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When depression becomes problematic it must be attended to, and by nipping it in the bud, you can regain control and keep it from getting worse. Professionals who work with patients with chronic illnesses identify one major theme as the feeling of loss of control over their lives. Because learned helplessness is a proven theory of depression it is logical that people with chronic illness very often become depressed. You will also feel angry and must be careful to not turn that anger inward or at loved ones.
The DSM IV (Diagnostic and Statistical Manual of the American Psychiatric Association) recognizes a particular type of depression associated with physical diseases. This is also the reason why it is critical to become an active participant in your medical care, to learn as much as possible, to be a whole person with the disease as just one part of who you are (and not how you think of and identify yourself). Your dermatologist may be the Captain of the ship with regard to your treatment, but you should not be satisfied to be just a passenger; at the very least you are the First Mate. And, when working with your other physicians you will often know more about your disease than they do. Sometimes your assertiveness in your care can lead to resistance when you attempt to educate professionals. Do not let this deter you. Your goal is to get the very best medical care you can and to remain a whole person, not a walking disease. You can use the PPS website, The Village online support group as well as other resources to stay knowledgeable about the disease, and learn how others are handling similar experiences. Be aware of your weaknesses, but also identify your strengths; it is working from and focusing on your strengths that will move you forward.
¨When family, friends, trusted and colleagues are not able to provide an adequate support system, you need to deal with this. For example, some people have difficulty dealing with others illnesses because they feel helpless, while others may be able to help at first and later get burnout or feel overwhelmed by the experience. Whatever you do, not voluntarily isolate yourself. Also remember that physical activity (even a short walk or going up and down stairs) has been proven to be helpful.
¨How can having a serious chronic illness, that can be debilitating, necessitating strong medications and which can make your every day life and moods a roller coaster, plus the uncertainty of your future, not affect quality of life and relationships? Other preexisting factors, such as age, other physical and emotional factors, lifestyle, etc., will also affect how the diagnosis and treatment will change your life.
Anxiety can be as debilitating as depression, but often they go hand in hand. I will give an overview of Major Depressive Disorder (MDD), which can be mild, moderate, or severe. Often physicians ask if you are depressed, rather than asking about particular symptoms. Some of the information I present in this article is from A Depressive Disorders from Highmark Blue Cross/ Blue Shield.
¨Per the DSM IV, If depressed mood or loss of interest or pleasure persists for more than at least a two-week period, consider the diagnosis of a depressive episode. Some diagnostic criteria are summarized here:
At least five of the following symptoms are present during the same two-week period, nearly every day, and represent a change from previous functioning. At least one of the symptoms must be either 1) depressed mood or 2) loss of interest or pleasure.
1. Depressed mood (or can be irritable mood)
2. Markedly diminished interest or pleasure in all, or almost all activities
3. Significant weight loss or gain
4. Insomnia (difficulty falling asleep, sleep continuity disturbance, early morning awakening) or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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How do you assess for someone at acute risk of suicide?
1. Severe agitation/ anxiety/ panic
2. Global (persistent) insomnia
3. Severe anhedonia (an inability to experience pleasure in usually pleasurable activities)
4. Recent substance abuse. This includes abuse of prescription or over the counter drugs.
Depression is treated with pharmacotherapy, psychotherapy, or a combination of both. Generally, because of the effectiveness of antidepressant medications (usually tricyclics or SSRIs preferably not addictive anxiolytics), most patients with moderate and severe depression will warrant a trial of a medication. Please note that even when a patients core symptoms have positively responded to a medication, referral for psychotherapy is usually appropriate for correction of dysfunctional behavioral patterns or sometimes just for an impartial and nonjudgmental person to vent to. Dealing with depression is a necessary part of coping, and it is a skill which can be learned.
In patients with MDD, relapses and recurrences are common. After remission of depressive symptoms, how long to continue on a medication (and dosage) becomes a key question. Never discontinue a medication without telling anyone! Just because you feel better does not mean you no longer need medication. In fact, the current position of psychiatrists is that when a patient no longer feels the need to be on medication, it is best to wait 6 12 months to taper or discontinue.
Once a decision to discontinue a medication is made, the dosage should usually be gradually tapered over at least 4 weeks to avoid potential withdrawal symptoms and rebound reactions with most of the tricyclic antidepressants, SSRIs and other drugs such as Bupropion, Remeron, or trazodone (Desyrel). Do not play doctor regarding medications, although second opinions are fine. Also, be careful with regard to self-medicating with alcohol, nicotine, caffeine, and herbs, etc.
Per the insurance company the keys to successful management of depression include: 1) thorough screening, 2) patient engagement and education, 3) early follow-up of adherence to the treatment plan and careful monitoring of response.
When I first received my PV diagnosis I tried to take care of necessary business and made an appointment with a psychiatrist and spoke to two valued colleagues to make sure my own case analysis was on track. I repeat this process regularly. Even professionals need objective professional opinions. I would never treat myself.
You can usually find out a particular psychologists specialty areas or areas of expertise from your insurance company, the local psychological association, or from other doctors. You may not need intensive therapy, and you may not meet the criteria for a Major Depressive Episode, but you will likely find therapy helpful in dealing with your unique problems, past and present. No professional likes to be used once and then traded for another, but if you feel a need to try more than one therapist or if there is a personality or other conflict, do not hesitate to try another psychologist, social worker, or counselor. And, dont be afraid to ask this person about their training, degrees, therapeutic approach and techniques.
This is your life, and you want to be active in your treatment. If you do not have insurance to help defray the costs of therapy, there may be doctoral candidates at a university near you who can provide inexpensive clinical services, while being supervised by a licensed psychologist.
In Pittsburgh we have two universities with clinical services provided by advanced students for as little as $10 - $15 per session. Your local psychological or social worker association may also have names of licensed professionals who will see you for no cost or a reduced fee.
Originally published in the February 2004 issue of Recovery.
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