A Challenge . . .

I have long searched for new and different ways to settle my mind down and to remain centered and grounded.  In my work with people who are decidedly NOT grounded, it is imperative that I maintain my focus.  This is important not only for the welfare of my patients but also for my ongoing mental welfare as well.  But long before I was a shrink, I was a seeker of knowledge.  One who was always on the prowl for titbits of knowledge and wisdom.  Some I found through my practice of standard religion, but I have also been open to wisdom from other sources as well . . . the tao te ching . . . A Course In Miracles . . . Castaneda . . . Chopra . . . wherever I can find it.  Putting this knowledge into practice is another issue, tho’.  The many things I want to accomplish each day vie for my attention and, if I am not very careful, meditative time for myself is left to last . . . and then does not get done.  For me, meditative practice MUST occur before the start of the day.  If not . . . won’t happen.   I was recently sent an email from a site my wife turned me onto called the Urban Monk (www.urbanmonk.net).  It was another case of “right place/right time” and I have found it very helpful.  It, combined with some other recent influences, led me to this particular entry which has at it’s core a list of affirmations that I found very inspiring.   I have recently been encouraging my family members to slow down and to do some regular meditating.  I intend to give this particular entry to them and encourage them to follow through with this.  At the bottom of this entry, I have added relevant links to the Urban Monk and to a set of CDs put out by Jon Kabat-Zinn that I think are the best for teaching meditative practices.  I encourage all to slow down . . . and keep exploring and keep learning.

TRY THIS . . .

Sit in a comfortable position.  Either on a chair or on the floor.  There are no rules here, just be comfortable.  Sometimes a little bit of stretching beforehand can help you feel more at ease and relaxed.  Once you have found a position that is comfortable, do the following simple breathing exercise . . .

     1.     Close your eyes and begin to pay attention to your breathing.  

     2.     When you are ready, start counting your breaths.  With every breath in . . . one . . . out . . . two . . . out.  

     3.     With every count in, allow yourself to feel more relaxed and peaceful.

     4.     Count up to 50 breaths.  When you find you have wandered in your thoughts (and you will . . . expect it), start back at the number you can last remember.  It doesn’t matter if you are wrong.  There is no test and no right and wrong with this.

     5.     When you get up to 50 breaths, open your eyes and read the following affirmations either aloud or quietly to yourself.  Whichever is most comfortable for you.

 

AFFIRMATIONS:

I make the conscious choice to be free, and to hold my freedom as a priority, not to be compromised.

I take full responsibility for my happiness and know that it is never dependent on anyone or anything outside of myself.

I prefer my essential and intrinsic happiness to the temporary fulfillment of desires.

I value my inner peace more than I do winning, defending my identity, proving my point, or reactivly expressing momentary emotions.

I refuse to be reactive, and to let my emotions be controlled by others.

Anger does not guide my hand.  Fear does not inhibit my action.  Desires do not govern me.

Attachments do not bind me.

I do not engage in self defeating behavior.

I accept that which I cannot change.

I have no need to control or possess others.

I do not depend on others for validation or approval.

I allow others the freedom of being themselves, without judging them or attempting to change them.

I can forgive others because I understand that we all act according to our current level of consciousness and understanding.

I am complete in the present moment and therefore do not look to the future for fulfillment.

I am free to give love, without conditions or expectation.

I know that my identity is self defined and self imposed.

I see the impermanence of all things and so do not cling unnecessarily to them.

I realize that all perspectives are fragmentary and incomplete.

I allow others to be free by dropping all demands and expectations of them.

I learn from the past, but do not allow it to interfere with the present.

Though I cannot always control my thoughts, I can control which ones I pursue and give energy.

I understand the difference between what exists in thought and what exists in reality.

I see that if my thoughts have no correlative in physical reality that they are little different than imagination.

I know that all answers lie within and that they can only be obtained through experience.

I will help anyone that I can, knowing that ultmately the responsibility is theirs alone.

I realize that, when I become disturbed, that nothing is missing.  Instead, something has been added and is obscuring my inherent peace and stillness.  That my attention has deviated from the present moment.

I am a light unto myself.

 

BREATHE

     1.     When you have completed the affirmations, repeat the breathing exercise that you started with, counting again up to 50 breaths.

 

In completion . . .

I challenge all of you who read this (and myself as well) to do this every day for the next 30 days and see what difference it makes for you.   Write to me and let me know what you have witnessed in yourself.  As I mentioned above, I did not write the affirmations listed above and am just passing them along.  I encourage all of you to go to the source for this and read the entry on the Urban Monk entitled “A Light Unto Yourself/In Case Of Emergency”.  It was originally written by John J. Patton and is very good.  In addition, I have given a link to an excellent set of CDs by Jon Kabat-Zinn that teach meditation better than any book or CDs I have come across.  I am especially fond of the “series 2″ CDs and would encourage all to get those as well.

http://www.urbanmonk.net/777/a-light-unto-yourself/

http://www.mindfulnesstapes.com/

Have a peaceful and happy week.

–Dan Hartman, MD

Why Don’t I Get Better When All I Do Is Medicine?

