Category Archives: depression

“Hard on yourself” can mean a hard time seeing support.

If you’ve been in a child therapist’s office, you’ve seen posters illustrating basic emotions – joy, terror, humiliation, etc. Research using photos of such broadly-expressed feelings has shown those with schizophrenia and autism struggle partly due to difficulty identifying others’ emotions. At the University of Cardiff, Kirsten McEwan and  her research team investigated people’s responses to photos of more-understated sentiments. They’ve found that highly self-critical people may have subtler difficulties recognizing a subtler emotion: compassion.  Embed from Getty Images

McEwan, et al began by photographing actors they’d asked to express ‘social emotions’, such as sympathy, embarrassment or a critical attitude. They kept or discarded images for future research, based on whether their first group of study subjects could consistently agree on the emotion shown.

journal.pone.0088783.g001

A sample set of social-emotion expressions from the research study.

They asked their second group of study subjects to watch the images on a screen, and press a button whenever a dot appeared. Such “computer visual probe tests” give clues to a person’s attention: the farther their eyes are from the dot, the longer they take to press the button. McEwan, et al separated their study participants into two groups: those who were highly self-critical and those who were no tougher on themselves than average. They found that those in the average category were quicker to respond when a compassionate face was replaced by a dot. Those who were higher in self-criticism took just as long or longer  – suggesting they were less attentive to supportive expressions.

High self-criticism is a common aspect of depression. While our depressed clients tell us, “Nobody cares,” their friends and family may well be wondering, “Can’t they see how worried we are? That we’re all here for them?” McEwan, et al’s data shows the answer, to an extent, may be, “No. They can’t.”

Afterthought: 

Therapists in private practice may want to consider the researchers’ comments about beaming faces:

“Recent research suggests the ‘full-smile’ of a happy/joyful face can actually be aversive, and processed as a threat by some individuals. Schultheiss and colleagues (2005, 2007) suggest that this is because some types of smile – especially broad smiles – communicate social dominance; hence, smiles can be aversive.”

Psychology Today‘s “Find a Therapist” site is a parade of clinicians grinning like lottery winners. Our photos may draw more clients if our expressions say, “Compassionate, gently-concerned clinician,” more, and “The cat who ate the canary,” less.

Citation: 

McEwan K, Gilbert P, Dandeneau S, Lipka S, Maratos F, et al. (2014) Facial Expressions Depicting Compassionate and Critical Emotions: The Development and Validation of a New Emotional Face Stimulus Set. PLoS ONE 9(2): e88783. doi:10.1371/journal.pone.0088783

@ 2014 Jonathan Miller All Rights Reserved

Advertisements

Leave a comment

Filed under depression

Depression: Overdiagnosed by the Overwhelmed

(Full disclosure: Dr. Mojtabai kindly furnished a copy of his article for review. I don’t think this freebie altered my judgement but then, no one ever does.)

A new study shows that 3/5ths of those diagnosed with depression don’t have Major Depressive Disorder. Damning proof America’s mental health system is riddled with quacks, right? Actually, no. But it suggests a worrisome disconnect between those with mild depressive symptoms and those trained to treat them.

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai of the Johns Hopkins Bloomberg School of Public Health studied 5,639 adults who reported, “a doctor or other medical professional,” diagnosed them with  depression in 2009 or 2010. He found only 38.4% had met criteria for a major depressive episode in the past twelve months. Nearly three-quarters of those who did not meet criteria had been prescribed medication.

Who’s making these diagnoses? Probably primary care doctors – the people we’re most likely to talk to if we gain weight, lose energy or have trouble sleeping. In 2011, Mojtabai found 7% of all doctor visits involved a prescription for antidepressants.[i]  For his current study, he started with data collected through the United States National Survey of Drug Use and Health. While this study didn’t ask participants what type of medical professional diagnosed them, he found only 34.6% of those who hadn’t met criteria for a major depressive episode received outpatient mental health services. It’s not much of a leap to surmise primary-care doctors are responsible – especially considering  Mitchell and Vaze’s 2009 study, which found such doctors misdiagnosed depression more often than they identified it correctly.[ii]

Is it a problem if family doctors reach for a quick fix when they encounter mild-to-subclinical depression? Per the studies Mojtabai cites, there’s little evidence antidepressants help such cases. Effective treatments include a referral to counseling, advice on boosting one’s mood with diet and exercise, or watchful waiting. Instead of these, three-quarters of those with only mild depressive symptoms got a prescription.

Three possible solutions come to mind. None would be quick, easy or cheap.

"I need more training in what, now?" (photo: Adam Ciesielski © 2013)

“I need more training in what, now?” (photo: Adam Ciesielski © 2013)

1. Better training in diagnosis

If misdiagnosis is the problem, more training is the answer, right? Bear in mind, for every public health problem, the initial thought is, “Let’s get the primary care doctors on the case.”  Family doctors are expected to follow up on everything from lead exposure to trampoline safety.  Depression has to compete with every other disease in need of greater public awareness.

