Psycho-Babble Medication Thread 75408

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Endogenous (Chemistry) vs. Exogenous (Life Events)

Posted by Rick on January 24, 2002, at 19:19:43

In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59

I probably shouldn't reprint an entire editorial here (the one I printed a snippet of in another post), but it may add some historical perspective to the Burns discussion. (Although it does veer off in a different direction.)

If I understand what folks are saying, Burns is suggesting that unipolar depression in general is what used to be called exogenous depression, i.e. caused by life events (vs. chemistry) and thus treatable only with talk.

From
Medscape Mental Health
Medscape Psychopharmacology Today
Endogenous Versus Exogenous: Still Not the Issue

Thomas AM Kramer, MD

[Medscape Mental Health 7(1), 2002. 2002 Medscape, Inc.]

Many readers may recall a time during the early 1980s when it was believed to be important to classify depression as either endogenous or exogenous. The idea was that there was a difference between depression precipitated by life events, called exogenous depression, and depression that was inherent to the patients' physiology, referred to as endogenous depression. The theory was that patients with exogenous depression did not respond to antidepressants -- ie, tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs) -- because, presumably, their depression was not a function of their physiology but rather a reaction to their life situation. As such, they required treatment with some form of talking therapy. This theory, as it was promoted at the time, not only made the distinction between endogenous and exogenous depression based on symptoms (ie, did they or did they not have vegetative symptoms of depression), but also by assumed etiology. Thus, it was believed that depression precipitated by the loss of a loved one or any other grief-inducing event would not respond to antidepressants because it was exogenous, ie, not physiological.

In retrospect, this rather dualist approach to depression seemed to imply that only some behaviors had anything to do with the chemistry of the brain, but other behaviors were somehow exempt. All of this thinking came, to a certain extent, from the discovery of monoamine neurotransmitters and their role in depression. Since antidepressants seemed to increase the amount of norepinephrine, serotonin, and perhaps dopamine by making more neurotransmitters seemingly available, it made sense at the time to understand depression as a deficit of these neurotransmitters. Ignoring the fact that the effect of these drugs on the neurotransmitters was virtually immediate, their effect on the patient took considerably longer. The assumption was that the depressed patients clearly needed more of something, and the neurotransmitters were the best candidate at the time. It was hard to believe, then, that life events could change fundamental biochemistry. We now are fairly certain -- armed with new knowledge from various studies about dietary manipulation, blood and CSF level monitoring, and other sophisticated methodology -- that the deficit model of neurotransmitters is considerably more simplistic than whatever the reality of the pathophysiology of depression is.

Much more recently, we came up with a new application of the semantic distinction between endogenous and exogenous. In spite of the data that question the validity of a deficit paradigm, we continue to think of psychopharmacology as somehow having an effect on some sort of balance. One often hears patients parroting this idea by referring to themselves as having a chemical imbalance. As we strive to somehow rebalance that imbalance, we struggle to conceive of exactly what it is that is out of balance. Throughout most of the history of the treatment of depression, we have done this with reuptake blockers, which ostensibly increase the amount of neurotransmitter available to the outside of the neuron by blocking reuptake. These drugs, by the semantic distinction described above, would be exogenous, ie, they are not something that the body naturally produces but are ingested to achieve an impact on the balance of neurotransmitters.

More recently, we have begun to get interested in the use of endogenous compounds, ie, hormones or other substances that are naturally produced by the body, in the treatment of depression. The idea is that if we administer substances that the body already has, but perhaps doesn't have enough of, this may treat the depression. Recent studies have shown that estrogen supplementation, growth hormone, and even secretin, which is used in the treatment of autism, may have beneficial effects in depressed patients. The idea here is once again to rebalance an imbalance by giving the actual substance that the body may be in deficit of. This brings about interesting discussions concerning the actual definition of a drug and whether it is somehow better or safer to give, as treatment, substances that are already found within the body.

This kind of work can be misleading or deceiving. Virtually every medical disorder that results from having too little of a hormone has a companion disorder that is a result of too much of that same hormone. In addition, it is often impossible to deliver a naturally occurring neurotransmitter or hormone to its target in all cases.

One intriguing example of this was the development of gabapentin. Gabapentin is a biologically derived compound that was developed with a very simple idea. Many of the drugs that we use to treat epilepsy are active in the gamma-aminobutyric acid (GABA) system. The idea was that if we could somehow give the patient GABA, instead of drugs that accentuate the GABA system, we would somehow have a better, purer response. There was only one problem with this idea: GABA does not cross the blood-brain barrier. All of the GABA that is in the brain was manufactured there. In order to give the brain a dose of GABA, you would either have to inject it directly into the brain, a procedure that most patients would object to if it were done on a regular basis, or modify the GABA molecule in some way that would maintain its action but allow it to cross the blood-brain barrier. That clever thing was done; a pentin ring was attached to GABA, and thus gabapentin was born. It works quite well, and everyone was happy until someone actually conducted studies of gabapentin receptor binding. What they discovered was that gabapentin had absolutely no interest in GABA receptors or any GABA circuitry, but seemed to be very interested in the glutamate system, where it turns out all of its actions take place. In other words, the drug's efficacy had nothing to do with the ideas behind its development. I have been told this story informally, and I have no idea if it is actually true, but it illustrates the point I am trying to make quite nicely.

I propose a reframing of the paradigms that we use for psychopharmacology and its relationship to neurotransmitters. Neurotransmitters slosh around the body, and specifically inside the brain, in relatively constant amounts. The drugs that we give, even MAOIs, do not really affect the number of neurotransmitters in the body very much. What these drugs do is affect receptors. Instead of being concerned about the effect of norepinephrine and serotonin, we really need to redefine our concept of psychopharmacology as receptor drugs. Saying, for example, that selective serotonin reuptake inhibitors (SSRIs) treat depression by increasing serotonin is like saying that a boat sinking on the ocean needs to have reduced water levels. The water is there and all around. To fix the boat you need to plug the holes. That will be a great deal more effective than worrying about decreasing the overall amount of water in the system.

SSRIs affect the serotonin transporters in cell membranes; they do not necessarily affect the overall level of serotonin. There is no deficit or surplus of serotonin; there are cells with impaired ability to have certain levels of serotonin on either side of their membranes. If serotonergic drugs really did affect serotonin overall, they would cause absolutely horrible GI side effects, since the gut has considerably more serotonin and serotonergic neurons than the brain has. This is also why different patients get better on different SSRIs. These agents may all block serotonin reuptake, but each is structurally distinct and thus may bind differently to serotonin transporters, depending on the patient. Similarly, dopamine blockers that are used to treat psychosis do not affect dopamine as much as they lower the sensitivity of certain cells to dopamine by blocking some of their receptors. This has no effect on the total volume of dopamine. It is even more likely that some drugs that appear to work by serotonin receptor blockade actually work by shunting the serotonin moving around from one receptor group to another. In other words, if a certain class of serotonin receptors is completely blocked, the serotonin has no choice but to bind to other receptors.

For years we have struggled to attribute fluctuations in neurotransmitters to drugs' mechanisms of action. Once we begin to conceive of drugs as affecting receptors, things generally seem to make more sense. Even the hormonal treatments described above have their effects at the actual receptors on the cells. Newer exciting treatments, such as the use of corticotrophin-releasing factor antagonists to treat depression and anxiety, and the most recent work, involving the noncontroversial use of a controversial compound, RU486, for the treatment of depression, are aimed at antagonizing hormonal receptors. Why should we concern ourselves with receptors? Because of Willie Sutton's law. Sutton, the noted bank robber, when asked why he robbed all those banks, replied, "Because that's where the money is."


