major means of coping was eloquently stated by T. H. White4 in The Once and Future King:
“The best thing for being sad,”replied Merlyn, “is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins…There is only one thing for it then—to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting…"
Continuing creative projects
I have been a photographer for many years, exhibiting my black-and-white photos, and sharing ideas with other photographers. Therapy has had a remarkable influence on my concepts for my photography. I express my feelings and my insights metaphorically through my photos. Photography is challenging and a way to look toward the future during a time that is full of uncertainty and pain. Although my mobility is limited, I can make photos of objects of beauty and symbolism, such as this surreal window that, for me, suggests looking onward and forward, although the path to insight may have many layers.
I also write poetry, and even in my darkest moments when I write my poems, I find out more about myself and my “less conscious”person. This poem is an example of this process.
I Dream
I dream I am walking
walking and running
I dream I am running
until I am breathless
and I stop running.
I dream I am swimming
swimming and diving
First from the low boards,
then from the high.
I dream I am dancing
dancing and sweating,
dancing in time to the
music of fast dancers;
I dream I am sleeping
sleeping exhausted,
sleeping unaware
sleeping deeply,
sleeping until
I dream again,
dreaming I am floating
dreaming I am dreaming
knowing I am not dreaming. (2006)
Accepting help when needed
One of my largest losses has been foregoing driving because of the effects the disease has had on my eye muscles. My therapy has helped me accept both my limitations and having to have a caregiver take me where I need to go, as well as help me with daily needs. This care has made it possible for me to have the energy to continue to show my photographic work in different places and to experiment with new photographic processes.
Dealing with the past and unhelpful family relationships
We are all products of our past relationships and happenings, our reactions to them, our ways of coping, the degree to which we have held on to “immature reaction patterns,”and the amounts of affection or dysfunction we experienced in our growing years. It is certainly possible to find out, even as we age, that parents, siblings, or spouses have problems that prevent them from sharing love easily. This can be especially true for one’s elderly parents who suffer strokes or have dementia.
Having a loved family member reject us when we reach out to him or her, especially as we climb the ladder from depression to hope, is tremendously painful. Whether the causes involve old hurts or jealousies, lack of communication for long periods, or fear and guilt regarding the disease process, the result can be an even greater difficulty in communication and an increase in sadness for both people.
When this involves the relationship with an aged parent, both psychopharmacological and geriatric psychotherapy can be very helpful.
Anger and resolution
Regardless of our wish for equanimity, anger is also a natural part of life, a normal reaction to the bad things that happen to us, to things we cannot control, to the death of a loved one, to one’s own or another’s disease, and to other significant losses.
Anger is a normal response, but if allowed to become overwhelming, can be destructive, can be “turned inward”along with guilt and can contribute to depression.
In Harold S. Kushner’s5 book, Overcoming Life’s Disappointments, he writes of an interpretation of Moses’ striking of the rock to get water in the desert for his tired and hungry brethren. This interpretation is that Moses is not frustrated and angry at his people for being so demanding of him, but rather, that he is angry at God for having imposed an “impossible burden”on him. The result is that Moses does not live to see the promised land to which he has been leading his flock for 40 years.
We, like Moses, have reasons to be angry at our “impossible burdens”—our diseases, our losses, those who have slighted us. But as Harold Kushner5 points out, we can prevent our anger from becoming a major and self-defining issue. Psychotherapy can help us learn harmless ways to vent anger, other than subjecting our spouses and family members to our temper, our sarcasm, or our withdrawal.
Gaining empowerment
Forgiveness is a necessary part of coping and of becoming empowered. Forgiveness and letting go of old hurts and disagreements can help tremendously in relieving tension and decreasing depression. As I have learned in my therapy, this does not mean that earlier hurtful behavior is excused, or forgotten, but it can be looked on with perspective, and sorrow, rather than with revenge or guilt. The more loving I can be, the more empowered I then become. The more I let go of old sorrows and disappointments, the easier it is for me to look forward, without denying the realities I am facing.
Other ways I become empowered include (1) continuing to learn; (2) keeping in touch with friends and family to avoid isolation and to gain the perspectives of others; (3) learning new ways to communicate—both physically and emotionally (I have a voice enhancer to enable me to speak when my vocal cords and surrounding muscles weaken, as well as a voice-directed and eye-directed computer system); (4) continuing to find ways to both give and receive love and realizing that the possibilities for both are endless.
It is empowering, although sometimes difficult, to tell others how much we appreciate or love them, or how much they have influenced our lives. I am finding it extremely helpful to take the opportunity—to make the opportunity—to do this. I felt much better after I told a dear teacher and loving friend how much her mentoring influenced my career and my success, something she had not truly realized.