2. Counter-programming

Primary care doctors are barraged by pharmaceutical companies which promise quick and easy solutions, based on often-dubious research. Olfson and Marcus found antidepressant use doubled from 1996 to 2005. In the same period, the number of patients who received therapy as well as antidepressants dropped by a third.[iii]  (Essay question: Should we allow unscrupulous Big Pharma to exploit human suffering by placing profit ahead of facts and the public’s health, or should jackbooted government thugs trample free speech by placing unaccountable technocrats in charge?)

Organizations such as the American Counseling Association and the American Psychology Association should return fire with their own brochures. On the front cover: fit, attractive people of all ages and cultures beaming over the success of their non-pharmaceutical treatment. Inside: large-print bullet-points on how to differentiate the different intensities of depression, and the relative efficacy of medication, lifestyle improvements and counseling. Last page: a handy list of local therapists for referrals.

3.  A nationwide program

In his article, Mojtabai mentions the United Kingdom’s National Health Services’ “Improving Access to Psychological Therapies“. This program trained thousands in cognitive-behavioral therapies and provided general practitioners with free on-line training about depression. As a result, patients move easily from a more-accurate diagnosis to a simpler referral for help.

In the U.S., surveys show we dislike government programs and government spending, but we do like the benefits that spending on government programs brings. Per NHS data, their big-government program moved 45,000 workers off public benefits by getting them back to work. It also benefited the UK’s economy by an estimated £272,000,000 by preventing the need for more expensive treatments.  The program has been criticized for restricting the range of therapies available and providing lightly-trained staff. Even with these limitations, it has delivered a respectable (if non-astonishing) recovery rate of 42.5%.

For the next go-round:

Mojtabai’s study is enticingly exasperating; the kind that raises more questions than it answers. Tough questions for a follow-up:

1. Exactly who provides these misdiagnoses? Which specialty is most on-target, and which is most likely to misdiagnose? Master’s-level counselors, social workers and psychologists should all be assessed for accuracy.

2. Out of the patients who received outpatient mental health treatment, what percentage received counseling and which only received more meds from a psychiatrist?

3. How hard is it for a primary medical doctor in other countries to refer a client to therapy? How much resistance do clients offer, and what would help doctors address their concerns?

The 3/5ths of participants that grabbed the headlines may not have met criteria for Major Depressive Disorder, but it’s a safe bet they weren’t happy and fulfilled, either. More information for better diagnoses and more-appropriate treatments, please.

Citation:

Mojtabai R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom. 2013;82(3):161-9. doi: 10.1159/000345968. Epub 2013 Mar 27.

© 2013 by Jonathan Miller. All Rights Reserved


[i] Mojtabai R, Olfson, M. Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing.  Health Aff August 2011 vol. 30 no. 8 1434-1442. doi: 10.1377/hlthaff.2010.1024

[ii] Mitchell A, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374: 609–19

[iii] Olfson M, Marcus SC. National Patterns in Antidepressant Medication Treatment. Arch Gen Psychiatry. 2009;66(8):848-856. doi:10.1001/archgenpsychiatry.2009.81.

4 Comments

Filed under depression, Diagnosis

Diluted DBT Still Effective for Bipolar Disorder

University of Washington psychologist Marsha Linehan has a strict definition of her ground-breaking Dialectical Behavioral Therapy (DBT). If a client doesn’t …

  • attend a DBT skills group and …
  • receive individual therapy from a DBT-trained therapist …
  • who attends a weekly DBT consultation group and …
  • offers phone coaching,

… they aren’t really in DBT. The full program is what she researched; she won’t vouch for anything less.  A new study by Van Dijk, Jeffrey and Katz of the Southlake Regional Health Centre in Ontario, Canada suggests even a cherry-picked form of ‘adherent’ DBT may still help those with Bipolar Disorder.

T-shirts like this are why I love the internet

T-shirts like this are why I love the internet

The researchers enrolled twenty-six adults with Bipolar I or II Disorder in a psychoeducational group. The clients learned about their diagnosis, but were also trained in mindfulness practice and DBT’s emotional-regulation, interpersonal-effectiveness and distress-tolerance skills. After twelve weeks of ninety-minute group sessions, the clients scored higher on Beck Depression Inventory, reported greater awareness of their emotional states and less fear of the same. Six months later, they also had fewer emergency-room visits and hospitalizations. These findings echo other studies that found DBT skills group training – by itself – can be effective for depressive symptoms.