I am not bipolar but am on 200 mg of Lamictal and 50 mg of Zoloft.  I have tried many meds and I never feel good.  I have read alot and done alot of research.  I have found that there is no proof of chemical imbalances or that these meds work better than a placebo.  Why don’t doctors try more natural solutions, and more talk therapy.  I would like to know your thoughts on this.  Thank you.

No . . . THANK YOU!!!  I don’t agree with all of what you say, but I agree with your underlying sentiments, that too often there is little done EXCEPT to throw medication at a problem.  As far as your initial assertion that there is no proof of “imbalances” in the brain, I disagree.  While direct measurement of neurotransmitters in brain tissue is not currently possible (I personally would NOT volunteer for that particular experiment), there is indirect evidence of neurotransmitter abnormalities.  Researchers do this by measuring the metabolites (the break-down products) of neurotransmitters in urine.  It is not an exact science and has not (and probably never will) reach the point of being a true test for depression.  But, if you gather a group of depressed patients and a group of non-depressed patients together and measure their urine metabolites, you can detect a statistical difference.  Not particularly helpful to me in the office, however.  PET-scans have been able to show a consistent reduction in the activity of parts of the brain, but this, too, has limited benefit.  Bottom line is, if you show up in my office with the clinical symptoms of depression . . . you are depressed.  Doesn’t take an Einstein to do this job.  

But what do you do next?

The standard of care is currently to go through an algorithm of medications.  An algorithm is a decision tree that helps you decide what you do next, given a set of circumstances.  You come in with depression and meet criteria, you get an antidepressant.  Usually an SSRI like Zoloft.  If that doesn’t work, then you get a trial of a different SSRI.  If that doesn’t work there is a next step . . . then a next step . . . then a next step . . . etc . . . etc.  Most people respond with the first antidepressant tried.  Some people, however, seem to not respond no matter what is tried.  Or, you get a partial response.  Some symptoms gone, others still in place.  It can be very frustrating for both patient and psychiatrist.  But the use of an algorithm is vitally important.  Without it, there is a randomness to the use of medicines that, in the long run, will not be beneficial to the patient.  It is important that each medicine tried be given in as high a dose as possible and given enough time to work before calling it a failed medication trial.  Too often I see patients who have had multiple brief medication trials with sub-therapeutic doses.  This can leave the patient with persistent symptoms and great frustration . . . and a hopelessness about their situation.  When they come into my office . . . I have to start all over again.  Doubly frustrating for them.  But even when the psychiatrist follows a coherent algorithm  and the patient is very cooperative, there can be residual symptoms of depression.

Thus, the importance of the second part of your comment . . . why more “natural” solutions and talk therapy are not tried enough.  I know of no psychiatrist who does not advocate non-medication management of symptoms of depression.  Getting people to follow through on these recommendations is another story altogether.  Use of therapy, exercise, nutritional supplements, meditation, spiritual practices, various cognitive strategies,  etc have all been found to be  beneficial.   But it requires WORK on the part of the patient . . . perhaps when they feel unmotivated and disinterested.  In the brief time I have with my patients I try to advocate for these practices, but patients rarely follow through.  But they are quick to come back to me and complain that the medicine is not working.  

Like all good things in life . . . a little work is often involved in the development of good mental health.  But it is something that must come from the inside and cannot be forced upon a person.  I am open to any ideas you might have to motivate positive behavior in my patients.

–Dan Hartman, MD

Driving Miss Daisy . . . aka watch what your doin’ with them meds!

So . . . I got in my car the other day and, much like every other day, put on my blindfold and sped off to work . . . 

“WHAT?????” you might be rightfully saying . . . “put on your blindfold and started driving?????” . . . “you CRAZY!!!”

Well, of COURSE I didn’t cover my eyes and start driving.  That would be foolish.  That would be dangerous.  I could hurt people . . . you have to see where you are going.  Have to be able to read the signs.  Steer clear of the pot-holes.  Know when to stop.  Know when to go.  And . . . especially important . . . when to realize you are going in the wrong direction.

I met with the parents of a young lady the other day.  I will call her Daisy.  Daisy has had a long history of low grade psychiatric issues that have worsened significantly over the last several months.  The parents are at wits end because of the escalation of her difficulties.  The piece of the story that bothers me the most is how she has floated in and out of several psychiatric hospitalizations and day program stints and has not gotten much better.  And she is, from their description, really, really ill.  The doctors have not been available and there has been a series of fairly rapid medication changes that leave her parents scratching their heads and wondering what is going on.  All this treatment, all this time, all these medications have had little positive impact on how well Daisy is doing.  In the short time I had with them, however, their story hung together and, even without speaking to the patient, I believe I have a fair idea of what is going on with her.  And I have concerns about how she is being medicated.