Dealing with the inevitability of losses and our own mortality
Acknowledging the people we care about while they are still alive helps alleviate the feelings of “I should have told her” that often occur after a beloved friend or relative has died. This leads to one of the most difficult parts of living, whether with disability, depression, or not—the deaths of colleagues, friends, and relatives. Realizing that death is a natural part of the life cycle is easy to say, but, in reality, we are all overwhelmed by its finality. This is true even though throughout my life death has been an accepted family event, not only in older members of the family, but in 5 boys affected by the genetic disease that I share. The finality and often the rapidity of death of a beloved friend or loved one causes grief, retrospection, and introspection for me. I remember the past life we shared and my feelings of what we still could have given each other. Of course, I find myself thinking of my own disease process and the probable lessening of the length of my own life.
It is said that we have to “move on,”after the death of a loved one has been integrated into our sense of reality . . . and we do move on. But do we move on completely? Or should we endeavor to recover and keep the love of lost relationships?6 Does the essence of a person that lingers with us and made possible such a relationship end at death? The death of a loved one remains a loss with us forever. Contemplating the permanence of death thoughtfully helps me become at ease with the truly indefinable concept of infinity, and makes this life, however limited, more valuable.
If death is a state of “nothingness,”then we should consider that we were in a state of nothingness before we were conceived. Likewise, in the deepest stage of sleep we are totally unaware of our own being and, as during anesthesia, we are not conscious, but we are not in an unpleasant state. This state is probably much like death. However, there is a basic difference between our deaths and our previous nothingness: we WILL HAVE BEEN alive, and we WILL HAVE left part of ourselves hereafter. Whether this part of us is a soul, our thoughts, or a memory in the mind of a child, it is real and increases the sacredness of the life we are permitted to have. It makes our life on earth precious and our deeds on earth meaningful.
It seems imperative to me to enjoy my impermanence and to make the most of it. This is why it is important for me to relieve my depression and continue my processes of mental and emotional discovery. I am learning to gratefully accept help from others when I need it, and I am coming to grips with my feelings and ideas about mortality so I can achieve a death that is welcome, kind, and dignified. Accepting the certainty of physical decline seems to enhance the possibility of finding my soul while I am still alive, and sharing it, finding those parts of me that are most meaningful, and making my life more sacred to others. Even in my darkest moments, I am uplifted, and I feel fewer burdens from my losses when I read Pablo Neruda. Here is a portion from his poem, “Oblivion”7:
I shall go on marching, opening broad roads against the shadow, making the earth smooth, spreading the stars for those who come. Stay on the road. Night has fallen for you. Perhaps at dawn we shall see each other again.
References
1.Kubler-Ross E, Kessler D. Life Lessons.New York: Scribner; 2000:31.
2. Severo R. Art Buchwald, whose humor hit the powerful, is dead at 81. New York Times.January 10, 2007.
3. Justice B. A Different Kind of Health.New York: Peak Press; 1998:31.
4.White TH. The Once and Future King.>New York: GP Putnam and Sons; 1958:185-186.
5. Kushner HS. Overcoming Life’s Disappointments.New York: Alfred A. Knopf; 2006:157-158; 1-3.
6.Vaillant GE. Love. In: Spiritual Evolution: A Scientific Defense of Faith.2008:82-101. http://www.adm.monash.edu.au/community-services/counselling/positive-psychology/posemotionvaillant.pdf. Accessed May 14, 2009.
7.Neruda P. Oblivion. In: The Captain’s Verses.Walsh DD, trans. New York: New Directions; 1972:83.
Dedications
This essay is dedicated to my always loving husband, Milton; to the memory of the gentle questions of the late Dr Chris E. Sermas; to the joy of reality, wit, common sense, and knowledge of pharmacology of Dr Herbert I. Dorfan; and especially, to the caring thoughts, teaching, wisdom, and spirit of Dr James W. Lomax. I am grateful for the careful editing and reviews by Dr Earle Silber and Rabbi Roy Walter.
This essay has been shortened to fit the requirements of the Psychiatric Times.Please contact the author by e-mail (jgfinegold@aol.com) if you would like a copy of the original essay.
Wednesday, June 3, 2009
Teens with family history of depression at risk. Combined talk therapy and meds most helpful combination.
This is pasted from this morning's American Psychiatric Newsletter:
Study indicates teens whose parents have history of depression may themselves be at high risk.
The New York Times (6/3, Rabin) reports that "depression often strikes during adolescence, and teenagers whose parents have a history of depression are at particularly high risk. Now," a study published June 3 in the Journal of the American Medical Association "has found that a group cognitive behavioral program that teaches coping and problem-solving skills to these high-risk teens can reduce their risk of developing the mood disorder." Notably, "the success rate of the prevention program varied greatly, depending on the mental health status of the teenagers' parents at the time they began intervention." Specifically, "the program was much more effective than standard care if the teens' parents were also without depression when the intervention began."
