Reflection on Depression

The long-term effects of childhood mental illness

I've advocated before that parents and doctors take childhood mental illness seriously. The developmental stakes are high, and an untreated mental or emotional illness can affect a child's academic, social, and emotional development for years to come. Also, an early age of onset is often a sign that a case is especially severe, warranting aggressive treatment to reduce the child's suffering. 

Prompt and effective treatment can also prevent or minimize the trauma of severe mental illness. The initial onset of mental illness can be so painful, so frightening, and so damaging to a child or adolescent's understanding of themselves that it leaves indelible scars. In my case, many of the most insidious effects of depression did not result from the illness itself, but arose from the long-lasting effects of that unresolved trauma. 

This article describes the results of a study that examined how children with mental illness fare later in life. Overall, they are less financially stable and less likely to form long-lasting relationships. I can relate, as my own illness has made work and school difficult at times, and was probably the biggest contributing factor to a major romantic breakup.

Of course, treating childhood mental illness is tricky because it's sometimes difficult to differentiate normal childhood behavior issues from the initial phases of mental illness. But by taking the possibility of mental illness seriously parents can get an expert evaluation early on to help tell the difference.

Dr. Owen Wolkowitz on depression

This talk by Dr. Owen Wolkowitz at UCSF is one of the best talks on the science of depression that I've ever seen.  Even though it is targeted to a general audience it gets across a lot hard science, including some of the newest research on epigenetics. Very interesting and worth a watch!

Dr. Wolkowitz on the biology of depression

 

Howie Mandel comments on Charlie Sheen

Last night I saw Piers Morgan interview Howie Mandel on CNN.  Mandel described his OCD as "torture" and explained that he doesn't consider it a laughing matter, even though the popular media makes OCD jokes at his expense. Voicing concern over the entertainment value the media has found in Charlie Sheen's breakdown, he noted that addiction and mania are serious mental illnesses like OCD and should be treated accordingly.   

Madel's story inspires me. Living with irrational thoughts (whether manic, paranoid, depressive, or germ-phobic) is not an easy road to hoe, but he copes. His approach to OCD reminds of Montel Williams' approach to MS. Although Williams admits he is in nearly constant pain, especially in his legs, he doesn't let the pain overshadow all else. He embraces the imperfection that comes with chronic illness, putting illness in its place and preventing it from taking over his life.

Is Charlie Sheen acting manic, or just acting?

Charlie Sheen's recent shenanigans have eclipsed, in sheer eccentricity, other celebrities' outrageous antics--even Tom Cruise's overzealous couch jumping and Mel Gibson's disturbing public tirades again Jewish people and women. In the words of Shrek, The Musical, Cruise and Gibson let their freak flags fly. Sheen, on the other hand, may think he can fly.

Whether it's real or contrived, Sheen's fall from grace is a good example of what mania can look like. His statements border on the bizarre (he has "Adonis DNA" and "can cure addiction with his mind"), his speech is pressured, and he connects words that sound alike but don't mean the same thing (speaking of his studio execs he noted "They continue to be in breach, like so many whales."). Most tellingly, he has a preoccupation with "winning"--a grandiose idea that is unsupported by the evidence (which, by all measures, indicates that he is losing everything). 

I find it interesting that his thoughts (to the extent they are reflected in his public statements) are the mirror image of the thoughts I had in the most extreme depths of my depression. Like Sheen, my thoughts were rooted more in irrational emotion than reality. I felt things so strongly that my mind began to fabricate reasons why those feelings were justified. I was convinced I was a horrible person--worse and more pathetic than even a serial killer or child abuser--despite having done nothing that would rank among those horrific wrongs. Sheen, on the other hand, has an obsessive and unsupported focus on his greatness.  

I was never floridly psychotic. Nor, it appears, is Sheen. When pressed, I conceded that my thoughts didn't conform to the evidence; that the things I thought weren't (or at least probably weren't) true. But they still felt so real. If Sheen is experiencing hypomania (short of full blown mania) he may have the same tenuous grip on reality--an intellectual understanding that what he is saying is not reflective of his situation, but the perception that is it.

