Thursday, July 29, 2010

Mood Disorders -- Tolerable, Bad and Downright Ugly, Part I

A friend recently asked me for a short description of the difference between Major Depressive Disorder and Bipolar II. I didn't keep it short.  This will not surprise my regular readers, and warn my newer ones.

But here is the short answer.  Normal mood cycles within a normal range, sad/okay/glad.  Major depression has bigger distances, between normal and really sad.  Bipolar has the biggest distances.  Bipolar I ranges from really sad to really really up, with more time spend down than up.  Bipolar II moves the base line down from bipolar I.  It goes up, though not so far, and way, way down, lower than the others.

There are other aspects to mood disorders, affecting thought, desire, motivation, energy, sleep, digestion, appetite and even physical pain.  But this astonishingly short answer says way more than your common perception that depression means you are sad; bipolar means you are crazy.

Since I regularly write about these and the other mood disorders in Prozac Monologues, it may be helpful to give the longer answer here.  So today begins another three-part series.  I do seem to like these three-part series.  Things stretch out when I want to make Prozac Monologues both clear and entertaining -- though I suspect that it's mostly people with diagnoses who get the entertaining part.

In the entertaining endeavor, I started playing with squiggly lines, charting the differences among most of the mood disorders, over a longer period of time than you are likely to spend with any one psychiatrist who is interested in the time he/she will spend with you, not the time you will spend with your particular mood disorder, or whatever you get diagnosed with by your next psychiatrist.

These are not the mood charts for managing recurrent depression and bipolar.  Rather, they are much abbreviated and simplified pictures, leaving out lots of details and maybe not following your exact track, you little snowflake you.

This week features the simpler mood tracks, what I call the tolerable.  Let's start with what normal looks like (chart on top), then chronic (in the middle) and single episode unipolar (bottom chart).  All three charts first, then commentary.  It may be easier to follow if you increase your magnification.  My charts were a bit ambitious for the room I have here.

First the legend, meaning, how to read the damn things.  The wavy line is the track of mood over time.  There's your normal mood, the white strip.  Normal mood is not the same every day.  How boring would that be.  But there's normal, and then there's not what you experience every day.  Normal ranges through the white stripe, pink is whey you feel high, blue is low.  Okay, blue would be obvious.  Age is indicated in the white stripe, and the darker vertical lines mark decades.  We start with ten years old and end with sixty, because more wouldn't fit.  Please don't be picky about the lighter lines.  It was way too much bother to change eight to ten, once I noticed it.

Yes, the normal chart is here, too, as a reference point.  Most of you normals know that the rest of us do not occupy a different planet.  Most of you might say to somebody who has a mood disorder, I have been to some dark places, but I realize I haven't been that low.  Some of you say, I know just what you are going through.  I was really depressed when I lost my girlfriendYou just have to...(fill in some platitude.)

If the second is what you say, then I am sorry for your loss and glad that you feel better now, but that is a really stupid thing to say to somebody who has a mood disorder.  I encourage you to stop saying it.  There is a difference between really sad and seriously sick, like the difference between heavy rain and hurricane.  No, you do not know what we are going through.

That said, the difference is not a different planet difference.  We all have moods.  We all occupy a mood continuum.  Actually, nobody is on a different planet.  Even those who are desperately sick with other diagnoses are on the same planet and same continuum of experience.  But that is another post.  And there actually is a limit to the digressions I will travel.

Anyway, normal, chronic depression and unipolar depression share a similar track, as you can see by the relatively similar charts.  That is why I am dealing with these three together, little grasshopper.

The first chart, Normal goes up and down, mostly in the white zone, but occasionally out of it.  Sometimes you feel better, sometimes worse.  These rises and dips usually correspond with life events.  They are situational, to use psych-speak.  So the teen years have a few more extremes.  Duh.  First love strays outside the realm of regular experience -- the old hootie owl hootie-hoos to the dove.  Also outside regular experience is that first breakup -- why do the birds go on singing(**Note to my younger readers -- read these lyrics to your boomer parents and ask them to sing the whole songs.)  Higher for first job, lower for losing it.  Another peak with the birth of the baby.