It’s tempting and dangerous to conclude DBT can be treated like a toolbox, instead of a unified whole.  Tempting, because DBT is a comprehensive therapy for challenging clients. That makes it dauntingly complex. Becoming fully versed is like learning another language. With all of its’ useful techniques, attitudes and approaches, it’s almost too simple to cherry-pick a few and call it DBT.

It’s dangerous because Linehan’s therapy depends so much on movement, speed and flow – rapidly shifting around all of those techniques, attitudes and approaches to meet a client’s needs.  Practitioners’ mailing lists often feature tales of clients firmly uninterested in DBT because of their previous experience – with non-adherent therapists whose treatment had some of the features, but none of the integrity of Linehan’s.

Carl Rogers’ use of reflective listening and Alfred Adler’s focus on the here-and-now were subsumed into the basic practice of therapy. Linehan’s DBT skills could be mindlessly assimilated the same way. Let’s have more research on how much and how little can be dropped before you no longer have an effective therapy.

Citation:

Sheri Van Dijk, Janet Jeffrey, Mark R. Katz. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders 5 March 2013 (volume 145 issue 3 Pages 386-393 DOI: 10.1016/j.jad.2012.05.054)

@ 2013 Jonathan Miller All Rights Reserved

1 Comment

Filed under Bipolar Disorder, depression, Dialectical Behavioral Therapy

“Six Harsh Truths” and depression

David Wong‘s Six Harsh Truths That Will Make You a Better Person is a New Year’s essay for those who lack resolution – one that applies directly to treating depression.

If you want to know why society seems to shun you, or why you seem to get no respect, it’s because society is full of people who need things … the moment you came into the world, you became part of a system designed purely to see to people’s needs.

 Either you will go about the task of seeing to those needs by learning a unique set of skills, or the world will reject you, no matter how kind, giving and polite you are. You will be poor, you will be alone, you will be left out in the cold.

 Does that seem mean, or crass, or materialistic? What about love and kindness — don’t those things matter? Of course. As long as they result in you doing things for people that they can’t get elsewhere.

He’s talking to those paralyzed by the dissatisfaction they feel with their lives, and that includes those with Major Depressive Disorder. As  Marsha Linehan pointed out, the best medicine for unpleasant emotions is often the opposite of what the emotion makes us want to do.  “Opposite action” is Wong’s prescription for those who are disgruntled but inert: do something. Anything. Anything  more than what you do now, that would also be useful to others. He stands with  Roy F. Baumeister, whose research shows we don’t achieve because we have good self-esteem. Per the Florida State University researcher, if there’s a relationship between the two variables,  it’s much more likely we have good self-esteem because we achieve.

It’s a shame Wong builds his argument on Alec Baldwin’s role in Glengarry Glen Ross as a manager who shames and threatens his sales force.  Who gets motivated from abuse? Those galvanized by anxiety – the sort of highly-motivated go-getters who rarely need our help. Wong doesn’t scorn his readers for freezing in fear of rejection and failure. His point is simpler: the world values you for what you do. You can be valued more highly by doing more.

In cognitive-behavioral therapy, the most effective reframes for thoughts of, “I’m worthless,” are usually about accomplishments – grades the client earned, projects they completed, people they have helped. Once I’ve helped a client identify all of the reasons they aren’t garbage, I’m going to ask, “Now that we’ve settled that, what do you want to do that would make you even more worthwhile?”

@ 2013 Jonathan Miller All Rights Reserved

2 Comments

Filed under depression, Uncategorized

Sleep Apnea: Depression’s subtle sidekick.

A client presents with irritability, drowsiness, lack of energy,  and hypersomnia. You’d suspect depression, possibly Bipolar Disorder, and you’d likely be correct. It might also be something more.

Just over a year ago, Texas governor Rick Perry was hailed as the Republican party’s best choice to win the White House in 2012.   Poor debate performances sank his candidacy, most notably when he couldn’t remember a third government department he planned to eliminate.  In his new book “Oops“,  Texas Tribune correspondent Jay Root claims Perry’s lapses were due to a sleep disorder:

“…by early October, days after the Florida fiasco, (Perry) had urgently consulted sleep specialists. After conducting overnight tests on Perry, they produced a rather startling diagnosis: He had sleep apnea, and it had gone undetected for years, probably decades.”

Rick Perry’s doctors: “Oops.”

Sleep apnea causes sleepers to stop breathing. These pauses can last several minutes and occur  thirty times or more per hour. Unknowingly, sufferers’ wake dozens of times per night. This sleep disruption can slip past diagnosticians because it shares so many symptoms with depression. When a client presents with  fatigue, forgetfulness and lack of motivation, a family doctor might refer them to counseling instead of a sleep study.  The assessing therapist might ask the person if they ever wake up gasping for air. More likely, they’ll focus on all of the mental health questions we have to squeeze into an assessment session.