Disclaimer
The opinions expressed are those of Dr. Kramer and do not reflect those of the American Board of Psychiatry & Neurology or the Directors of the ABPN.


--------------------------------------------------------------------------------

Thomas AM Kramer, MD, is Clinical Associate Professor of Psychiatry, Northwestern University, Chicago and Deputy Executive Vice President of the American Board of Psychiatry and Neurology.

 

Re: David Burns and Parnate Lisa01

Posted by Elizabeth on January 25, 2002, at 1:13:25

In reply to Re: David Burns and Parnate, posted by Lisa01 on January 24, 2002, at 13:14:45

> Burns does say that he will sometimes go to 30 mg. Parnate but very rarely to 40 or more. He emphasized that many respond so well to 10 or 20 that they do not need to go any higher. I was hoping to be one of those people. One thing that is unclear in Burns is how long to give it at 20 mg before determining you need more (my fam. phys. says 2 weeks).

A general rule that I find helpful: your doctor should always overrule what you read in a book!

It is certainly true that you may need to raise the dose (and I doubt that 20 mg/day is a sufficient dose of Parnate for most people; chances are you will need to raise it). I think that you should wait if you're having trouble tolerating it, though -- don't rush it unless your situation is truly urgent. Most side effects will dissipate with time.

-elizabeth

 

Re: David Burns-Emme

Posted by Cecilia on January 25, 2002, at 2:56:47

In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59

> Hi Folks,
>
> Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
>
> Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
>
> On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
>
> Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
>
> Emme

Yes, I definitely feel there`s a sort of "blame the patient" attitude about CBT. He talks a lot about doing homework; if you don`t get better it`s because you haven`t done your homework. And his dramatic success stories do indeed make me feel worse about myself, though I seem to have that problem with all self help books. Cecilia

 

Re: David Burns

Posted by Blue Cheer 1 on January 25, 2002, at 5:39:48

In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59

> Hi Folks,
>
> Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
>
> Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
>
> On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
>
> Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
>
> Emme

I see Dr. Burn's as more of an opportunist than anything else. Essentially, he took the ideas of Aaron Beck, M.D. (father of congitive therapy) and ran with them. He did his psychiatry residency at the Philadelphia VAMC and gave the hospital an undeserved black eye when he described (in his preface if memory serves me) a patient he passed on the elevator there who was returning from his 18th shock treatment, and was yelling "I want to die." I haven't looked at Feeling Good since it was first published, but I think he claimed that it was at this point when he decided there 'must be another way' (to treat depression). In any case, I know psychiatrists who remember him well, and he routinely used drugs in his practice.

I don't care about his drug recommendations since he's not a psychopharmacologist.

I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.

Blue

 

Re: David Burns

Posted by Lisa01 on January 25, 2002, at 7:42:10

In reply to Re: David Burns, posted by Blue Cheer 1 on January 25, 2002, at 5:39:48


> I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.
>
> Blue

I see that most of you are referring to CBT in the context of depression. I am inclined to agree that depression is likely more brain-based than mind-based (for lack of more scientific terminology). My personal demon is SP, and I do think there is--for me anywhere--a direct correlation between my thoughts ("I'm going to blow it" , "Everyone can see how nervous I am") and how anxious I become. I also know I am pre-disposed to social anxiety in that I had several early traumatic experiences with performance situations and have, I believe, come to dread them based on that. I think that I need meds at least temporarily until I can learn to 'correct' the way I look at performance situations, because my fears are overblown in terms of--and this is something Burns talks about--extremity and likelihood (I'm not using his terminology here)i.e. the outcome is not usually as bad as I anticipate and sometimes the situation I dread most does not even occur (e.g. someone asking a question I cannot answer at a presentation). I don't think CBT can be written off, or seen as a cure-all either. A combination of both meds and some kind of therapy can be more helpful for some than meds alone.

Anyone out there had luck with CBT for SP?
Lisa

 

in defense of CBT

Posted by sid on January 25, 2002, at 9:06:28

In reply to Re: David Burns, posted by Lisa01 on January 25, 2002, at 7:42:10

Behavior and thoughts affect brain chemistry. CBT does not pretend that depression is not a brain chemistry problem. It can be used, as well as meds to treat depression. It does not have a 100% rate of success, and meds don't either. Acupuncture can help too, and it does not have a 100% success rate either.

I did have success with CBT and acupuncture to get rid of a major depression, and I think CBT helps me everyday of my life now. It is some kind of emotional/psychological education that everybody should have in my opinion. The world would be a much better place if all of us were aware of the f*** up behavior, thoughts and relationships we carry on. But some people are not open to learning. I bever did much of the homeworks as I used to find them to anal for me. However I did understanf the different concepts that could help me and found ways to "catch myself" thinking or doing something that could hurt me in the long run, and change some of my behavior and thoughts. It was difficult at first, felt artificial, and then, with time and practice, it felt more normal. And the depression lifted.

Also, CBT has nothing to do with guilting the patient. Does a diabetic feel guilty because he has to learn to eat better and exercise more? Does he think that the insuline will do all the work, no matter what he does? Of course not ! So why do depressive people think the meds will do it all? I am not sure... I think it's another tool that can help, and I don't see why people don't use it more.

Since all this I thought I had chronic depression that would not lift, although I felt 90% better than during my major depression, which was horrible and not event-based. I still wonder how it is I did not kill myself then. So I decided to try meds for the residual depression. As it turns out, it seems I have an anxiety disorder, and my doc is not convinced that I still have depression. I did a test the other day and ranked very very low for depression and high for anxiety. So I guess I'm taking meds for anxiety at this point. I am not sure if different CBT techniques could help, I just got tired of making efforts and decided to rely on meds at this time. CBT does require efforts indeed, that's the downside: no free lunch. However, it does help for the rest of your life, even if it is not a panacea. Meds aren't either, from what I read on this web site.

 

Re: in defense of CBT

Posted by Dinah on January 25, 2002, at 9:33:21

In reply to in defense of CBT, posted by sid on January 25, 2002, at 9:06:28

Actually, if you read this board you will find me frequently recommending CBT because both studies and my personal experience show that it works well for some disorders. The ironic part is that I hate it, at least in it's purest form. Whenever I read someone like Burns or when my therapist used to give me homework I would feel like I was a dog or seal being trained. I would want to balance a ball on my nose and clap my flippers. And it did make me feel bad about myself. It makes it sound like simple behaviorism and life's not like that.
That being said, there's no reason to throw out the baby with the bathwater. There is a lot of good common sense in CBT and I extract that part of it and leave the rest behind. I've learned to stay calm during a panic attack and deal with my OCD. There are certain things like agitated depression that CBT cannot touch. I've learned to work around what I cannot change and to change what I can. But I don't use pure CBT. I read a lot and skim over what irritates me. My therapist has learned to slip in CBT in a non-doctrinaire conversational style that doesn't irritate the heck out of me. And medication fills in where CBT can't help.

 

Re: David Burns-Emme

Posted by OldSchool on January 25, 2002, at 11:25:47

In reply to Re: David Burns-Emme, posted by Cecilia on January 25, 2002, at 2:56:47

>
> Yes, I definitely feel there`s a sort of "blame the patient" attitude about CBT. He talks a lot about doing homework; if you don`t get better it`s because you haven`t done your homework. And his dramatic success stories do indeed make me feel worse about myself, though I seem to have that problem with all self help books. Cecilia


The problem with many talk therapies is that they simply do not work for the more severe mental illnesses. And when the therapy fails to provide the "relief" the psychology people sometimes claim it will provide, then the problem is with YOU. "Oh you didnt work hard enough in therapy." "Oh you dont want to get better bad enough." Its all a crock.

