Medical Weblog

Support groups now exist for many serious and debilitating illnesses, and depression is no exception in this regard. Such organizations provide up-to-date information and meetings to help members and their families cope with depression. A listing of available support groups that deal with depression and related disorders is provided in the Resources chapter at the end of this book.

Recovery or 12-step groups are modelled on the principles set down by Alcoholics Anonymous, which was the first such group to be developed. There are currently recovery groups for drug addicts, sex and love addicts, compulsive gamblers, overeaters and the adult children of alcoholics. There are also separate groups for the spouses, partners or family members of those who participate in these various groups. Recovery groups combine a programme consisting of working through a series of specific steps with fellowship, support and simple wisdom. In meetings people learn that they are not alone in their unhappiness. They are encouraged to talk freely and are listened to in a non-judgemental way without being challenged or confronted. There is a spirit of respect for what people have to say and the problems they are grappling with.

I have encouraged many of my patients with depressions and addictions to go to an appropriate recovery group, often with good results. At times I have managed to locate another group member who is willing to pick the newcomer up and take him or her to a meeting of the group. I have encountered considerable reluctance in my patients to go along with this suggestion and they have frequently cited concerns about confidentiality and their professional reputations. Nevertheless, all those who have followed my suggestion have found such groups to be quite valuable. It is very important in choosing a group to pick one where you feel you can identify with the other group members. Token contributions are requested of members. I often appeal to the ordinary human instinct (possibly genetically programmed) for finding a bargain, by pointing out to my patients that at 50 pence a meeting, recovery groups are the best deal in town.

Even if one is not an addict, these groups might still be helpful and, given the large number of groups available, it is usually not difficult to find one where you feel at home. One of my patients, a woman in her mid-sixties, has suffered from severe intermittent depressions for decades despite my best efforts at medicating her with multiple anti-depressants including St John’s Wort. She would qualify as an adult child of an alcoholic as her mother was drunk through much of her childhood and died of cirrhosis of the liver when the patient was a young girl. She was reluctant, however, to go to a recovery group, so I shared with her some of the slogans that members of recovery groups often repeat to themselves and to others by way of encouragement.

To my surprise, this extremely sophisticated woman, a veteran of many years of all sorts of psychotherapy, repeated the slogans to herself several times and wrote them down carefully every day. The slogans I shared were:

One day at a time.

Just get your body there; the rest will follow.

Fake it till you make it.

These are all useful slogans for the depressed person, who amplifies his or her troubles and projects them into the distant future. Take one day at a time, the slogan urges. If you consider all possible future problems at once they will seem overwhelming and you can drown in a sea of sorrows. In the case of an addict, this can drive a person to drink, drugs or acting out in some addictive way.

In a depressive person, it can drive one to despair. In contemplating some professional or social commitment, a depressed person frequently asks, ‘How can I possibly handle it?’ Just get there, urges the slogan. Often your automatic pilot will take over and see you through. In a song written to encourage those in despair, the singer Billy Joel counsels the listener not to forget his second wind but rather to wait for the momentum to kick in. My patient used this way of thinking to help her get to a wedding which she had no wish to attend. Once there, however, she surprised herself by having quite a good time and afterwards felt very pleased that she had been able to come through for her friends and family. The slogan ‘fake it till you make it’ suggests that if you pretend you are managing, you might be surprised to discover that you really are managing after all. Things may turn out this way for all sorts of reasons. First, the anticipation of the task or event may be worse than the thing itself. In certain types of depression it is impossible to anticipate pleasure, but once placed in a pleasurable situation you may actually be capable of enjoying it. Another reason why you might make it after you fake it is related to daily or circadian rhythms of mood, whereby it is common for a person’s depression to be at its worst in the morning and to improve as the day wears on.

Some people balk at recovery groups because many of the steps are geared round the concept of a Higher Power and, as such, may offend a person’s religious sentiments or lack thereof. Nevertheless, the whole matter is generally handled with a light touch and in a non-coercive way that many people find acceptable.

In summary, support groups offer invaluable information and encouragement around specific illnesses including depression, while recovery groups provide fellowship, wisdom and tangible assistance for people with all manner of sorrows and problems.

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Yes, it is. Prozac has a powerful effect on the frightening bursts of anxiety and rising waves of panic that characterize panic disorder, the symptoms of which include shortness of breath, dizziness, rapid heartbeat, sweaty palms, trembling, choking, chest pain, and fear of going crazy, passing out, or dying. In one study, nineteen out of twenty-five patients who were treated with Prozac for panic disorder and, in some cases, agoraphobia, showed moderate to remarkable improvement in their symptoms. Treatment was most effective when it started at the low level of 5 mg a day.

It is likely that Prozac and other medications, by alleviating panic attacks, can also cause a decrease in the symptoms of agoraphobia, the debilitating fear of open spaces, including going into crowded streets and department stores that often results in patients becoming completely housebound, sometimes for years on end.

Behavioral therapy, typically including exercises aimed at desensitizing the patient to frightening stimuli, also plays an important role in the treatment of both panic disorder and agoraphobia. Patients with panic disorder, agoraphobia, or social phobia, should use a combination of an antidepressant and behavioral therapy.