The details of her presentation and the details of her medication trials are not important here.  It is the process.  In this age of HIPAA and attempts to strictly protect a patients confidentiality, we sometimes miss opportunities to gather information that could, in some circumstances, save lives.  There is NO substitute for good history gathering. Without it, a physician is prescribing like he is playing darts.  And the consequences of this somewhat random application of psychoactive chemicals can be devastating.  Mental illness is much like rolling a boulder down a steep hill.  Once it gets rolling, it is hard to stop.  And getting the boulder back up on top can take a lot of time and effort.  It is imperative, therefore, that all efforts are employed to get accurate and complete information prior to the introduction of medications to a patient.  Once an accurate diagnosis is made, it is imperative that medications be given time to work.  Sometimes the medications are switched after only a day or two . . . as  if 48 hours constitutes an adequate trial of any medication.  We all know that it can take weeks to get benefit from some medicines.  Yet, it is not uncommon for patients to enter my practice from an inpatient hospitalization having had three or four “medication trials” in the space of a week.  This makes no sense (at best) and is potentially dangerous (at worst).   I HOPE that the doctors that do this are knowledgeable enough to know that this is not good clinical practice.  I can only imagine that they are under tremendous pressure to do something . . . ANYTHING . . . to justify continued treatment in the inpatient setting (authorization for inpatient stays are metered out a day at a time by the insurance company and the hospital must justify each day;  medication adjustment is one of the best justifiers for continued stay).  Taking a day or two to get information and plan treatment is not supported in the current health care environment.  Yet the failure to do this has, in this case, resulted in numerous additional inpatient days and partial-hospital days.  When Daisy does come out of the hospital, it is likely that she will need another partial hospital stay.  When she is done with that, she will likely need intensive outpatient treatment, as well as frequent visits with the psychiatrist.  I suspect that much of this could have been avoided with more time devoted to history-taking.  

Basic third-year medical student stuff.

How could we have let these most basic principles slip by us in the name of (supposed) fiscal responsibility?

–Dan Hartman, MD

Mother’s Day . . . yahoo . . .

I’m not answering questions today.  Just thought I’d ramble.  Here in the States, we are celebrating our mothers today with a Hallmark-inspired day known as Mother’s Day.  While it is a wonderful and delightful day for some of you, for most, it is a day filled with mixed emotions and pitfalls.  No person in this world (except, perhaps, our new president) is infused with more hope or expectation.  These expectations are easy to fulfill when the kids are young.  Parents, in general, are GODS to the young kids.  The bringer of all good things.  Even if you mess up big-time, the capacity for young children to forgive is quite extraordinary (and a good example for the rest of us).  As the kids get older however, they get increasingly critical of you and everything that you do.  They look for and pounce on inconsistencies and errors.  There is a certain glee that comes to an adolescent’s eye when they ‘catch’ mom in a contradiction.  When mom is less than available.  Less than prophetic.  Less than saintly.  As adolescents become more aware of themselves and their own difficulties in dealing with peers, responsibilities and expectations, it is far easier to look for a cause outside of themselves rather than taking an honest assessment, forgiving yourself, and moving forward.

If my life is a mess . . . it must be MOM’S FAULT!!!! 

“If only she was less annoying” . . . “if only she was smarter” . . . “if only she would leave me alone” . . . “if only she would trust me more” . . . 

For moms, it is a catch-22.  If you do those things that you know in your heart are best for your kid, there is a good chance that your gonna catch some heat for it.  In my experience (both in my house and in my practice), it has NOTHING to do with what is said.  I can give the same message to my teenagers and it will be viewed as supportive, helpful, reasonable, etc.  My wife says it and it is . . . nagging . . . not-understanding . . . unreasonable . . .

And I have GOOD kids.

Looking back on my own childhood growing up with two older brothers provides me with some insights and perspective.  Mom was a professional woman at a time when that was rare.  That just meant that she worked long hours (always brought home work to do) and still had to be a June Cleaver and make sure dinner was on the table, the house was clean, the laundry was done.  My dad didn’t lift a finger.  And we boys were unruly and difficult to train.  I learned from my oldest brother who approached my mom with a salt and vinegar attitude and was in a constant state of tension with her.  What I learned . . . was to run under the radar and be nicer.  To this day, I will still hear about how difficult mom was (although he will now admit how difficult he was as well).  My experience of mom was different.  To me (my perception), she was kind and reasonable.  I think it had to do with me being kind and reasonable to her.

Did I make sure that I showed her how much I cared on Mother’s Day.

No.

Not till I grew up.

I have watched my oldest daughter’s attitude change toward my wife as she has moved from the difficult and rebellious teen that she was (and MAN was she difficult) to being a wife and mother with all the stress that that brings.  She has a new found appreciation for my wife and calls her frequently to touch base and to get advice.  Not that she takes it, mind you . . . but she does call and ask.  It’s a start.  And even tho’ my brothers and I went through a long period where we did not keep in contact with mom very often, as we got older and had our own families, we were able to see her in a different light.  We were able to see that life is full of so many difficulties, so many difficult decisions to be made, that it is impossible to please young people with any regularity.  As we got older . . . and our kids got older . . . mom did become the valued matriarch.  We were able to give her the respect she so richly deserved.  When she passed away, I am sure she knew that she was respected, appreciated and loved.  But it took time.  Years.  My wife’s mother died when my wife was 19.  And the relationship that her mom had with all of the kids became frozen.  There was no chance to move forward.  To heal wounds and find that common ground.  My wife has been able to do this.  Despite her mother’s various difficulties and ailments (and from her description my mother-in-law was a difficult person in many ways), my wife has developed a good perspective and can forgive and love her mother.  Not all of the siblings have been able to do this.  Some are still very angry and negative.  