Major depression is a neurological illness, a brain based illness and anything less is a lie. Many people who adhere to these psychological notions of severe mental illness are in serious denial. They cant face up to the hard fact that they are truly sick in the medical sense. Talk therapy is an excuse, a reason to avoid the cold hard fact that major depression is a brain based illness.

Old School

 

Re: David Burns-Emme OldSchool

Posted by ray on January 25, 2002, at 15:16:29

In reply to Re: David Burns-Emme, posted by OldSchool on January 25, 2002, at 11:25:47

Sorry I didn't read all this thread but noticed topic and wanted to throw in 2 cents.

I only have a few books I like, one is Burn's.
I have a (my opinion) at least 50% baseline untreated very severe SP and dysthmia. I don't think it is 100%, but somewhere between 50-100 genetic.
I think the chronicity of a given disorder and (I suppose better by idential twin studies) are good indicators of genetic involvement.

Anyhow, I still think Burn's is helpful. For severe chronic disorders I consider it a 2nd add on, not a primary.
But I think CBT and Burn's extra ideas can be very useful. I've used them myself at times with success.
Recognized ones distorted, illogical, irrational thoughts real time can be very helpful, as many of these disorted thoughts tend to be "automatic" and the person is unaware of their irrationality.

As an example (we all do it but just as example).
The statement "it's all a crock" below ....

This is a good example of "all or nothing" thinking, or "black and white" thinking.
There are no inbetween's in the statement "It's all a crock".
The statement implies something (the book's techniques) are either:

a) Totally good. 100% the best way to go.
b) Totally bad, a sham, 100% useless

A more realistic statement would be that clearly some of the techniques are helpful for some people. It is an overwhelmingly popular book and I myself who come across as pro-med and anti-therapy to most of those I talk to still feel different therapies can offer a lot of help.
Sorry not trying to critize just wanted to point out something applicable to CBT.

I noticed that I do a lot of "mind reading",
"jumping to conclusions", "should statements",
"all or nothing thinking", and a few others.
(ie; about half of the 10 main ones!!!)

True it is not science, just an approach.
However I do want to say I don't think it is a crock.
I also think it is especially useful for mild to moderate depression.

And I notice he likes Parnate best! :)

Jumping down (from box) , I have plenty of problems I have to get to work on!!! :)

Ray

http://www.socialfear.com/

> >
> > Yes, I definitely feel there`s a sort of "blame the patient" attitude about CBT. He talks a lot about doing homework; if you don`t get better it`s because you haven`t done your homework. And his dramatic success stories do indeed make me feel worse about myself, though I seem to have that problem with all self help books. Cecilia
>
>
> The problem with many talk therapies is that they simply do not work for the more severe mental illnesses. And when the therapy fails to provide the "relief" the psychology people sometimes claim it will provide, then the problem is with YOU. "Oh you didnt work hard enough in therapy." "Oh you dont want to get better bad enough." Its all a crock.
>
> Major depression is a neurological illness, a brain based illness and anything less is a lie. Many people who adhere to these psychological notions of severe mental illness are in serious denial. They cant face up to the hard fact that they are truly sick in the medical sense. Talk therapy is an excuse, a reason to avoid the cold hard fact that major depression is a brain based illness.
>
> Old School

 

Re: in defense of CBT Dinah

Posted by sid on January 25, 2002, at 15:21:58

In reply to Re: in defense of CBT, posted by Dinah on January 25, 2002, at 9:33:21

Good for you.

I read about CBT years ago, and with time, I keep doing some of the stuff that helps. I simply forgot what got on my nerves. Indeed, the "homeworks" are sometimes weird and I once fought with a therapist not to do an assignment that I found pointless and a sheer waste of time. Each person needs to adapt depending on their personality, as in anything else in life.

Indeed, CBT can be a good complement to meds.

 

Redirect: in defense of CBT

Posted by Dr. Bob on January 25, 2002, at 16:02:09

In reply to Re: in defense of CBT Dinah, posted by sid on January 25, 2002, at 15:21:58

> I read about CBT years ago, and with time, I keep doing some of the stuff that helps...

How about if discussion of CBT moves over to Psycho-Social-Babble? Here, I took the liberty of starting a thread:

http://www.dr-bob.org/babble/social/20020125/msgs/17202.html

Thanks,

Bob

PS: And any discussion of posting policies should of course take place at Psycho-Babble Administration...

 

We all know it's a brain-based disease!

Posted by sid on January 26, 2002, at 11:43:44

In reply to Re: David Burns-Emme, posted by OldSchool on January 25, 2002, at 11:25:47

It is a brain illness, we all know that much. What many people don't realize is that our behavior and thoughts affect our brain chemistry. So if CBT can help, why discard it?

Yes, many psychologists are bad ones. One needs to be choosy and careful. Heck, CBT can be learned on one's own, reading about it. The effect of behavior and thoughts on the brain have been known for thousands of years. Indeed, yoga is based on that and has existed for at least 5000 years. The western take on yoga is CBT. Nothing new there; new techniques, westernized approach. What's new is neurologist's realization that it can work indeed.

I just don't understand why some people posting here are so stubborn in their views on CBT. I take meds, I use CBT, I practice yoga, and I don't plan to be on this web site posting for very much longer, simply because I will heal myself using all I can to do so. The very fact that a person has dealt with depression for years, and that meds have not worked, should make them look for alternatives. Anyway. It has helped me, continues to do so, and I will continue to use the concepts of CBT on a daily basis. And my depression was VERY brain based. It happended to me during one of the best times of my life, when I should have felt great, surprisingly. I ended up staying in bed 22 hours a day for an entire week before I went to look for help (remaining 2 hours were spent going to the bathroom, showering, eating and crying while sitting in a chair). And I had a constant headache ("the depression headache," I used to call it) during my major depression, making it clear that somewhere in my head, something was not working the way it should. And CBT helped to get out of it. It took time, but the difference with meds is that CBT stays with me forever. I am convinced that I have smaller chances of having depression again because I did not rely only on meds.

That was my 2 cents, and I hope it can help other people.

 

Re: David Burns-Emme ray

Posted by sid on January 26, 2002, at 11:45:30

In reply to Re: David Burns-Emme OldSchool, posted by ray on January 25, 2002, at 15:16:29

Totally agree with you, Ray. Good for you!

 

Re: Redirect: in defense of CBT Dr. Bob

Posted by sid on January 26, 2002, at 11:50:23

In reply to Redirect: in defense of CBT, posted by Dr. Bob on January 25, 2002, at 16:02:09

Dr.Bob,
you're perperuating the problem by redirecting this thread.

Many of us think that CBT and meds and acupuncture and yoga, and... whatever works! can be used in conjunction against depression. If you put this thread in SPB, some people, for whom this might be beneficial, won't read what we have to say. I find that a lot of undfounded beliefs are transmitted on PB, and it is time for that to change.

Are you open minded? Do you want us, and your patients to get better? Then the conversation should include it all. With all due respect, I believe you are wrong here.

