Reflection on Depression

Senseless suffering from childhood mental illness

CNN published a great article on childhood OCD this week.  One reader left a heartbreaking confession in the comment section:

"I had this [OCD] when I was little, too. I'll never understand why an "all-loving" god would put a defenseless child through this inescapable hell. I still deal with OCD to this day, albeit not in physical displays. There's absolutely no excuse for suffering like this.  Just further proof that we're all alone in this Universe."

I thought exactly the same thing when I was 15 -- and I still wonder why a benevolent God would permit this kind of suffering. Children have an innate sense of fairness that condemns undeserved pain. In light of the "inescapable hell" that the commenter (and countless other defenseless children) experienced, his conclusion that we're alone in the universe is intuitive and understandable.

I tried to address the problem of evil in this post and this one, but I don't have an answer.

New challenge!

After a nice break and a chance to reflect, I've decided to reduce my posting frequency while I train for a half marathon. I enjoy writing and talking with many of you about mental health issues, but my writing time is becoming running time.

I'm running to raise money for the Brain and Behavior Research Foundation.  I've been going to a personal trainer these past nine months so I'm ready for a challenge! Once in awhile I'll post updates about training and a link to my donation page. 

Ciao for now,

Nina

Be Back Soon!

I'm taking a little time off -- I'll be back in two weeks or so.

I've loved blogging for the past year and a half, but I need time to clear my mind, think about new projects, and decide where I want to take my interest in mental health advocacy.

I also want more time to have fun; time to go ice-skating in San Jose; time to swim in the heated pool downstairs; time to watch Stanford cream Duke; time to read on my Kindle; time to visit family.

I don't want this blog to feel like an obligation. I don't want to ever want get burned out from being a mental health advocate. It's an important issue, and I'm in it for the long haul.

I wish there were more people to step up and fill the silence--more voices calling for better understanding and better treatment. Perhaps, if more people spoke out--if there weren't a void where there should be activism--I would feel less obligated to write.

If you'd like to guest post while I'm gone please let me know.

UNC's Center for Women's Mood Disorders and Kendra Wilkinson 2 Years Post-PPD

I'm getting back into the groove after being back on the East Coast for a few days, so I'll just point out two awesome news stories: 

The first is the creation of UNC's Center for Women's Mood Disorders (bonus -- UNC is my college alma mater).  It includes the first freestanding inpatient perinatal psychiatry unit in the country.  The unit is specially designed for new mothers, with things like rocking chairs, breast pumps, and extended visiting hours so that moms and babies can maintain a close bond even while a mother is hospitalized.

On a related note, I also read that Kendra Wilkinson is doing well two years after her bout with postpartum depression and is raising awareness for other women struck by the disorder.  See here for an article about her recovery. 

Sick but so skinny!

This article made me laugh -- the author lost weight during a flare up of lupus and ended up getting a lot of compliments from envious friends.

She says:

"I was a walking skeleton and eventually wound up in a wheelchair . . . [b]ut the crazy thing was people thought I looked great because I was so thin. They'd ask if I was working out and I didn't have one muscle. You could see every bone protruding out of my shoulders, my elbows, my wrists."

"[P]eople suffering from broken jaws, gastrointestinal woes — even cancer — have all had friends and strangers alike brush off their suffering in order to rejoice in their 'fabulous' weight loss," the article adds.

I remember feeling uneasy about getting compliments for my weight loss when depressed. Not only did it feel like the person who complimented me missed what was important (I was in an awful state that involved a combination of appetite loss, weakness, immobility, and vomiting), but the "compliment" drew attention to the noticeable (and now undeniable) impact of the illness on my life.

The depression diet was not worth it. As much as I liked fitting into a size 0-2 instead of a size 4-6, I resented the weight loss for distracting people from the underlying problem. I sure wouldn't voluntarily go through that much pain just to fit into my skinny jeans.

Antidepressant drug trials: One reason the research isn't reliable

My impression from following open clinical trials (in order to participate) is that the bulk of antidepressant research is conducted on outpatient subjects -- people who can drag themselves to a research facility, sign up for a study, go through an intake process, and risk a 50% chance of placebo. Because few severely depressed patients can do all of that, I suspect that severe depression is underrepresented in the subject pools. No wonder, then, that the trials show low efficacy; it's well known that the drugs work best (or only work) in cases of severe depression.

The last time I was acutely depressed I called my doctor the day after Christmas to schedule an emergency appointment (it took everything I had not to call her on Christmas). If I hadn't been able to see her I would have gone to the nearest ER. There is no way that I would have had the wherewithal, the ability, or the spectacularly bad judgment to participate in a study instead of seeking immediate treatment.

Severe depression is also underrepresented in pools of research subjects because there are ethical proscriptions against allowing obviously suicidal patients to participate in studies. Those patients are referred to a hospital instead. In other words, patients have to be reasonably well in order to participate. Moreover, patients with delusions or hallucinations are often disqualified from participating in research on depression unless the study is looking specifically at psychotic depression. 

These limitations may explain why antidepressant medications show more clinical benefit than the research predicts. After all, in real-life practice doctors treat patients from across the severity spectrum, whether or not they would qualify for a drug trial.

