Reflection on Depression

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Last week's suicide of former Chicago Bears safety Dave Duerson indicates he may have suffered from a depression associated with chronic traumatic encephalopathy (CTE)--a type of brain injury caused by repeated blows to the head.  Researchers are beginning to take note that the neurological effects of CTE have plagued a number of NFL players. Before shooting himself in the chest (protecting his brain for research), Duerson texted friends and family asking them to donate his brain to CTE research.  See here for coverage from CNN.

Preventing Suicide: The Facebook Help Center

Suicide is an admittedly somber topic to start off the work week (I promise to be more uplifting later this week if you keep reading), but this blog is designed to address any and all issues regarding mental illness, however unpleasant. No sugar coating. No denial. No avoidance.

Last week the friends of a British woman who posted suicidal content on Facebook mocked the facebook suicide note that she left and failed to call police in response to her post. As a result, she died. The incident reminded me about the Florida teenager who streamed his suicide live via webcam in 2008 while 1500 people watched. It was 12 hours before anyone called for help.

For those who have trouble understanding suicide--who understandably feel betrayed in the wake of what seems like a selfish act of abandonment--there is a beautiful column in Salon today by a woman who couldn't comprehend her mother's reasons for committing suicide until, decades later, she experienced her own devastating depression. It's the interesting perspective of someone who has experienced anger in the aftermath of a loved one's suicide, and, later, understanding in the wake of her own attempt.

Anyway, I just learned about the Facebook Help Center. It's a place where you can report suicidal content you may see on the site (please also reach out to the person yourself and/or call someone who can get to them). Once notified, Facebook will report the content to a national suicide crisis center that will step in and try to reach out to the person.

On a related note, I know I've neglected to write about the nationally publicized suicides of several LGBT teens recently. I need to get to that . . . . I sometimes find myself avoiding writing about tragic current events, especially when they involve children, because it's really tough to think about them long enough to compose a post without getting pretty sad. 

The issue of child and teenage bullying also makes me feel helpless, because I don't know what the answer is. I feel like I don't have expertise in the area because I was never bullied in school. I can't imagine what some of these kids have to go through, and I don't know what to say it make it better.

How to save a friend from the brink

Simple, common sense advice that really helps.  See CNN's "how to save a friend from the brink".  Even I sometimes have a hard time knowing what to do when a friend is depressed, so this is useful.

An inspiring story of how one soldier saved a friend from suicide

The Army can finally point to a concrete win in its battle against suicide. Read how a solider in Iraq saved a friend's life.  

Army Spc. Albert Godding received a medal this April for preventing the suicide of his friend, Spc. Joseph Sanders, while both were deployed in Iraq in 2008. Sanders was depressed over the breakup of his marriage, and confided to Godding that he was thinking about suicide. Worried that he might try to shoot himself, Godding removed the firing pin from Sanders' rifle. The next morning, when Sanders pulled the trigger, nothing happened.

The army's suicide prevention training seems to be working. Godding credits it with preparing him to save his friend's life. In this case, the army also did a good job providing follow up mental health services. After his suicide attempt Sanders was taken to a combat stress center where he was able to meet with a mental health professional while he recovered. Both Godding and Sanders are now participating in the Army's upcoming suicide-prevention video. 

Identifying adverse reactions to SSRIs -- new scientific breakthrough

Researchers have made a breakthrough in identifying which patients will experience suicidal thoughts as a side-effect of SSRIs. They've discovered that imaging reveals telling patterns of brain activity in these patients. This could be a BIG step in making antidepressants safer.

SSRIs are widely prescribed because of their relative safety over older antidepressants. However, a small subset of patients (between 5 and 14%) experience an increase in suicidal thoughts while taking them. Now, researchers report that QEEG imaging reveals a distinct pattern of brain activity in patients who experience this side effect. Apparently, certain regions of the brain display a sharp decrease in activity during the first 48 hours that patients who will experience the side effect are taking an SSRI.

A method of identifying patients who are experiencing (or will experience) an adverse reaction to antidepressants is critical--especially in the case of children and adolescents who are at a heightened risk for this reaction. As I've discussed previously, early-onset depression should be treated aggressively because of its potentially serious developmental consequences. This means that parents should remain open to the idea of treating their children with medication.

After black box warnings were added to antidepressants in 2004, the number of parents forgoing medication for their children increased significantly. Following the warnings, the teen suicide rate spiked by 20%, possibly because too many doctors and parents were scared off. Now there's hope that we can have the best of both worlds--adequate disclosure of the risks as well as the ability to try the antidepressants in children and quickly terminate the treatment if it's causing an adverse reaction. Hopefully this research can be transferred to a clinical application soon!