 

CBT is superior to medications

Posted by johnhill on January 27, 2002, at 1:04:37

In reply to Sorry Elizabeth Elizabeth, posted by sid on January 26, 2002, at 18:47:09

I was on several antidepressant with moderate sucess. I took effexor for 2 years, then Paxil for 1.5 years. Boy the side effects were tough. Then I bought Dr. Burns' book and read 10 pages a night. It was like a lightbulb went off in my head. My thinking patterns were distorted, and with the techniques in the Burn's book I corrected the self defeating behavior. No more medication for me, off for 3 years.

I suggest everyone here stopped obsessing on the medications and put some effort into therapy. The medications are just a crutch, a temporary bandaid, placebo. All you people need is alittle time on the therapist couch. It will cure depression and anxiety.

Love,

JohnnyJohn

 

Re: separating discussions

Posted by Dr. Bob on January 27, 2002, at 2:55:30

In reply to Re: Redirect: in defense of CBT Dr. Bob, posted by sid on January 26, 2002, at 11:50:23

> Many of us think that CBT and meds and acupuncture and yoga, and... whatever works! can be used in conjunction against depression. If you put this thread in SPB, some people, for whom this might be beneficial, won't read what we have to say. I find that a lot of undfounded beliefs are transmitted on PB, and it is time for that to change.
>
> Are you open minded? Do you want us, and your patients to get better? Then the conversation should include it all.

I understand what you're saying, but I think of the discussions on the different boards as parts of one big conversation.

It's fine to remind people about CBT by mentioning it here, but I'd like any ongoing discussion of it to take place at Psycho-Social-Babble (where it can be linked to from here, of course). I think it's important for the discussion here to stay focused on medication, but that does *not* mean that's all people should think about.

Like in the grocery store they separate the ice cream and the vegetables. That doesn't mean you should eat only one, it just makes *both* easier to find.

True, people might not go to the vegetable aisle. But they won't necessarily buy vegetables just because you have them next to the ice cream, either. You can lead a horse to vegetables, but...

I hope that makes some sense. Further discussion of what should be posted where should take place at Psycho-Babble Administration. Thanks,

Bob

 

cbt discussion restarted at social

Posted by jane d on January 29, 2002, at 14:40:57

In reply to Re: separating discussions, posted by Dr. Bob on January 27, 2002, at 2:55:30

Thanks sid.

http://www.dr-bob.org/babble/social/20020125/msgs/17445.html

Come one, come all.

 

Re: assumptions elizabeth

Posted by Dr. Bob on January 30, 2002, at 18:59:24

In reply to assumptions about talk therapy and meds sid, posted by Elizabeth on January 30, 2002, at 8:19:11

[Posted by Elizabeth on January 30, 2002, at 8:19:11

In reply to http://www.dr-bob.org/babble/20020124/msgs/91533.html]

> [Dr. Bob: This post concerns both medications and talk therapies and doesn't necessarily belong in one forum or the other. I prefer to post here in part simply because I don't generally read PSB. I'm not willing to say that one board is better than the other, but the attitudes expressed on PSB seem to me to be more intuitive or emotional than those here, so I feel more comfortable here on PB. I hope you'll respect this. TIA.]

Well, let me try something new: part I'm leaving here (reposted below) and part I'm moving over. You don't need to read all of PSB, you know, you can just read these particular threads. :-)

http://www.dr-bob.org/babble/social/20020125/msgs/17202.html
http://www.dr-bob.org/babble/social/20020125/msgs/17445.html

Bob

> It is possible for people who are in talk therapy to recognize why it may not be working for them (often, as has been mentioned, because they're just too depressed) and decide to pursue other forms of talk therapy (e.g., psychodynamic psychotherapy instead of CBT) or that talk therapy in general isn't likely to help them (or that they need to wait until they're less depressed, for example). In contrast, we can't see what's going on in our brains at the molecular level, so we don't have a way of evaluating what medication is most likely to yield success, or whether medication is likely to help at all. I hope this illustrates why people feel justified in making a decision to pursue psychotherapy or not but can't be certain that medications will or will not work for them without trying them (it's a mixed blessing that there are so many of them to try these days). I also think there are things that we don't understand about how talk therapy works (although in this regard CBT is probably the most simplistic type of talk therapy), so it's not necessarily a good idea to rule it out altogether.

> > So I decided to try meds for the residual depression. As it turns out, it seems I have an anxiety disorder, and my doc is not convinced that I still have depression.
>
> What sort of residual symptoms do you have? Residual depression is by its nature hard to treat, since it's the part of the disorder that doesn't improve with the treatment being utilized. I think that it often requires some creativity to treat residual symptoms.
>
> > I did a test the other day and ranked very very low for depression and high for anxiety.
>
> Which test was it? IME, the results of self-report rating scale tests can be misleading. Self-report is important, but it's only one tool in making a diagnosis. Sometimes people's answers on these tests can be misleading. For example, I've noticed that some people with dysthymia seem to exaggerate the severity of their depression. (This is understandable, since dysthymia is chronic.) A problem I sometimes have in trying to answer questions on diagnostic questionnaires is that I tend to take the questions on these tests more literally than they probably were intended to be taken.

> -elizabeth

 

Re: depression, etc. elizabeth

Posted by sid on January 30, 2002, at 23:56:59

In reply to Re: assumptions elizabeth, posted by Dr. Bob on January 30, 2002, at 18:59:24

> > It is possible for people who are in talk therapy to recognize why it may not be working for them (often, as has been mentioned, because they're just too depressed) and decide to pursue other forms of talk therapy (e.g., psychodynamic psychotherapy instead of CBT) or that talk therapy in general isn't likely to help them (or that they need to wait until they're less depressed, for example). In contrast, we can't see what's going on in our brains at the molecular level, so we don't have a way of evaluating what medication is most likely to yield success, or whether medication is likely to help at all. I hope this illustrates why people feel justified in making a decision to pursue psychotherapy or not but can't be certain that medications will or will not work for them without trying them (it's a mixed blessing that there are so many of them to try these days). I also think there are things that we don't understand about how talk therapy works (although in this regard CBT is probably the most simplistic type of talk therapy), so it's not necessarily a good idea to rule it out altogether.


Well, we agree then. I was under the impression that you were against therapy after reading a few comments you wrote. We still know little about therapy (its effect on depression and why or how it might have an effect) and about meds and other alternatives as well. Depression itself is not well well yet. I guess I was so traumatized by my major depression that I am doing all I can not to have it again. I used therapy (CBT + other unidentified types - if it made me progress, I did not worry about what exactly it was) and acupuncture at that time. Both helped me and now meds seem to work too (for dysthymia), so in my experience, having tried different approaches to heal was a good thing. So when I read comments that seem to rule out some approaches altogether (not saying you did), I feel the need to say that many things did help me and that perhaps one should consider different things in order to maximize the probability of healing.

I realize I was lucky that it all had some positive effect. Although I went through a number of therapist because it did not work with some of them (one especially). Finding the right person and the right approach for oneself can be long and costly however. Same thing with the acupuncture. I moved away and have not found another acupuncturist that could treat me the same way. The first one I had made a difference in my major depression, and she could help with what I now know is anxiety. Whenever I was too stressed out to function well, her treatments would help tremendously. But I am still looking for another acupuncturist in my new city. That's one advantage of the drugs: Effexor XR anywhere is the same. Other approaches vary greatly because of the human contact and the ability of the service provider, and so they are difficult to assess and compare with drugs or with each other.

> > > So I decided to try meds for the residual depression. As it turns out, it seems I have an anxiety disorder, and my doc is not convinced that I still have depression.
> >
> > What sort of residual symptoms do you have? Residual depression is by its nature hard to treat, since it's the part of the disorder that doesn't improve with the treatment being utilized. I think that it often requires some creativity to treat residual symptoms.