A national paper publishes the OTHER side of the antidepressant debate

Last weekend an article titled "In Defense of Antidepressants" appeared in the New York Times.

It's refreshing to finally see a newspaper provide balanced coverage of the antidepressant debate!

The author, a psychiatrist at Brown University, examines the controversial study I discussed in my last post -- a study that many news organizations sensationalized and oversimplified earlier this year. He also describes the limitations of antidepressant research generally, including the inclusion of non-depressed patients in studies, the conflation of different types of depression, and the danger of ascribing too much authority to single trials. 

Are antidepressants better than placebo? A podcast from Stanford Medical School

Below is a link to a Stanford Medical School podcast of an interview with Robert DeRubeis, the lead investigator of a meta-analysis which revealed that antidepressants are no better than placebo in many cases of mild, moderate, and even severe depression (essentially, in all but the most severe cases of depression). DeRubeis discusses media coverage of the study, the reactions of primary care physicians, and his interpretation of the study's results.

See here for the podcast. 

The results of the study align with my own anecdotal experience. During my most acute depressions--those times when I truly felt like I was losing my mind--the illness responded rapidly and robustly to medication. (These are the two episodes when my HAM-D score was over 30). However, the drugs have done little to treat my milder, residual depression (even if they are still important as a maintenance measure to stave off relapse).

I'm glad that someone is parsing our coarse classification of depression into more exacting categories and examining the effectiveness of medications for those different tranches of the disorder. Experience and common sense suggest that the disorder is heterogeneous and that treatments need to progress beyond a "one size fits all" approach. Patients should be channeling resources to the most effective evidence-based therapies first, not prolonging their pain and wasting resources by starting with unsupported treatments.

I wasn't surprised by the study but I disliked much of its media coverage. (The pic above is from an egregiously irresponsible Newsweek article:  Why Antidepressants are No Better Than Placebo). As DeRubeis points out--and as many media outlets failed to mention (or bury as a caveat several paragraphs in)--a mountain of evidence indicates that antidepressants are effective at treating the most severe depressions. His study, however, examined treatment of a wide range of severities.

Antidepressants and mood stabilizers had an enormous effect on my worst episodes and probably saved my life. That doesn't mean they are the right solution for many (even most) patients. 

YouTube clip of a teenage girl in the midst of a depressive episode

Here's a link to an extremely salient clip of a teenager struggling with severe depression.  The 8 minute clip is an entry from her video diary. From what I can tell she's at a residential treatment program for eating disorders. Most of the clip, however, is about her struggle with severe depression. The clip brought tears to my eyes because it reminds me so much myself when I was 16 (she even looks like me when was 16!).

Her pain is palpable. She hates every part of herself. When her therapist asks if she can appreciate any part of herself (even just her heart for beating), she says that she can't.  She hates her heart for beating and wishes it would stop. 

I wish every parent with a child suffering from depression could see this video. Thanks to her honesty they can see what their child might be thinking.

Toward the end of the clip she also talks about getting caught for shoplifting on the day of the video. Again, I'm amazed (and impressed) that she's so honest. She seems like such a sweet girl that I was surprised she had just committed a crime, but it demonstrates that depression sometimes manifests as self-destructive behavior problems. 

In later videos she also describes having a heart attack (and she's only in her early twenties) -- a reminder that mental illness, especially eating disorders, can cause permanent damage at a very young age.

I wish I had the courage to be as open as she was when I was 16. As painful as her account of depression is to watch, her honesty means she probably got help a lot faster than I did.

The great thing is that she has recovered. She's posted a number of videos over several years in which she gets progressively healthier. In the latest videos she seems happy and confident, and is leading an eating disorder recovery group.

 

Depression and Weight Changes

Most symptoms of depression are hidden (which is both a blessing and a curse).  Weight changes, however, are public and embarrassing. People notice. They make you self-conscious.

The first two pics below are still hard for me to look at because they remind me of what a bad time I was going through. Still, they are worth sharing so that folks know these physical changes are a normal part of the illness.

 

This was taken around Christmas 2007--not long after I had descended into the worst depths of that last major depression.  My appetite was non-existent and my bones are starting to show. My smile here is deceptive -- I'm amazed at how normal I looked despite feeling so bad. 10 mins after this pic I was wallowing in bed, and was unable to stand up for more than a few minutes the rest of the day.

 

This was me later that spring, after losing even more weight. Not flattering. It would look even worse without the massively padded push-up bra giving me some curves.  

 

 

Whoops . . . . those medications sure helped but they made me gain back a little too much weight. (Notice how much weight my uncle has lost since the first picture!)

 

This pic was taken the summer I was studying for the bar exam. By then I had recovered physically (although I was still struggling with mood issues and intrusive thoughts). Still, not a bad pic for someone in the library 12 hours a day and not working out (ok -- I totally should have been working out, but instead I was wigging out like a lot of other bar takers. . . thank goodness it all turned out ok and I passed). 

 

Ahhh . .  back to a healthy weight.  Crashing an SLS party with a fellow alum.