And for what purpose?

My best wishes go out to my wife and to all mothers out there.  You have a difficult job with great rewards in the end.  The road will be difficult and long.  Be patient with your kids . . . and patient with yourself.  Give yourself the extra dose of forgiveness and understanding that your kids may not be giving to you right now.  Know that success as a parent is not measured by perfection, but in doing a better job than your parents did for you.  Take the best that your parents had to offer you and pass it along.  Try not to pass along the mistakes.  And teach your kids to forgive.  To forgive you.  To forgive themselves.  To allow their “human-ness” not to get in the way of expressing love, thanks and appreciation.  Someday . . . they, too, will be old enough to have their own kids.  Someday . . . they will understand.

–Dan Hartman, MD

Hard on the Liver??? . . . Good for the mood???

My mother has cirrhosis of the liver and also severe depression. She is 70 yrs. old What would be the safest med for her to take??? She seems to be unable to live and manage her issues due to depression.

In general, depression in the elderly can be very difficult to treat.  As with children, they are very often NOT the masters of their environment as much as we “adults” are.  They are increasingly dependent on others for their needs and look forward to a future where that dependence grows.  They have a variety of aches and pains and, again, look forward to a future where that pattern of aches and pains tends to grow.  Add to that the growing number of peers/family/friends that have passed on along with a growing sense that your time is coming soon . . . lots of reasons to feel sad.  Sometimes, that normal stage of life sadness that must be addressed can move over into true clinical depression.  The criteria are the same as depression in the adult population, but the presentation can be a little different.  Too often, the presentation of the depression is chalked up to “grandma getting older . . .” .  This can include reductions in appetite, increase in sleep, worsening concentration, etc.  Older folks can truly look and act quite demented when, in fact, it is not related to an organic cognitive decline, but be part of the depressive syndrome.  Because of the overlap of depression with “normal aging”, dementia, medical illness, and side effects from medicine (an often missed cause of mood issues in older adults), it is imperative that you have your mother seen by a psychiatrist who is competent in the management of older adults.  There are some psychiatrists who specialize in the management of the geriatric population (there is a Board Certification that is now available), many general psychiatrists have extensive experience and good clinical skills and can do just fine.  As in the search for a psychiatrist for anyone, it often takes a bit of searching and probing to find the right fit.  If your parent is very dependent on you, you might even go in with them to the interview to make sure that all the information is given to the provider.

As far as medication for depression in the elderly, most of the SSRI’s are just fine.  Of that group, I tend to use Zoloft and Lexapro more often that the others.  Prozac is just so slowly metabolized, anyway, and in someone with a compromised liver, I would shy away from that.  Paxil and Prozac tend to have more drug-drug interactions than Zoloft and Lexapro.  Of the antidepressants in general, Cymbalta is the medicine to stay away from if you have compromised liver functioning.  Studies have shown significant delay in metabolizing this medicine effectively, making it more difficult to manage and it can possible be damaging to the liver if liver disease already exists.

–Dan Hartman, MD

Approaching the (possibly) Unapproachable Doctor

I am a 33 year old female diagnosed with major depression 7 years ago and ADD about 5 years ago. I’ve been on several Tricyclics, SSRIs, Cymbalta, Effexor, Wellbutrin, Tegretol, Abilify, Provigil, Klonapin, Synthoid(for slight underactive thyroid possibly contributing to depression),Yaz (for possible PMDD contributing to depression), and Concerta, plus more (many of these I’ve tried in combonations under my psychiatrist’s orders as well). I’ve never been on any MAOIs. I am currently taking 100 mg of Pristq, 50 mg of Vyvanse, and 100mg of Trazadone for sleep, as well as a multivitamin and a b-12 supplement. I was hospitalized in October 2008 as I’d decided that I wasn’t going to try and deal with my depression – I wasn’t going to live anymore. When I began taking Concerta about 5 years ago, it really seemed to help with both depression and ADD. However, it pooped out on me along with Cymbalta after awhile. For about two years now, I’ve been feeling emotionally numb along with depression and ADD. I no longer aspire about my future nor do I enjoy the things I use to. I’ve isolated myself from friends/family and any type of social functions, including church. I feel as though I’m slowly waisting away and my children suffer because of this. I read constantly about different medications and the effects (good or bad) they’ve had on others on your blog as well as other blogs. I’ve been doing research on the dexedrine lately and it seems that many individuals have had success with this drug for both ADD as well as depression. However, I can’t seem to encourage my psychiatrist to try it in my ‘cocktail’ to see if it will help. I’ve never abused or attempted to abuse any prescription or illegal drugs so I’m uncertain why my psychiatrist won’t try it as my depression is classified as atypical or treatment resistant at this point. He wants me to stay on this current ‘cocktail’ of meds until May 2009. If there are no changes, he’s going to refer me for ECT – which I’m not totally against because nothing else seems to be working. I’m just surprised he’d consider ECT prior to trying Dexedrine. I would never tell any professional how to do his/her work, but I should have some say so in my personal treatment options as long as they’re within good reason. What is the best way to approach my psychiatrist with my concerns without seeming as though I’m questioning his/her professional or knowledgable approach. Or worse, ruin any rapport we’ve established thus far? I thought your suggestion to the gentleman that adding a small dose of dexedrine to enhance his Vyvanse could be beneficial was interesting. I would like for my psychiatrist to consider this as I just want my passion for living, dreaming, exploring and loving back. Any advice you can give me will be greatly respected and appreciated. P.S. Have you prescribed the EMSAM patch? If so, what has been your patients’ overall experiences with it?