Brain imaging to identify suicidal thoughts in patients taking SSRIs

Irrational Guilt and Intrusive Thoughts

Two years ago during my last episode of severe depression I became consumed with guilt. To assess just how bad I was, I mentally tallied every good or bad thing I could remember doing in my life; when I couldn't hold the score in mind any longer I made a table that listed as many of my "good" and "bad" actions as I could remember. Every day I made new additions; given my mental state at the time it's not hard to guess which column they were in. 

Last night I ran across this old table. Among the "bad" things on the list were many misjudgments, misunderstandings, and actions taken out of desperation when life simply got too hard to handle with grace. With fresh eyes these transgressions no longer seemed as malevolent or as pathetic, as they once did. They seemed human. And some just seemed ridiculous. Not walking the dog every day when I was in middle school was on my list. PETA might disagree, but I'm now amazed that remorse over my treatment of a dog ever drove me toward suicidal self-loathing. 

True, there were more substantial transgressions on the list that might--and should--induce guilt. But depression is guilt that is out of proportion with action. For each of the actions I had listed my guilt was out-of-proportion, my actions seemingly unforgivable. 

I still suffer from too much guilt (although the part of me that's sick says I should suffer from more guilt). And when the guilt is paralyzing I feel guilty for not being able to do much. Any thoughts on overcoming guilt/self-loathing? 

Tales of the weird - bizarre symptoms of depression and anxiety

Last week, a friend of mine who is a third year medical student recounted a particularly interesting case to me. A patient presented with suicidal thoughts at the hospital, which is not entirely unusual. But a blood test revealed that his kidney function was also dangerously abnormal. Two unrelated problems, right? 

Wrong. The patient revealed that he drank 12-15 "cups" of water a day. When my friend asked him how big his cups were, the patient pointed to a large, 1 liter water bottle he was carrying. This man had been drinking 12-15 liters of water a day! 

Why? The doctors believe he had developed an almost compulsive habit of drinking water to quell his pathological anxiety. The huge amount of water had altered his kidney function, and was most likely contributing to a severe vitamin B-12 deficiency, which can cause depression. My friend pointed out that a lot of depressed and anxious patients abuse substances, and water seemed like a better alternative than some. But in this case the patient's compulsion was so out of control it had endangered his life and contributed to a feedback cycle of depression, anxiety, and self-soothing but self-harming behavior. 

The patient was admitted to the hospital where his liquid intake was restricted and he was given vitamin supplements. Hopefully he can get his mind/body problem under control. 

The mind/body connection never ceases to amaze me. Most people who have suffered from depression or anxiety know that these disorders are just as much physical as mental, but rarely is the connection so clear. 

(photo by Creative Tools AB, on Flickr's Creative Commons)

Talking to a depressed friend

I live in Silicon Valley where many folks are transplants from around the world. I'm nearly 3,000 miles from my family on the east coast. Given that so many people live far from their immediate and extended families, friends are becoming an even more important weapon in fighting mental illness. It's often the people who see you the most--on a daily or weekly basis--that can spot those changes that signal trouble. In legal scholar Ellen Sacks' memoir "The Center Cannot Hold" she describes how it was one of her Yale Law School professors who, during office hours, first recognized her psychosis and took her to an emergency room.

The trouble is, many people don't know when to speak up or what to say if they do. Others feel like it's none of their business. Checking in on a friend or acquaintance who seems to be struggling can be lifesaving, though (remember, depressed people are often bad at maintaining relationships, so even if you don't consider them part of your inner circle you should speak up. They may not have an inner circle). Just the act of expressing concern may be enough to sustain them. And if you don't know what to say, don't worry -- no one does. In this case it's truly the effort that counts. All you may be able to say is "I don't understand how you feel, but I know you're in pain." That's ok. It's knowing that someone can sit with you in your pain that makes a depressed person feel more human and more connected. The following article from today's CNN Health provides some useful advice on talking to a depressed friend.

How to Save a Friend from the Brink  

Sometimes speaking up may feel intrusive or patronizing, so it's a judgment call. People will not always be receptive. But, for the most part, I think people are not offended by genuine and well-meaning concern. And the results from not speaking up are far worse than the awkwardness of saying too much. 

I cannot even begin to describe how grateful I am for those people in my life who sit with me in my pain, tolerant of my inability to carry on a normal conversation or normal activities. I know I can't be fun to be with at those times, but their concern sustains me and makes me feel like I am loved, even at my worst.