Well, I'm not up to date in my depression vocabulary. I've had dysthymia for 21 years, and that's what I think I still have. I have no symptoms of major depression anymore, but there remained a deep sadness in me that I could not explain. During my major depression I read about the different types of depression and realized I had had dysthymia for a long time. In my case, therapy and acupuncture did not cure the dysthymia. Now meds seem to be helping, even though I am not yet at a supposedly effective dose (75mg Effexor XR a day). I don't feel sad anymore and a specific irrational negative attitude (thought and feeling, strong reaction) I've had for a long time have decreased in the past 2 months. So it seems the meds are helping already. The info I've read on effective doses of Effexor XR were for major depression, so for dysthymia perhaps it takes less? I am not sure. My doc also diagnosed my me some anxiety problem, hence her choice of Effexor. I am not sure what the exact diagnostic would be, but indeed, I freak out more often than most people, sometimes about nothing. I did not know about the anxiety before. I am taking yoga too now to help with it, and as a long run investment for the future stressful times of my life.

I've had dysthymia for so long that I am not sure if I can ever heal from it, but I hope so and I am doing all I can to be mentally healthy some day, hopefully without meds, but with them if need be. Plus I want to do all in my power to avoid recurrent major episodes because I am not sure I could live through it again. I am not sure I would want to either. My desire to live is conditional on my metal health at this point. I can't imagine living the never ending lightless pit that depression felt like.

> > > I did a test the other day and ranked very very low for depression and high for anxiety.
> >
> > Which test was it? IME, the results of self-report rating scale tests can be misleading. Self-report is important, but it's only one tool in making a diagnosis. Sometimes people's answers on these tests can be misleading. For example, I've noticed that some people with dysthymia seem to exaggerate the severity of their depression. (This is understandable, since dysthymia is chronic.) A problem I sometimes have in trying to answer questions on diagnostic questionnaires is that I tend to take the questions on these tests more literally than they probably were intended to be taken.

It was an informal test on www.brainplace.com., nothing formal. It pointed out which parts of my brain could be problematic and what it means in term of illness or disorder. I ranked "may be possible" for limbic system hyperactivity (associated with depression) and "probable" for basal ganglia hyperactivity (associated with anxiety disorders). All other categories were rated "not probable." I realize it is not a comprehensive test, but it is in line with how I feel these days.

I wish I had taken meds before as I think my major depression would have cleared faster and I would possibly have lessened the likelihood of recurrence. But I made the choice not to take meds at the time because I was too scared of them. I looked for more info since then, and I decided to try them for the dysthymia.

 

Re: depression, etc. sid

Posted by Elizabeth on February 1, 2002, at 18:41:55

In reply to Re: depression, etc. elizabeth, posted by sid on January 30, 2002, at 23:56:59

> Well, we agree then. I was under the impression that you were against therapy after reading a few comments you wrote.

I'm not terribly impressed with it (CBT in particular), but I don't think that it's bad or useless.

> We still know little about therapy (its effect on depression and why or how it might have an effect) and about meds and other alternatives as well.

I think that CBT makes implicit assumptions about why people get depressed, or have panic attacks, or whatever. (It's unfashionable for therapists to admit this, of course; they claim to be interested only in fixing the problem, not in knowing the cause.) And I don't think that these assumptions apply to everybody.

> I guess I was so traumatized by my major depression that I am doing all I can not to have it again.

Believe me, I'm doing everything I can, too -- but that doesn't mean I continue to do things that are ineffective! (If what you're doing isn't working, find something else -- you learned that in CBT, right? :-) )

> So when I read comments that seem to rule out some approaches altogether (not saying you did), I feel the need to say that many things did help me and that perhaps one should consider different things in order to maximize the probability of healing.

That's reasonable, although I'm wondering what you read that seemed to rule out certain approaches. I remember people posting things that they found harmful or unhelpful about CBT, but I don't recall anyone saying that it's not even worth trying.

> Although I went through a number of therapist because it did not work with some of them (one especially).

Heh. :-) I think that finding a therapist who's a good match is essential to any kind of talk therapy. It's important to be able to work with a medical doctor, too, but you really have to "click" with a therapist, IMO.

> Other approaches vary greatly because of the human contact and the ability of the service provider, and so they are difficult to assess and compare with drugs or with each other.

That's very true, and it's one reason I'm not impressed with the attempts that have been made to test psychotherapies in clinical trials. (There are a lot of design issues as well.)

> Well, I'm not up to date in my depression vocabulary.

You can still say how you feel, though, right? :-) I was curious about the quality of the residual depression/anxiety.

My residual symptoms have to do with a sort of general emotional "dulling" (no, it's not medication-induced). I have trouble enjoying things, and I seldom feel very motivated or energetic. I also can't concentrate very well. Buprenorphine helps a lot with these problems.

BTW, 75 mg of Effexor is at the low end of the therapeutic range. The threapeutic range is quite wide -- I'm taking 225 mg/day, with a target of 300 or more.

> My doc also diagnosed my me some anxiety problem, hence her choice of Effexor.

Generalized anxiety disorder, maybe? Paxil is labelled for that too, and I think pretty much any of the new ADs could get approved for it if the drug companies wanted to get them approved. Generalized anxiety overlaps a *lot* with depression, and most depressed people (including dysthymics) have some anxiety.

> I wish I had taken meds before as I think my major depression would have cleared faster and I would possibly have lessened the likelihood of recurrence. But I made the choice not to take meds at the time because I was too scared of them. I looked for more info since then, and I decided to try them for the dysthymia.

Well, what's done is done; you seem to be doing pretty well, so I wouldn't worry about it. I'm glad things seem to be working so well for you -- a lot of us aren't so lucky!

-elizabeth

 

Re: depression, etc. Elizabeth

Posted by sid on February 2, 2002, at 12:04:09

In reply to Re: depression, etc. sid, posted by Elizabeth on February 1, 2002, at 18:41:55

> > Well, I'm not up to date in my depression vocabulary.
>
> You can still say how you feel, though, right? :-) I was curious about the quality of the residual depression/anxiety.

For the past 3 months I've started to talk about my (major) depression in the past tense. So I am not very afraid for it to come back. I feel it's far enough from me not to be scared all the time and not to constantly ask myself how I'm doing (like someone with a heart disease would check his BP or pulse all the time). I think it's dysthymia I'm left with, although even that seems to be lifting. From time to time, I find myself feeling as happy as when I was about 12 years old, and that was before the dysthymia. There is more joy and potential for craziness (in a good sense) in me now. I can have fun again, which I have not had in a very long time.

> My residual symptoms have to do with a sort of general emotional "dulling" (no, it's not medication-induced). I have trouble enjoying things, and I seldom feel very motivated or energetic. I also can't concentrate very well. Buprenorphine helps a lot with these problems.

I felt like that for a long time too, I know what you mean. I could function again, but nothing mattered much to me. I had trouble making plans for the future because nothing seemed worth the effort I had to put in. I preferred being a couch potato to being active and social. Weirdly enough, it's going away now, so there's hope! The Effexor (even such a low dose?) might be helping. I did make changes in my life that may have helped though. I moved back to where I grew up (the previous 8 years had been spent in foreign countries) and last summer I spent time with old friends, swimming on hot days, playing ball, etc... things I would do before I ever know what depression was. That seems to have helped. I would be surprised at how much fun I was having and how carefree it made me feel. I never thought about it doing me good, I just went swimming one day and remembered how I was before. Somehow I found part of my old self back in that swimming pool, with pleasant memories of summer vacations.