If manic, Sheen's mental state could either deteriorate into psychosis or flip into suicidal depression and self-medication; or we could find out that this whole episode has been a hoax, a la Joaquin Phoenix. Regardless of what happens, his behavior is an instructive presentation of mania that has familiarized the public with symptoms that people now may recognize in friends or family. Hopefully it has also acquainted us with the importance of getting treatment.

What happened?

Last week, police shot and killed a mentally ill man in San Mateo (a few miles from Palo Alto, where I live). Click here for the story. 

Robert Caron, 35, apparently threatened CVS employees when he was unable to pick up his medication (Caron reportedly had schizophrenia but it's unclear what the medication was for). He then returned to his house and, according to a neighbor, was brandishing a weapon in his backyard when police surrounded the property. A police negotiator tried to engage him but Caron was killed by police fire after he discharged his own gun.

Several questions immediately come to mind:  Why couldn't Caron get his medication? Did Caron suffer from paranoia, believing that the police were going to harm him? Did the officers and negotiator respond appropriately knowing that Caron was schizophrenic (police were familiar with him because of several previous runs ins)? Why did he have a gun? Could his family have done more to prevent him from having weapons?

Too often police treat the mentally ill like criminals when their only "crime" is being sick.  I don't want to speculate about Caron's motives--we don't know if his illness contributed to the shooting or not--it's possible he was thinking and acting just as intentionally as any other criminal when he fired his gun. However, if Caron was persuaded by paranoid delusions that the police were out to harm him or his family then his actions, in light of those delusions, were arguably rational (or at least understandable). Should the police have considered this possibility when responding? Should they have refrained from surrounding his house with lights and sirens knowing it might feed the delusions, exacerbating an already precarious situation?

We may never know Caron's state of mind when he fired his gun, but his case highlights the challenge of responding appropriately to mentally ill offenders. 

Treat smarter, not harder

Last week I read about a couple who lost their daughter to suicide after she "stuck with a single therapeutic mode and her prescribed medications even though the combination seemed to just make her worse". Her conscientious adherence to a single therapeutic regime even when it wasn't working reminded me of the importance of changing or supplementing treatments when one isn't working.

In my experience, patients are too hesitant to change treatments mid-course if progress stalls. There's a misconception that recovery requires holding fast to any treatment prescribed, and it's exacerbated by the tendency of psychiatric patients to blame themselves for not getting better because they aren't "trying" hard enough. 

Effective treatment does require time, patience, and persistence (often, effects aren't seen for a couple of weeks), but sticking with an ineffective treatment indefinitely diverts resources from alternatives that may work better. In my case, I stuck with (and my parents paid for) a vitamin and nutrition program long past the point at which more serious medical intervention was necessary.

Also, you may hit upon a good therapy but at the wrong time. That was the case when I first tried cognitive behavior therapy (CBT). I was so depressed--and my brain was so out of whack--that I couldn't even begin to pull out of the depression without biological intervention. Trying CBT before medication was discouraging. It made me feel like I was "failing" at therapy, and my lack of progress made me worried that I would never get better, regardless of treatment.

Finally, some treatments can exacerbate depression. SSRI medications that induce suicidal thoughts in a small percentage of patients are the most obvious example. When this is the case, diligence can be deadly. It sounds like common sense, but if your treatment is making you worse, you should STOP that treatment. Every brain is different. Don't assume that a medication is right for you just because you know another patient who experienced its benefits.  

It's true that certain treatments are supposed to be uncomfortable. The standard treatment for phobias, "exposure therapy," is a perfect example of a treatment that involves purposely leaving your comfort zone. Moreover, opening up to a therapist or adjusting to some medications may be difficult at first. However, if the treatment is ineffective, then you need to take action. An unwavering commitment to getting well is necessary, not an unwavering commitment to one treatment modality, one doctor, or one therapist. 

Most important, do NOT let failure at one mode of treatment convince you that you won't get better. Sometimes people who don't response AT ALL to medications respond well to therapy, and vice versa. Also, researchers are developing new therapies every day. Deep brain stimulation, transcranial magnetic stimulation, and vagus nerve stimulation, are all examples. The odds are on your side--most people eventually find a treatment that works.