Along with serious physical risks, sleep apnea can cause depression and memory troubles, via sleep deprivation.With depressed clients who report fatigue, but no trouble sleeping, it’s smart to ask about the following:

  • Morning headaches
  • Memory or learning problems and not being able to concentrate
  • Waking up frequently to urinate
  • Dry mouth or sore throat when you wake up
  • Snoring
  • Reports from bedmates that you stop breathing in the night.

Two years ago, I started to encourage clients to report such symptoms to their family doctors. An impressive percentage have returned with a positive diagnosis for sleep apnea. So far, each who pursued treatment have reported improved mood and energy. Each was genuinely depressed; disrupted sleep made each’s depression significantly worse. With sleep apnea, sleep deprivation can hamper therapy even when a client believes they sleep all too well.

 

@ 2012 Jonathan Miller All Rights Reserved

Leave a comment

Filed under depression, Diagnosis

Bad for your heart, bad for your mood

It’s a therapist’s job to help people find their own answers. When it comes to healthy living,  we spend a lot of time telling them what they should do. By the time you’ve explained how one’s mood and stress level benefit from exercise, regular hours, spiritual practice and skipping drugs and alcohol,  your index finger can be exhausted from the waggling.

Luscious, hot, salty yummy-nummies, just dripping with despair

This paradox will only grow worse, with the University of Montreal Hospital Research Center’s new study on diet and mice’s behavior.  Stephanie Fulton, Ph.D and her team found that after twelve weeks of high-fat, high sugar meals, their subjects froze under stress. They were less likely to explore new environments, and more likely to scurry for safety. Compared to a control group of mice fed the pelletized equivalent of grilled quinoa and kale, they gave up faster in tests of  ‘behavioral despair’.  In short,  they looked anxious and depressed.

Behavior can have lots of explanations, of course. It’s  been assumed that anxiety and unhealthy eating correlate, because we seek solace in ‘comfort food’ when we feel stressed.  Sadly, Fulton’s study suggests the reverse. Brain scans indicated the mice on high-fat diets had elevated levels of corticosterone, a hormone conclusively linked to anxiety and CREB, a molecule implicated in the fear response. Saturated fat appears to be the enemy here – the mice who were fed “good fats” like olive oil didn’t show as much anxiety.

Dopamine depletion in T-minus 100… 99… 98…

In interviews, Fulton theorized there’s also a neurological link between scrumptiously unhealthy food and depression. She surmises  that because high-fat, high-sugar eats are so ineffably delicious, they trigger releases of dopamine. That’s a neurotransmitter associated with pleasure, particularly with reward-driven learning. Life being unfair, the rush of dopamine leads to a corresponding crash, which causes symptoms of depression. Over time, per Fulton, this can reshape the brain’s reward circuits. Instead of easing life’s suffering, steady consumption of greasy, sugary treats may create an addictive pattern of short-term highs and long-term gloom.

… told you so.

David C.W. Lau MD PhD, editor of Canadian Journal of Diabetes emphasized this study only shows association, not causation.  The researchers freely admit it is hard to square their findings with other studies where mice on similar diets became more docile. Given that, two points come to mind:

1. The clash between offering health advice and helping people find their own answers? It’s an irony, but not a conflict. We’d be remiss if we didn’t tell people there are quick steps to improve one’s mood. “You have worse problems than lack of exercise,” I’ll say. “But exercise would help.”

2. Occasional indulgences are not a high-sugar, high-fat diet. Vegetarians’ organic, easy-going good humor is enviable, but not every client will be pried away wholly from sugar and fats. Good food is one of life’s great pleasures, and life has to be worth living. As  clients often ponder when they’re offered MAOIs: if you give up chocolate, cheese and wine entirely in trade for an effective antidepressant, has your life actually improved?

Citation: Diet-induced obesity promotes depressive-like behaviour that is associated with neural adaptations in brain reward circuitry. Sharma S, Fulton S. Int J Obes (Lond). 2012 Apr 17. doi: 10.1038/ijo.2012.48. PMID: 22508336 [PubMed – as supplied by publisher]

@ 2012 Jonathan Miller All Rights Reserved

1 Comment

Filed under anxiety, depression

Napoleon Bonaparte on Depression

At age sixteen, 2nd lieut. Napoleon Bonaparte despaired. Always having dreamed of military greatness, he was enlisted in a military run by incompetent French nobility – one that offered Corsicans little chance of advancement.

“Always alone among men, I come home to dream by myself and to give myself over to all the forces of my melancholy, ” he wrote.  “My thoughts dwell on death… What fury drives me to wish for my own destruction? No doubt because I see no place for myself in this world.”

Eventually, he would rule much of Europe.

@ 2012 Jonathan Miller All Rights Reserved

2 Comments

Filed under depression, The Client's Side