> BTW, 75 mg of Effexor is at the low end of the therapeutic range. The threapeutic range is quite wide -- I'm taking 225 mg/day, with a target of 300 or more.

Yes, I know. I find it weird that I am doing so well, although before starting the meds I was on an upward trend. So I am not sure if it's just the upward trend continuing or if the meds are doing me some good already. I started meds when I was feeling the best I have in a long time, so it's hard to evaluate anything. I knew I could feel better and felt brave enough to try meds (I was and still am sh** scared of them). I felt strong enough to deal with the side effects, stick to a plan, discuss it with my doc and defend my point of view if I needed to. As it turns out, I found someone I agree with a lot without arguing, so at least that's going well. I am not feeling 100% yet, but things are improving. I know that 150mg+ of Effexor XR is needed to treat anxiety, so I guess we'll get there at some point.

I do exercise a lot more than before too. I went from nothing at all to badminton once a week, yoga class once a week plus home routine everyday, twice a week of threadmill and once a week of swimming. And I FEEL like moving, like exercising, I am not forcing myself to. That's a major thing. My body is toning up, I lost some weight (still lots to lose, but I don't focus on that for now), and that's making me feel less tired and less prone to sleep too much and eat too much.

As much as during the major depression I seemed to be on a downward spiral and after I seemed stuck at a less than happy place for a long time, now I seem to be on an upward spiral. I hope it lasts! Lately I've been thinking that I was happy (wow!) even though my current situation is less than enviable (esp. money problems, no stable job yet), but it's still fragile. I'm still anxious (of course) about it getting away from me again.

> > My doc also diagnosed my me some anxiety problem, hence her choice of Effexor.
>
> Generalized anxiety disorder, maybe? Paxil is labelled for that too, and I think pretty much any of the new ADs could get approved for it if the drug companies wanted to get them approved. Generalized anxiety overlaps a *lot* with depression, and most depressed people (including dysthymics) have some anxiety.

We did not get into the details, but yes, it's probably GAD, from what I read. I'll talk to her some more about it next week. I see her every 3 weeks (unless there is a problem), so sometimes it takes time to get answers. I read about Paxil too, but for now the Effexor XR is satisfying, so I'm keeping Paxil in mind in case Effexor XR poops out later on. I may ask you med advice as my treatment continues; you certainly are knowledgeable about that. Do you work/study in mental health?

In any case, I do hope you feel better soon. My experience has been that it takes time, and I often lost patience. I felt it was unfair for me to go through all this just to feel OK, which was the norm for most people, without any effort.

Let's all keep trying and hoping for the best.

- sid

 

Re: depression, etc.

Posted by Elizabeth on February 3, 2002, at 23:42:49

In reply to Re: depression, etc. sid, posted by Elizabeth on February 1, 2002, at 18:41:55

> For the past 3 months I've started to talk about my (major) depression in the past tense.

It's a great feeling, isn't it?

> I feel it's far enough from me not to be scared all the time and not to constantly ask myself how I'm doing (like someone with a heart disease would check his BP or pulse all the time).

A hypochondriac with a heart disease, anyway!

> I think it's dysthymia I'm left with, although even that seems to be lifting.

I think that what I need right now is mostly to get my life back on track: depression has been incredibly disruptive to my education and my career plans. So now I'm trying to get on track, to salvage some scrap of those plans. A big roadblock is my inability to drive; unlike Boston and New York (and even, sort of, Jersey), this North Carolina town doesn't have any public transportation to speak of. My difficulties controlling my attentional focus (maintaining focus, or shifting it -- shifting is actually the bigger problem) have prevented me from being able to drive safely enough to get a license (just one screwup is all it takes). I haven't had a seizure since September, but that's something that's been at the back of my mind too. Anyway, I've gotten to the point where I'm just not improving with practice; the limiting factor is my attention problem. I worry about how this would affect my ability to work, too. But that's sort of moot at the moment. I could go back to Boston, but I'd need some money to pay the rent until I could find a job (rent in the Boston area is painfully high); so I'd have to work here for a while at least.

> From time to time, I find myself feeling as happy as when I was about 12 years old, and that was before the dysthymia. There is more joy and potential for craziness (in a good sense) in me now. I can have fun again, which I have not had in a very long time.

I think that a lot of people don't appreciate the effect that emotional blunting can have on a person. It is a joy to be free of it.

> I could function again, but nothing mattered much to me.

I was more functionally impaired by the anergia-anhedonia, I think. With the buprenorphine, I'm pretty much back to normal. That's why it's so frustrating to be held back for want of a driver's license.

> I moved back to where I grew up (the previous 8 years had been spent in foreign countries) and last summer I spent time with old friends, swimming on hot days, playing ball, etc... things I would do before I ever know what depression was.

I'm starting to get back in touch with old friends as well. It's nice to be able to hang out and not just be a downer. Being in NC is kind of tough because I can't get anyplace on my own, but it's also sort of a vacation, and of course a chance to be with my family.

> I never thought about it doing me good, I just went swimming one day and remembered how I was before. Somehow I found part of my old self back in that swimming pool, with pleasant memories of summer vacations.

When I was "down" -- when I had untreated residual symptoms, that is -- I found I wasn't able to enjoy things like that. I'd visit friends but I couldn't think of anything to talk about with them. I'd try going swimming (I like to swim too) but it just didn't do anything for me. Even reading, which has been a favorite passtime ever since I learned how (i.e., as long as I can remember), didn't come easy; I'd keep reading the same sentence over and over without really grasping the meaning, and I couldn't get myself interested regardless of what the material was. It's a thrill to be able to enjoy reading a good book or going for a walk or being with friends now that I can. I've even reviewed a bit of math and chemistry.

> Yes, I know. I find it weird that I am doing so well, although before starting the meds I was on an upward trend. So I am not sure if it's just the upward trend continuing or if the meds are doing me some good already.

How long have you been taking the 75 mg? I've been on 225 for a couple of weeks.

> I knew I could feel better and felt brave enough to try meds (I was and still am sh** scared of them).

Why scared?

> I felt strong enough to deal with the side effects, stick to a plan, discuss it with my doc and defend my point of view if I needed to.

Being able to advocate for yourself as a patient is crucial, and this creates big problems in doctor-patient relationships (especially in psychiatry, where patients are particularly unlikely to be able to speak up for themselves).

> As it turns out, I found someone I agree with a lot without arguing, so at least that's going well.

That's ideal. I find that so many doctors want to fight with me about the medication that I'm already taking, that I know works, and that I need, which is frustrating.

> I am not feeling 100% yet, but things are improving. I know that 150mg+ of Effexor XR is needed to treat anxiety, so I guess we'll get there at some point.

I don't think that's always true; it's possible that 75 will prove to be enough for you. Remember that generalized anxiety is a really broad diagnostic category; people with GAD are a very heterogeneous group.

> ... I FEEL like moving, like exercising, I am not forcing myself to. That's a major thing. My body is toning up, I lost some weight (still lots to lose, but I don't focus on that for now), and that's making me feel less tired and less prone to sleep too much and eat too much.

I'm eating more now that I'm feeling better, but I'm also more active. It's nice. One thing I miss about Boston is that I got to walk around a lot (I was about a 30 minute walk from Harvard Square and 15 minutes from MIT) -- there's not really anywhere I can get to on foot from here.

> As much as during the major depression I seemed to be on a downward spiral and after I seemed stuck at a less than happy place for a long time, now I seem to be on an upward spiral. I hope it lasts!

