Thursday, June 23, 2011

Sad, Angry, or Anxious Depression

People commonly say that "I am depressed", thinking that they have accurately described something like a 'fever'.  "I am depressed, I have a fever".  Mood is seen as a scale going from zero to 10 or 1-10 positively and 1 to 10 negatively.  If a person has a fever, we can give them aspirin, a very good "anti fever" medication.  However fever can be caused by a 'myriad' of things and it is considered very bad medicine to treat a 'fever' without a 'cause'.  Yet commonly people will say "I am depressed" and be given an "anti depressive" medication and never delve into what is the 'cause'.  The discussion can quickly get into which antidepressant is better in much the same way that a person my discuss with a pharmacist technician whether to take aspirin, tylenol or advil for a fever.  There is often a 'collusion' between the doctor and patient as to not explore the 'cause'.  Indeed some doctors would say 'there's no money in that, it's just opening a can of worms'.

And yet the very expression of the word 'depression' can mean many different emotions.  HALT - hungry, angry, lonely, tired is just one acronym to help people to become 'emotionally aware".  Most people are 'emotionally illiterate'.  Their knowlege of 'emotional language' is rudimentary at best.  Yet if I ask a person is there 'depression" more 'irritability' or 'sadness' I learn an immense amount about cause and indeed that simple question should refine which of the antidepressant approaches is most likely to succeed.

One of the most important questions of all in regards to depression is to ask, 'when did you last not feel depressed."  One patients said "I think in the womb".  Now there's limits to this questions as there is 'emotional retrospective falsification'.  The severity of this cognitive distortion is seen mostly clearly in divorce proceedings where two very angry depressed people will insist "I never loved him", "I never loved her", yet a dozen little cherubs will be living in the soon to be divided home going from kindergarden to high school.  Yet if the person can't remember a time when they were not depressed this is a very different matter from a 'mild' 'acute' fever.  This is more likely a 'chronic' depression and the cause of 'chronic' depressions are even bigger cans of worms than 'acute' depressions.

A useful way to look for 'causal associations' in regards to depression is to look first for 'loss'.  It's common for a person to have depressed feelings when they lose someone or something important to them.  Indeed, some theorists have opined that depression is simply prolonged and pathological grief.  Loss of a job, a marriage, a home, a loved one all can cause grief but if it persists it may become depression.  This is the tradition "sweety boy and sweety girl' approach to looking at depression. Many clinicians like to assume this and everyone can 'play sweet' and no one gets hurt and there's no need to look further because we all collude in believing that this loss sometimes incredible minor can explain this ofttimes over reactive gargantuan depression ("I can't go back to work, I can't have sex, I can't get out of bed, since I broke my fingernail.)    That said, loss is common, especially in the family physicians office and this is a very good place for the use of antidepressants and indeed antidepressants work best in  this scenario.

The alternative loss however is 'failed expectation".  Expectations have been called "preformed resentments'.  Much of depression is 'resentment'.  It's also been described as narcissistic entitlement though this is a bit over the top for what more commonly comes into the office.  People may have had an expectation of having a job, all their lives they've been told if they are good people, and work hard, they will in fact have a job. One day through no fault of their own, really, they find themselves unemployed. There's loss, alright but the depression happens not in the 'grief' over the lost job but in the failure to find another. This commonly occurs after divorce. Many people celebrate divorce and are thoroughly relieved to no longer have to care for a drunken drug addicted chronically depressing whining complaining spouse with ugly family and friends.  However, if months or years go by and no Angelina Jolie or Brad Pitt has come along to fulfill there dreams this person may describe themselves as 'depressed'.  Antidepressants may work in these situations but more commonly atypical antipsychotics are the medication of choice because they get at the underlying irritability and anxiety.  This patient is often quite terrified that they are never going to work or love again.

Of course , no one really wants to look at whether their expectations are realistic and what they can do to change their life course so that they are more likely to have less depressing life in the future. In one case the person is 'depressed' whereas in the next case their life is 'depressed'.  Learning to see the good in what is obviously not so good takes more than medication or a pat on the shoulder and 'there, there' that classic mommy 'ego massage therapist' approach.  In this latter scenario it's best to take a 'hard' look at one's life with the help of someone who isn't afraid to ask 'tough questions'.  Alternatively a person can keep coming back to the doctor for life and keep not getting beyond that 'knot' or 'set back' that seemed to change 'their luck'.   Medications make both kinds of depression better but in one 'simple' case the person tends to 'self heal' whereas in the latter case there's a need for adjustment or actual 'psychic surgery'.  Chiropractics and surgery were the terms for the cognitive and analytic therapies which worked best in this group in combination with medication.
That said, there are even more forms of depression related to 'cause' and to the particular culture of an individual.  More often than not the word 'depression' is used for 'anxiety'.  Indeed many theorists accept depression as 'chronic anxiety'. The question then is 'what are you afraid of" and more importantly 'where did you learn to fear like this' and 'what do you need to protect yourself from your 'fear''.  Maybe a 'rabbits foot' in the pocket or a baseball bat at the door would make an antidepressant work a whole lot better. Certainly education has help chronic depression considerably.
I just mention this as a means to counteract the 'reductionist' approaches that so often have patients feeling 'belittled' when they are only offered a pill to 'all life's problems'.  Penicillin is a pill and it cures a myriad of infections but a variety of things are combined with penicillin for maximum benefit. This is the same with depression and antidepressant medication.

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