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The expression “normal mood” is basically an artificial construct. In reality, most people experience mild and transient moodswings. Anyone can feel more down than usual or more up than usual for a few hours or several days; those mild mood fluctuations are part of what we mean by normal. But when the person is always revved up or always down in the dumps, when these up or down feelings become so strong that they go beyond the usual baseline range, psychiatrists begin to consider the mood pathological even if the patient does not

Patients are likely to define the word normal in individual ways that entirely depend on their personal fusion. For people with a life-rime history of minimal depression, normal is for them slightly depressed. To psychiatrists seeing these patients and comparing them with hundreds of other people in the general population, these patients are clearly more depressed than the cultural norm and would be diagnosed as such. These people might be considered hypothymic; their mood is at the bottom of normal or slightly below.

Similarly, hyperthymics who have been energetic, driving, and productive all their lives usually see this as their normal mood. However, experts in mood disorders know that these people are more energetic and active than are most people in the population. These people lead lives at the top of normal or slightly beyond—although they describe themselves as “normal.”

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Because 15% of patients with bipolar manic depression ultimately commit suicide and the rates for unipolar depression seem to be similar, it would appear that suicidal thoughts are very common.

Between 40% and 60% of patients undergoing an acute episode of major depressive disorder have suicidal thoughts, and an even higher percentage may have a history of suicidal thoughts or wishes. Many other psychiatrists and psychophannacologists would go even further, believing mat as many as 90% of patients who appear in the psychiatrist’s office for the treatment of acute or chronic depression have at some time at least expressed the thought that “I sometimes wish I were dead,” or “My family would be better off without me,” or “I wish I could go to bed and never wake up,” or “I just wish I’d get hit by a car.”

In 1991, a total of 30,810 people killed themselves, making suicide the eighth leading cause of death in the United States. Provisional data indicate that fewer people killed themselves in 1992, dropping suicide a notch on the ladder of death. As of this writing, suicide appears to be the ninth leading cause of death, right behind a new entry in the top eight HIV infection.

But regardless of the precise figures, the likelihood is strong that far more people than reported actually died by their own hands. Because there is still a stigma against suicide, not all self-inflicted deaths are so labeled, and many forms of suicide, such as single-car accidents and death through drug abuse, are neither acknowledged nor identified as such.

Moreover, the number of people who attempt suicide without success is thought to be fully eight to ten times larger than the number of those who succeed.

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Depressed patients are first required to have a complete physical exam, an EKG, and a blood chemistry profile that measures, among other substances, the level of thyroid hormone. Because an amount below the normal range is sufficient in itself in some cases to cause depression, patients with underactive thyroids may need first and foremost to take thyroid medication. If the depression has not begun to disappear on thyroid hormone alone after seven to ten days, a trial of an antidepressant is initiated. However, if patients are already in a major depression superimposed on hypothyroidism, they may need an antidepressant as well as the thyroid hormone.

Fortunately, studies have shown no important interactions between Prozac and thyroid hormone. The two medications can be taken simultaneously. Thyroid hormone is usually given as levothyroxin. Cytomel or T3 (triiodothyronine) is given to boost the action of tricyclic antidepressants and used as a step-up treatment with Prozac if the antidepressant is not doing the job on its own.

To date, no clear-cut warning has been given regarding any important adverse effects of Prozac on the thyroid. Very infrequent cases of hypothyroidism have been reported with patients on Prozac. Even more rarely, goiter and hyperthyroidism have been reported, although they probably are not related to the Prozac treatment.

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Prozac is usually taken in the morning after breakfast, which seems to produce fewer side effects, particularly nausea and insomnia. But some patients have been able to tolerate it with other meals or at other times of the day, including bedtime, without adverse side effects. Many patients take Prozac at a time when it is most convenient for them or simply easy to remember, whether in the morning, after dinner, or at bedtime.

Can you overdose on Prozac? Not easily. During preclinical trials with Prozac up to 1993, no deaths occurred in patients receiving Prozac in normal doses. Two deaths were reported during comparative clinical trials, but in both cases other drugs were involved, so the role of Prozac is not clear. Another thirty-two patients recovered after overdose without any lasting harm, including one who reportedly took 3000 mg of Prozac, which is over thirty-seven times the recommended maximum dose of 80 mg.

In contrast, it is easy to overdose with other antidepressants such as the TCAs and MAOIs due to the toxic effects of high doses on the heart. With Prozac, even in large amounts, the risk of serious cardiovascular or neurologic harm is very small. Prozac should be considered one of the safest of all the antidepressant drugs.

If I will take a capsule by mistake, will it hurt me? No. A single dose of Prozac should not hurt a healthy person. The possible side effects and risks of using Prozac in small doses in conjunction with tricyclic and tetracyclic antidepressants appear to be minimal. However, the use of Prozac with MAOI antidepressants such as Nardil, Parnate or Marplan is considered dangerous. Prozac taken by mistake with an MAOI could conceivably cause a toxic reaction with elevated blood pressure, nausea, vomiting, or shock. Immediate transport to an emergency ward is indicated if such symptoms follow. A patient switching from an MAOI to Prozac must wait at least two weeks. A patient switching from Prozac to an MAOI must wait at least five weeks. Failure to observe these precautions can result in severe toxic reactions and even death.

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