Sorry for the long comment above, but I thought it very clearly highlights a dilemma faced by many.  How do you contribute to your health care decisions without insulting your health care giver.  This is just as true in other branches of medicine as it is in Psychiatry.  People are more inclined, however, to hand over their back surgery to their orthopedic surgeon without a lot of questioning than they are to hand over the management of their mood to a shrink.  Not that your mood is any less complicated than your back is . . . but their is something so . . . personal . . . about your mood and emotions that people do not want to let go of the control of them.  And, in my humble opinion, you should NOT just hand the decision process over to anyone.  Part of getting better from this depression thing involves taking control over your life.  Not sitting around waiting for it to get better.  That includes having some control over the medication management of your illness.  

The entry above has multiple questions to it, but their are overriding themes.  Clearly, many medications have been tried with partial or incomplete response.  The order, combination, etc of meds is not highlighted, so that no conclusions can be drawn from the entry EXCEPT that you are with a psychiatrist who is willing to try different things and experiment.  That is good.  As annoying as the “wait till May” thing might be, it might be good clinical judgement.  Giving a medication regimen a chance to work is imperative, especially if you have failed multiple other trials.  That might be what he is doing here.  Is it time for ECT?  Not if you are willing to take an MAOI.  I have no experience with the EMSAM patch, mostly because my patients with treatment resistant depression have no interest in the MAOI diet (quite restrictive, but doable).  

I would also suggest that you be straight forward with your psychiatrist about this.  Praise him for his efforts and for the rapport that you have with him.  If you want ECT to be the LAST thing on the to-do list, tell him that.  There clearly are other options to be tried.  Either with his knowledge or without his knowledge, I think it is time to get a second opinion.(  (I personally love it when difficult cases go for second opinions–I don’t claim to have all the answers).  Find someone else in your area that does medication management (local hospitals or university centers are often a good place to look) and get an appointment to meet with them for one or two visits.  You may need to pay out of pocket for it but the insights into your illness might be worth the money, if only to know that your current psychiatrist is covering all the bases.  Make sure you take with you a COMPLETE chronological listing of the medications and combinations of medications you have taken over time.  If you are not sure of dates, you can often get that information from your pharmacy.

Good luck and HANG IN THERE.  Sometimes it takes a long time to find the right combinations of medicines and circumstances that make you feel better.  

–Dan Hartman, MD

Depression Not Getting Better, But Not Out Of Options

Over the past 2.5 years I have been on and off 7 different antidepressants (5 SSRIs, one SNRI) but my doctor has not been satisfied that the benefits outweigh the risks/side effects. He says he is out of drug options and is looking to my psychologist to help me. For about the past year and a half I have consistently struggled with a heightened sensitivity to trauma, TV news, movies, sudden noises (jumpy) that significantly limit my lifestyle. I recall after one antidepressant telling my doctor I now know what anxiety is. Could antidepressants cause these problems – longterm? I have been off the last antidepressant (Trazodone) for about a month.

You raise a number of interesting points with your letter.  Let’s jump to the last issue first . . . can antidepressants cause long-term anxiety issues?  As I have noted in other entries, one of the side effects of antidepressants can be heightened anxiety.  This is typically an early onset side effect caused, presumably, by the rapid increase in the amount of neurotransmitter present between nerve cells.  Remember, the “RI” in “SSRI” stands for “re-uptake inhibitor” . . . a blocking of the recycling channel nerve cells use.  When the recycling is blocked, levels of neurotransmitter between cells goes up.  This provides for the clinical benefit from the medicine, but can also lead to the side effects.  If the anxiety side effect is not too much and you can wait it out, it will often decrease over time.  This does not always happen tho, and sometimes, the anxiety is just too much.  Some people benefit from really, really low starting doses of a medicine that is titrated up very, very slowly.  This can allow your body to get used to it gradually over time.  It may take a longer time to get to the dose that is effective, but it can work.  Some people are just sensitive to the medicine.  

Can the anxiety that is “caused” by the medicine continue when the medicine is stopped?  Not likely.  Once the medicine is gone, the medicine is gone.  We are all changed by our life experience, however.  If you had a particularly traumatic experience from a medicine . . . or a car crash . . . or a soured relationship . . . it can hang with you.  Therapy is absolutely important through the process of treatment, and can help limit the progression of symptoms.  It is difficult (if not impossible) to know if significant anxiety symptoms might have come out over time anyway.  People with significant depression often develop significant anxiety at some point in the illness.  

So, where do you go from here????