I'm still struggling uphill, but that's more a lifestyle thing than a mood thing. (Still, I wouldn't say I'm on an "upward spiral!")

> I read about Paxil too, but for now the Effexor XR is satisfying, so I'm keeping Paxil in mind in case Effexor XR poops out later on.

Any SSRI would be fine; it doesn't have to be Paxil. Remeron or Serzone could be good too. And the MAOIs (Nardil especially) are the best antidepressants for most anxiety disorders, IMO.

> I may ask you med advice as my treatment continues; you certainly are knowledgeable about that. Do you work/study in mental health?

I'm a mathematician by training, and more recently I was taking classes (a couple of the basic sciences that I didn't take in college) to prepare for the MCAT. I haven't worked in a while. But neurobiology and psychopathology (and the bridge between them) are among my interests(one could even call them hobbies -- I have a lifelong history of weird hobbies).

> In any case, I do hope you feel better soon. My experience has been that it takes time, and I often lost patience. I felt it was unfair for me to go through all this just to feel OK, which was the norm for most people, without any effort.

I have trouble even understanding what it's like to be "normal." You know?

> Let's all keep trying and hoping for the best.

Or trying in the absence of hope, if need be.

-elizabeth

 

Re: depression, etc. Elizabeth

Posted by sid on February 4, 2002, at 17:35:04

In reply to Re: depression, etc., posted by Elizabeth on February 3, 2002, at 23:42:49

> I think that what I need right now is mostly to get my life back on track: depression has been incredibly disruptive to my education and my career plans. So now I'm trying to get on track, to salvage some scrap of those plans.

I know about that! There have been delays in my Ph.D. and now in my career. Because of them, I am not sure I still have a career. Had I survived cancer, I could explain it in a presentation letter, while looking for a job. But depression still has a stigma to it; that would possibly ruin my career for good instead of help. This is really unfair. We are sick, we suffer AND there are long term consequences to it too.

> A big roadblock is my inability to drive; unlike Boston and New York (and even, sort of, Jersey), this North Carolina town doesn't have any public transportation to speak of. My difficulties controlling my attentional focus (maintaining focus, or shifting it -- shifting is actually the bigger problem) have prevented me from being able to drive safely enough to get a license (just one screwup is all it takes). I haven't had a seizure since September, but that's something that's been at the back of my mind too. Anyway, I've gotten to the point where I'm just not improving with practice; the limiting factor is my attention problem. I worry about how this would affect my ability to work, too. But that's sort of moot at the moment. I could go back to Boston, but I'd need some money to pay the rent until I could find a job (rent in the Boston area is painfully high); so I'd have to work here for a while at least.

Well, I hope you get well enough soon to get some attention back and get the driver's license. You could then be more active and that could possibly help a lot in the healing process.

> How long have you been taking the 75 mg? I've been on 225 for a couple of weeks.

I was on 37.5mg Effexor XR for 6 weeks (I felt better already; after 10 days or so, there were some improvements), and I've been on 75mg for about a month now. I'm seeing my doc on Thursday.

> Why scared (of meds)?

I told you a few months ago, but I'll tell the story again. My father was hospitalized with major depression when I was 20 years old. After a few weeks in the hospital, he'd come out on weekends. One weekend he decided not to take his meds, and we knew nothing about dosage, etc, it basically his responsibility without supervision. He "lost it" threatening to kill himself or us if we didn't leave him alone, etc... Major crisis. I managed to reach our family doctor, and he said that he probably didn't take his meds, that we needed to put him to bed and force him to take his meds, physically control him if we needed to. When it's your father, you freak out, and I did. Else we needed to call an ambulance and get him right back to the hospital. That threat is what I reasoned him with to go to bed, rest, and take his meds. Thereafter, I swore I'd never take ADs.

> Being able to advocate for yourself as a patient is crucial, and this creates big problems in doctor-patient relationships (especially in psychiatry, where patients are particularly unlikely to be able to speak up for themselves).

I have a general doctor, which may make things easier relationship-wise. I know that she treats a lot of people for mental illnesses, so she developed some expertise over time. I'll go see a pdoc if I feel the need to, but for now, things are going OK.


> it's possible that 75 will prove to be enough for you. Remember that generalized anxiety is a really broad diagnostic category; people with GAD are a very heterogeneous group.

That would be great. We'll see, on Thursday I should know better whether I'll increase the dosage or not.

> I'm eating more now that I'm feeling better, but I'm also more active.

I'm more active and I eat less. Thank God because I loaded up on carbs like crazy during the depression and I gained a lot of weight. I find myself physically repugnant now. I'm not too severe in the sense that I went through a lot of hardship, but I want to improve my physical appearance. I've been a mess for a long time and it shows still. It's not my priority, but it's on my to-do list.

> I'm still struggling uphill, but that's more a lifestyle thing than a mood thing. (Still, I wouldn't say I'm on an "upward spiral!")

Upward spiral was strong. Let's say that I don't have to do as much as before to feel good. That in itself makes me feel even better!

> Any SSRI would be fine; it doesn't have to be Paxil. Remeron or Serzone could be good too. And the MAOIs (Nardil especially) are the best antidepressants for most anxiety disorders, IMO.

OK, thanks. I'll take note of it in case it's needed later. I know my doc told me we'd augment at some point with another molecule in order to affect the brain in a different way and cover more bases (or something like that... I don't know much about it).

> I'm a mathematician by training, and more recently I was taking classes (a couple of the basic sciences that I didn't take in college) to prepare for the MCAT. I haven't worked in a while. But neurobiology and psychopathology (and the bridge between them) are among my interests(one could even call them hobbies -- I have a lifelong history of weird hobbies).

Cool. I love math. I use it rather than develop it, but I do use it (pretty basic stuff) everyday.

> I have trouble even understanding what it's like to be "normal." You know?

Oh yeah. A couple of weeks ago I asked on this board how it felt to be "OK". My doc said I'll take the meds at the same dosage for at least 1 more year, providing it doesn't poop out, once we consider I'm "OK." Then we'll taper and see what happens (I pray not to have to take meds all my life, but I may have to). I asked what she meant; she simply said "one thing at a time." So I'm not too sure. Perhaps I'm close to it, perhaps I'm still far. No idea.

Take care, and take your meds (this is Psycho-Babble after all)!

- sid

 

Re: depression, etc. sid

Posted by Elizabeth on February 7, 2002, at 13:04:06

In reply to Re: depression, etc. Elizabeth, posted by sid on February 4, 2002, at 17:35:04

> I know about that! There have been delays in my Ph.D. and now in my career. Because of them, I am not sure I still have a career. Had I survived cancer, I could explain it in a presentation letter, while looking for a job. But depression still has a stigma to it; that would possibly ruin my career for good instead of help. This is really unfair. We are sick, we suffer AND there are long term consequences to it too.

Yeah -- some people at least pretend to believe depression is a medical condition like any other, but we do still get treated differently, and there's plenty of reason for us not to want to "come out of the closet," so to speak. Maybe if people pretend long enough, future generations will really believe it.

> Well, I hope you get well enough soon to get some attention back and get the driver's license. You could then be more active and that could possibly help a lot in the healing process.

I agree. The concentration thing is a real problem for me, though. And I'm sort of hesitant to ask for a stimulant when I'm already taking buprenorphine (which is also a stimulant for me).

> I was on 37.5mg Effexor XR for 6 weeks (I felt better already; after 10 days or so, there were some improvements), and I've been on 75mg for about a month now. I'm seeing my doc on Thursday.