Focusing on the study's methodology, USA Today (6/3, Szabo) explains that researchers from Vanderbilt University "focused on" 316 "high-risk teens whose parents had a history of depression. All...of the teens already had experienced depression in the past or had some symptoms of depression when the study began." Half of them "were randomly assigned to attend eight weekly group sessions with other teenagers. After nine months," those "who attended group therapy were less likely to have had an episode of depression than teens who had their usual care, but didn't receive therapy." However, the "prevention program didn't help at all...for teens whose parents were currently depressed."
In the Wall Street Journal (6/2) Health Blog, Shirley S. Wang observed that the study authors theorized that "having a currently depressed parent could mean that the teen had more stress to deal with, or the parent was less responsive to the teens' new skills."
HealthDay (6/2, Mozes) quoted study author Judy Garber, PhD, "director of the developmental psychopathology research training program at Vanderbilt University," as saying, "The bottom line is that depression in adolescents can be prevented among kids who are at risk." She added, "But this finding is consistent with other studies that have found that children who are in treatment for depression do not do as well if their parents are currently depressed." She also "described the findings as 'interesting' and 'important,' in that they offer further confirmation that children of actively depressed parents are themselves at risk and should be monitored." She stated, "The message to parents is pay attention to how their children are doing if they're depressed." For "public health policy makers," however, she said that "the message is that it would be good to pay attention to prevention programs."
According to WebMD (6/2, Boyles), "cognitive behavioral therapy (CBT) has been shown to be an effective treatment for depression in teens, either alone or in combination with antidepressant" medications. For example, "in a 2007 study, the combination of CBT and a selective serotonin reuptake inhibitor...which is a class of antidepressant medication, was found to be more effective for treating major depression than either treatment alone." And, in a study "reported in February, the combination of CBT and an antidepressant was more effective than" medication "therapy alone in the treatment of teens who had not responded to initial" medication "treatment."
Study indicates teens whose parents have history of depression may themselves be at high risk.
The New York Times (6/3, Rabin) reports that "depression often strikes during adolescence, and teenagers whose parents have a history of depression are at particularly high risk. Now," a study published June 3 in the Journal of the American Medical Association "has found that a group cognitive behavioral program that teaches coping and problem-solving skills to these high-risk teens can reduce their risk of developing the mood disorder." Notably, "the success rate of the prevention program varied greatly, depending on the mental health status of the teenagers' parents at the time they began intervention." Specifically, "the program was much more effective than standard care if the teens' parents were also without depression when the intervention began."
Focusing on the study's methodology, USA Today (6/3, Szabo) explains that researchers from Vanderbilt University "focused on" 316 "high-risk teens whose parents had a history of depression. All...of the teens already had experienced depression in the past or had some symptoms of depression when the study began." Half of them "were randomly assigned to attend eight weekly group sessions with other teenagers. After nine months," those "who attended group therapy were less likely to have had an episode of depression than teens who had their usual care, but didn't receive therapy." However, the "prevention program didn't help at all...for teens whose parents were currently depressed."
In the Wall Street Journal (6/2) Health Blog, Shirley S. Wang observed that the study authors theorized that "having a currently depressed parent could mean that the teen had more stress to deal with, or the parent was less responsive to the teens' new skills."
HealthDay (6/2, Mozes) quoted study author Judy Garber, PhD, "director of the developmental psychopathology research training program at Vanderbilt University," as saying, "The bottom line is that depression in adolescents can be prevented among kids who are at risk." She added, "But this finding is consistent with other studies that have found that children who are in treatment for depression do not do as well if their parents are currently depressed." She also "described the findings as 'interesting' and 'important,' in that they offer further confirmation that children of actively depressed parents are themselves at risk and should be monitored." She stated, "The message to parents is pay attention to how their children are doing if they're depressed." For "public health policy makers," however, she said that "the message is that it would be good to pay attention to prevention programs."
According to WebMD (6/2, Boyles), "cognitive behavioral therapy (CBT) has been shown to be an effective treatment for depression in teens, either alone or in combination with antidepressant" medications. For example, "in a 2007 study, the combination of CBT and a selective serotonin reuptake inhibitor...which is a class of antidepressant medication, was found to be more effective for treating major depression than either treatment alone." And, in a study "reported in February, the combination of CBT and an antidepressant was more effective than" medication "therapy alone in the treatment of teens who had not responded to initial" medication "treatment."
Thursday, May 28, 2009
Texting taking toll on teenager's anxiety levels
Watching drivers texting while in traffic and complaints from college professors about inattentive students, I found this article of interest.
I love technology, but it does come at a price.
CLICK HERE TO GO TO ARTICLEI love technology, but it does come at a price.
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