I agree with the therapy.  Get yourself a good therapist.

I have no information about your SSRI trials.  Remember, a good trial consists of enough meds for long enough.  If you did not tolerate or were not prescribed medicine with these guidelines in place, then you must start all over (with someone new).  I have several concerns about your brief description of your medicine.  There is little reason to give trials of five SSRI’s.  Generally speaking, if one of my patients does not tolerate or benefit from two SSRI trials, I move on.  I am glad that you had an SNRI trial (again, no idea if it was a complete trial).  But, if that does not work, there is still a huge list of options available for your potential benefit.  That would include use of Wellbutrin to augment the SSRI or SNRI, use of mood stabilizers like Lithium or Abilify, addition of thyroid hormone, stimulants, Provigil, nutritional supplements . . . LOTS OF OPTIONS.  

My point is, don’t despair.  Get yourself a therapist that will work with you on addressing the behavioral and emotional experiences that you are having.  But get yourself in with a psychiatrist who will be thinking creatively (and systematically) with you.  It appears to me (from your brief description) that you have many options left and no reason to think pessimistically.

–Dan Hartman, MD

Stop Whining About Your Wife and Start Getting Your Life Back

I’m depressed and I’ve had to work really hard at even getting my wife to acknowledge my condition. It has got better but yesterday we went to visit my aunty and uncle in the country. he has had long-term depression like me and it just amazed me how open they were in their house about talking about it. She even asked my 2 teenage kids how they cope with their dad’s moodiness and they seemed openly relieved that someone enquired and allowed them to talk about their suffering too. It was so refreshing, my parents never talk about ‘it’ in front of me, anyway, and my wife was very quiet during the visit yesterday.
I wish I lived in a home like that but my wife is the stumbling block. If one of the kids had my condition, [which I fear one day they will], she’d be gleaning as much information as possible from books, internet, health professionals, etc. and be all over them. But for me, it’s like, f*** you, you’re an adult, fend for yourself.
I can really relate to the comment: ” If you are married, you married someone with a specific chemistry. And if that person has a problem, you promised to help them out. You are not allowed to be a miserable tyrant. If you don’t understand, don’t just complain and be negative. Follow through on your vows . . . for better or worse . . . get in there and help out . . . be active . . . be positive . . .” I could also add the advice: “Don’t just ignore it and pretend it’s going to go away.”
Recently I have been feeling better about things here as through my fairly constant badgering of her, things have got a bit better; occasionally she’ll turn off the TV and talk to me, so I’ve felt better about the improvement. But, after seeing my aunt and uncle yesterday I feel downright depressed today, it’s like we’re light years from where they’re at. I get a similar feeling when I go on those depression forums and you get people saying ” but my partner is sooo supportive, caring and helpful to me.” Hearing that just makes me want to slash my wrists.
I mean what do I frigging do? Split up, hurt the kids more and put myself under even more work and financial pressure or buckle down and accept that I’m only going to get a fraction of the support I deserve?

This is all too common of a situation.  The difficult part to accept here is that YOU cannot change HER.  YOU can only change YOU.  You can influence her.  But little else.

As an exercise, I want you to do something for me.  I want you to step outside of yourself and see yourself as others might see you.  Your wife.  Your kids.  Now, I know very little about how you are.  In your letter, you spoke more about others than about yourself.  I know you are moody and depressed, but I don’t know if you are irritable depressed or hide under the covers depressed or both.  So I am going to take some creative license here . . .

Within a family unit, we all do the best that we can most of the time (hopefully).  We all have needs, however, and we look to those we live with for help with our needs.  Whether it is emotional help such as talking/bonding or practical help such as doing the dishes, we all look to our house-mates for assistance.  If someone in the house is emotionally unable to participate in the giving of support, the others in the house must manage in other ways.  Sometimes it is TV.  Sometimes it is drugs or alcohol.  Sometimes it is relationships outside the home . . . which is fine for kids but not for a spouse.  A difficult dynamic can get set up where everyone develops their independent coping skills that soothe their individual pain, but does not lead the family unit together.  It can lead to everyone feeling very alone.  This is difficult for everyone, but it can feel particularly difficult for a family member who is feeling depressed.  You can feel alone, ignored, and guilty for “causing” problems for your family.  YOU might want to talk about it, but THEY might not.  They might feel that by talking about it, it ‘feeds into’ your depression.  They might also feel at a loss for how to help make you feel better.  They might be frustrated that you have not done more for yourself.  Again, conjecture based on limited information.

I think that the best way to address the issue of your depression within the family is to change how YOU are approaching the depression and the discussions about it.  From here on, no more discussions about how crappy you feel.  Save that for your psychiatrist and your therapist.  From here on, you will only discuss what you are DOING to feel better.  Notice I did not write “going to do”.  I wrote DOING.  From here on, you are going to make a commitment to a more active role in your mood and in the management of your depression.  Get yourself a notebook and each evening before you go to sleep you will write one thing that you are going to do to make yourself better.  It can be simple at first like taking your medicine.  Like talking to or visiting your shrink.  Make it attainable.  Next week . . . write down two things that you are going to do.  And then three.  And then four.  Each week adding an additional thing that you are going to do to make yourself better.  Don’t talk about your depression anymore.  And DON’T tell anyone you are doing this writing down thing until you have done it for a month and it is engrained as part of your new pattern of managing your life.  Then, share it with your family.  But the act of sharing should be an . . . “oh, THAT is what you are doing!!!” experience for them.  By the time a month is over, they should already notice how you are eating better, getting more exercise, reading positive books, meditating, listening to positive and inspiring CD’s, watching inspirational shows on TV and changing what you say and how you say it.  