Wow, that's cool. You've been increasing it pretty slowly, but it sounds like it's paying off for you. The 225 is definitely helping some, but I think I could stand to go up to 300.

> I told you a few months ago, but I'll tell the story again.

I'm sorry! I have trouble keeping up with all the stories people tell here, although I do like to read them (I almost typed "hear" instead of "read" there!).

> My father was hospitalized with major depression when I was 20 years old. After a few weeks in the hospital, he'd come out on weekends. One weekend he decided not to take his meds, and we knew nothing about dosage, etc, it basically his responsibility without supervision. He "lost it" threatening to kill himself or us if we didn't leave him alone, etc... Major crisis. I managed to reach our family doctor, and he said that he probably didn't take his meds, that we needed to put him to bed and force him to take his meds, physically control him if we needed to. When it's your father, you freak out, and I did. Else we needed to call an ambulance and get him right back to the hospital. That threat is what I reasoned him with to go to bed, rest, and take his meds. Thereafter, I swore I'd never take ADs.

Things have changed since then, I think. But I would have been scared of *not* taking meds based on what you've told me there!

> I have a general doctor, which may make things easier relationship-wise.

I don't know. I think that the attitudes of GPs toward us (psych patients, that is), overall, are probably similar to those of psychiatrists. If I had a GP who I had known for a long time and who I felt was qualified to treat my depression, I'd see him/her instead of a psychiatrist.

> I know that she treats a lot of people for mental illnesses, so she developed some expertise over time.

A lot of GPs treat depression and anxiety, at least -- not so much the more serious things like schizophrenia, and I think that most GPs would want to make a referral to a psychiatrist if someone had severe treatment-resistant or psychotic depression, bipolar, OCD, ADHD, or borderline personality. Most of them have experience prescribing the new ADs, TCAs, and benzos, at least. I don't know how exceptional your GP is.

> That would be great. We'll see, on Thursday I should know better whether I'll increase the dosage or not.

Are you getting any side effects? I haven't noticed any so far.

> I'm more active and I eat less. Thank God because I loaded up on carbs like crazy during the depression and I gained a lot of weight.

That's always surprised me, that some people do that. Like, "who wants to eat when they're depressed???"

> I find myself physically repugnant now.

I felt that way when I was depressed. I avoided mirrors.

> I'm not too severe in the sense that I went through a lot of hardship, but I want to improve my physical appearance.

So do I (I'm not fat as such, but I am out of shape), but it's no longer something I worry so much about.

> I've been a mess for a long time and it shows still. It's not my priority, but it's on my to-do list.

Yeah, that's how I feel too.

> Upward spiral was strong. Let's say that I don't have to do as much as before to feel good. That in itself makes me feel even better!

I had given up on feeling good and settled for feeling flat. Being *able* to feel good feels like such a blessing now.

> OK, thanks. I'll take note of it in case it's needed later. I know my doc told me we'd augment at some point with another molecule in order to affect the brain in a different way and cover more bases (or something like that... I don't know much about it).

That's a typical strategy, adding something that has a different mechanism or affects different neurotransmitters. One of the first things that I tried when I became depressed in college (this was my second diagnosed episode -- I may have had one episode before I was diagnosed) was prozac + desipramine (this was 1993, and the SSRIs were the only "new-generation" ADs around). Augmenting SSRIs or Effexor with Remeron or Wellbutrin is also a popular strategy. Sometimes stimulants or direct dopamine agonists are used. I'm finding that the Effexor + buprenorphine strategy is working nicely, activating the endogenous opioid system in addition to monoamines.

> Cool. I love math. I use it rather than develop it, but I do use it (pretty basic stuff) everyday.

Maybe you've said this already, but what do you do?

> Oh yeah. A couple of weeks ago I asked on this board how it felt to be "OK".

Ahh yes. Well, I wish you luck in your search for OKness. :-) I'm really beginning to regain my confidence, feeling like "I can do this" ["this" being living life]. It was scary feeling like I might have to depend on my family for the rest of my life. I don't know how close I am to getting back to where I was (living on my own, working, taking classes, etc.), but I know that I now feel like it's a real possibility. And that's a big step in itself.

-elizabeth

 

Re: depression, etc. Elizabeth

Posted by sid on February 7, 2002, at 20:38:22

In reply to Re: depression, etc. sid, posted by Elizabeth on February 7, 2002, at 13:04:06

> > I was on 37.5mg Effexor XR for 6 weeks (I felt better already; after 10 days or so, there were some improvements), and I've been on 75mg for about a month now. I'm seeing my doc on Thursday.
>
> Wow, that's cool. You've been increasing it pretty slowly, but it sounds like it's paying off for you. The 225 is definitely helping some, but I think I could stand to go up to 300.

Saw my doc today. She gave me something to help me sleep (fall asleep, has 4 hours of effect only) and I'm staying at 75mg for at least 3 more weeks. She confirmed what I felt: I'm doing better already. We'll see, but I may not even go higher than 75mg of Effexor XR.

> > I told you a few months ago, but I'll tell the story again.
>
> I'm sorry! I have trouble keeping up with all the stories people tell here, although I do like to read them (I almost typed "hear" instead of "read" there!).

No problem; same for me. I'm rather visual and remember faces more than names, so on a board like this I have trouble keeping track of who's who and who said what.

> > I know that she treats a lot of people for mental illnesses, so she developed some expertise over time.
>
> I don't know how exceptional your GP is.

Wel,, she was recommended to me by 2 people she treated for depression, and I notice in her waiting room, there's a lot of info on mental diseases. She may not be exceptional, but it seems like people go to her a lot for depression.

> Are you getting any side effects? I haven't noticed any so far.

Oh yeah! I never took any drug before except aspirin, birth control pills or antibiotics. The first week at 37.5mg per day, I slept about 2 hours per night. The first 5 days I felt "drugged." I was spacey and had trouble with my vision and psychomotricity. I payed badminton one night and I looked like I was drunk or something. Couldn't follow the birdie, had trouble coordinating my movements, etc. Couldn't think straight either.

Then most side effects subsided except recurring constipation and sleep problems. After 6 weeks, I went up to 75mg and I've had sleep problems since. Once I fall asleep I sleep well, don't wake up before about 7-8 hours after, but falling sleep is a challenge. I fell asleep at 4AM this morning and had a doctor's apptment at 8:15AM.
:-(
Anyway, we're trying to address that. I waste too much time because of the sleep deprivation and my work is suffering from it. I still have recurrent constipation; I simply adjust my diet accordingly.

> That's always surprised me, that some people do that. Like, "who wants to eat when they're depressed???"

Well, I ate carbs without even noticing I was eating, I was like an eating zombie. I wouldn't say I wanted to eat, I just did it automatically. There was no pleasure in it, it was almost like an addiction: carbs, carbs, carbs. And I slept way too much during the depression. A big couch potato. :-(

> Maybe you've said this already, but what do you do?

Reasearch and teaching in economics. Writing mathematical models of human, firm and institutional behavior all the time.

> Ahh yes. Well, I wish you luck in your search for OKness. :-) I'm really beginning to regain my confidence, feeling like "I can do this" ["this" being living life]. It was scary feeling like I might have to depend on my family for the rest of my life. I don't know how close I am to getting back to where I was (living on my own, working, taking classes, etc.), but I know that I now feel like it's a real possibility. And that's a big step in itself.

Good for you. It sounds like you're on the right path to OKness or at least for now for betterness!

- sid


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