The most important lesson you can teach your kids (who may be at risk for depression) is to actively manage their moods.  Sitting and whining about it (or complaining to others about it) does NOTHING for mood.  It is all about what you do and how you change the pattern of your thinking.  Once you are more active in the management of your mood, maybe your wife will want to talk to you about it.  She is probably tired of hearing you complain.  Instead, talk to her about the positive things you are doing.  Old habits die hard (notice already how you are reacting to my suggestions of change) so don’t expect her to drop all of her previous coping strategies and start engaging whole heartedly with you.  It will take time.  It may never happen (I do not know what she is like, really).  But DO NOT use her as an excuse to continue to be depressed and miserable.  If you need others to support you emotionally, get others that will support you emotionally (within the bounds of your marital commitment to her–you don’t need guilt on top of all of this depression stuff).  But get moving on feeling better for yourself.  Make your wife and your kids proud!

–Dan Hartman, MD

Measuring Success . . . “I think I’m a 5″

“So, Mrs. Kapsmanjacketter, on a scale of 1 to 10 with 10 being the most depressed you have ever been, how have you been feeling since our last visit . . . “

And so, yet another rapid fire med check begins in the land of managed care.  How many times have you, my devoted psychiatric public, been in the position where YOU have been the recipient of that question.  I cannot count the number of times I have said it.  It is close to mandatory at this point.  There is the expectation that the experience of our lives be reduced to a numerical format that allows for evaluation and comparison to our past experience, our future expectations and the moods of all of the other millions of people showing up for their med checks.  Our treatment is supposed to be problem focused, solution oriented, and results are expected to be framed in a way that is measurable.  And so, we ask the question.  You assign the number.  And somewhere, someone is happy . . . a “3 out of 10″ happy.  Or is that a “7 out of 10″ happy?  See the depress-o-meter goes from 1 to 10 but so does the happy-sappy-meter.  So you have to be vvvveeeeerrrryyyy careful as a clinician which meter you are using and so does the patient, cause sometimes I am using the depress-o-meter and the patient thinks they are using the happy-sappy-meter and I get an answer of “8″ and I think they are really depressed when they think they are really feeling very happy and then they get confused about why I am pushing their medication up when they are feeling very happy and I am writing about how their affect does not match their mood because no one who is an “8″ on the depress-o-meter should be smiling like they are a “2″ on the depress-o-meter and maybe they are hiding their true feelings and maybe they are actually psychotic or suicidal and are smiling because of other things going on in their head that they are not sharing with me and maybe they need to go to therapy TWICE a week even though their insurance company raised their co-pay to FIFTY DOLLARS and who can afford that sort of payment twice a week and getting that kind of advice is enough to sink your mood to a “4″ on the happy-sappy meter (or is that a “4″ on the depress-o-meter ) . . .

Whoever said it was easy being a shrink???

Point is . . . who the hell is ever a “10″??? 

I meant a happy “10″ . . . like a “10″ on the happy-sappy meter.

There is such a grand and varied range of human emotion.  The last several months have certainly reminded me of that.  But the experience of a happy “10″ is far from the typical.  I can look back on some peak moments in my life when everything fell into place and,  for  brief periods, life was grand.  But then . . . life re-asserted itself.  The children, the parents, the siblings, the dog,  the boss, the situation . . . and I was again reminded about the wide and varied range of human emotional experience.  So how do we measure success when we are applying treatment?  Is the medication or the therapy really supposed to park our emotions in a state of static ecstasy?  Is anyone ever really a “10″ on the happy-sappy-meter or would that, by itself, indicate that I have gone too far with the medication and need to consider a mood stabilizer?  And what about “happy as a clam?”  or “happy as a pig in shit?”  What about good old fashioned “happy enough”???

In my line of work, the end-point can be difficult to determine.  Blood pressure is easy.  Glucose levels are easy.  Blood flow is easy.  Either the numbers are in the “normal” range or they are not.  ”Normal” is such a vague term for our experience as humans.  Some who come to me for treatment seem to want more from the medicine than I think the medicine can deliver.  They want a level of happy that is not appropriate for their circumstance in life or for how they manage their life and their relationships.  They want the medicine to deliver happy when a huge stumbling block to “happy” is that they are too sedentary, and don’t eat the right foods, and don’t read good books, and watch too much TV, and don’t pray or meditate, and don’t resolve long-standing conflicts with their spouses or children or parents or co-workers.  Anti-depressants are NOT supposed to make you happy.  They treat depression.  The endpoint of treatment with antidepressants cannot be expected to be a “10″ on the happy-sappy-meter (a “1″ on the depress-o-meter).  The endpoint is to take away the intense black-hole experience of depression that keeps one from living life.  Happy comes from how you live your life.  What you do when you don’t feel like doing (cause everyone doesn’t feel like doing at times).  What you eat when you feel like eating junk (cause everyone feels like eating junk at times).  What you think about when your brain keeps going to the negative (cause everyone’s brain goes to the negative sometimes).  There is a degree of choice with the management of one’s mood.  Certainly medicines play a role for many who are depressed.  The the role is not one of “miracle-pill”.  The medicine is one piece of a big puzzle of good mental health that must be joined by other good habits in order for it to be most effective.  

Life is an active process.  Good mental health takes time, effort and patience.  If you are sitting around waiting for the medicine to “kick in” so that you can go do those things that you know are good for you, you are putting the cart before the horse.  Feeling good comes from living a good life.  Take the medicine . . . but start living the good life now.  THEN watch as things fall into place.

–Dan Hartman, MD

Hospice and Beyond

So . . . some of you more loyal listeners might remember previous blarticles concerning my wonderful father-in-law.  A man who has, over the last 26 years, become my best friend.  When I started this entry several weeks ago,  I sat beside him, his old body feverish. His breathing rhythmic . . . slow . . . tired . . . his light was dimming.  He was unable to talk to us.  Unable to share his stories.  Unable to care for himself at all.  He was finishing his life’s journey in my living room.  My kids had come in from out of town to help support my wife and I as we made this transition.  And, as is typically the case, all the relatives descended on my home as well.  For four days, we held vigil.  Each day expected to be the last.  But, he lingered.  Not in pain.  Hospice makes sure of that.  Each dawn brought new speculation about the end.  When . . . how . . . and comments about his strong heart.  And questions about whether we were doing the right thing in this.  And waiting.  And watching.  And making sure he got his morphine every few hours.  But there was no soothing tonic for my pain.  No escape from the certainty that my friend was lost.  I certainly found the time I had with all three of my kids and my wife soothing, supportive and helpful.  The hardest part was not dealing with Pop’s impending death.  It was dealing with the relatives who, after some significant absences, came to be involved in this process.  Too many personalities . . . too many opinions . . . too many egos . . . it certainly turned into the kind of event that Pop would have hated.  He didn’t like a fuss to be made over him.  And this . . . this was a big one.  Having been in control of him for such a long time (he lived with us, ate with us, was bathed by us, watched TV with us, shared stories with us, etc) letting go of the control was, admittedly, a bit hard.  I know in my heart that I knew what he wanted through every painful step in this process.  But others had to have their say, as part of their process of feeling involved and important.  And everyone wanted to be important.  

Pop breathed his last at 505 AM on February 16th.  About six hours after I began to write this entry.  My brother in law got up to pee and saw that he was breathing.  By the time he got back from the bathroom, he was not.  He was finally quiet and still.  We gathered as a family around him and, as is our custom, prayed a Chaplet of Mercy (a Catholic thing done on a rosary for those who are not familiar).  We are not a whack-o religious family but we do fall back on our traditions at our times of need and transition.  The unbelievers (we have a few atheists in the bunch) sat respectfully with us.  Pop would have been proud.  There were tears.  And kisses.  And hugs of his old body.  But he was not there anymore.  His cooling shell no longer held the spark.  It no longer held the laugh or the stories.  He was gone.

The process of setting the arrangements was an ordeal.  Having thought about this a hundred times over the last several serious illnesses he lived through, and having spoken with him about this, my wife and I had a good idea what he wanted.  We had to curb our tongues a few times as the relatives made their wishes and demands known.  In the end, his wake and his Mass would have pleased him.  He had a good turn out for a man his age . . . who’s friends and acquaintances are mostly dead or infirm.  And all who came spoke about his kind and gentle manner.  His friendly smile.  Having never driven, he was especially adept at using public transportation, so there were stories about how he could be seen in all areas of Philadelphia getting the best rolls . . . the best corned beef sandwich . . . the best deal on a box of Gas-X.  And every wet eye would affirm that his passing left us all a little empty.   For me, the best/worst part of the process was escorting his flag-draped casket from the church.  We had taken him so many places over the years.  I had made him a promise of taking care of him.  And with that final act, I was taking him to his final resting place.  The final trip.  I was so proud to have known him and prouder still to be able to carry his body from the church.  Already missing him terribly.

The process of watching an old friend die is painful.  I consider being a part of that for him an honor and a privilege. It allowed me to fulfill my promise to him that I would be there for him and help him every step of the way.  Now, two weeks later, his portrait sits on a table in the room in which he died.  I have one of those battery powered flameless candles “burning” next to it.  His apartment is emptied and all his belongings are now piled in that room waiting for the relatives to join us next weekend to go through it.  And I am sad.  And in my sadness, I can find in myself . . . how I think and how I feel and how I sound . . . vestiges of him and how he carried himself through the years . . . and for that, I am happy.  He goes forth through me.  As my oldest said before she flew back to California this week . . . “You are the Pop-Pop now”.  A big responsibility.  But one made easier by the example of my old and dearest friend.

–Dan Hartman, MD