Then in your mid forties, Nelson Mandela is released from prison, and you are jumping up and down, dancing around the living room.  Or the Cubbies win the World Series, if that's what makes your heart sing.  You call all your friends and talk a mile a minute.  You can't concentrate on work, you read the same news over and over.

If you stayed that way, we would call it manic or hypomanic.  But after a couple days, you normals go back to work.  You hit a lower low when your mother dies.  Maybe you take a sleeping pill for a while.  Eventually you level out.  Later, while you still cry on her birthday and even on yours, you need your friends, not medication.

Your moods are congruent with your life events.  The ups and downs are mostly in the normal range and occasionally extreme.  That's normal.

Chronic depression is not that different.  Your mood line goes up and down for the same events.  It's just that your baseline is set lower, in the blue zone, not the white.  Why?  There doesn't seem to be much research on this question, though there is some debate -- is this personality or disorder?

In the Middle Ages people recognized a variety of temperaments, caused by particular humors.  They didn't mean ha-ha humor; they meant liquids: blood, phlegm, yellow bile, black bile.  Today we would call them personalities.  These humors are what make people sanguine/cheerful, phlegmatic/calm, choleric/angry and melancholic/sad, respectively.  We all have all the humors.  The problem comes when the balance is lost, when one humor begins to dominate, even when not appropriate to the circumstances.

Some people are just melancholic.  It doesn't necessarily mean that they are sick.  People in the Middle Ages even identified occupations that work best for those whose predominant humor is melancholia -- night watchman, gardener, writer.  Is that chronic depression?  Maybe.

I know a couple people who have had chronic depression.  Antidepressants work for them.  There is that problem of Prozac poop-out, a phenomenon that surprised practitioners when their patients started reporting it.  But it makes sense.  Prozac and other serotonin reuptake inhibitors are stimulants.  Like other stimulants, they raise that mood track up a line.  Then after a while (usually years, we hope, if the stimulant is an antidepressant), the body adjusts to the presence of the stimulant.  It returns to its steady state.  With luck, you can find another antidepressant that stimulates in a slightly different way and returns you to that stimulated state.

Okay, now for the bottom chart, major depressive disorder, single episode.  This is the diagnosis you get when you have the symptoms of clinical depression, and you arrive at the doctor's office for the first time.  You have never been diagnosed before.  Notice that its chart tracks with normal, until something knocks you off your pins and throws your brain out of whack, so that it cannot return to its steady state.

The disruption is often a major event.  A baby is born, menopause, somebody dies, you lose your job, you get a divorce.  Something like that.  Normals go into the blue zone, but later return to normal state.  But people with major depressive disorder do not snap out of it.  Whatever coping mechanisms you have are not sufficient to handle this one.  The tipping point of your brain's ability to right itself has tipped too far.

If your mood chart gets stuck in the blue zone and not in the pink, it is called unipolar depression.  For most people with unipolar depression, therapy and exercise are the best treatments, just as effective as antidepressants and without the depressing side effects.  Loss of sexual desire and impotence are pretty depressing, don't you think?  And they don't tell you this when they are writing the prescription, but sometimes sexual side effects don't go away even after you discontinue the antidepressant.  That's really depressing, don't you think?

So therapy may be embarrassing (or so you think), and exercise doesn't fit into your schedule.  But keep the whole picture in mind when you weigh your costs and benefits.  Unless you are seriously and dangerously sick, you may want to try therapy and exercise first.

But if you are seriously suicidal, hit it with all you've got, every tool out there, including antidepressants, hospitalization if necessary to help you survive this disease that kills 15% of those who get it.  Friends, do not believe that your loved one with suicidal depression has too much to live for or is stronger than that or has too much faith to ever do that .  Get him/her help.  Fast.

Pharmaceutical companies do clinical trials before they can market their antidepressants.  They try the medication out on real people to prove that it works better than a placebo.  They want people with single episode unipolar depression in their trials, and screen chronics and recurrents out.  Because people with single episode unipolar get better and stay better anyway.  They don't relapse.

These are the ones for whom the promise is true.  Depression is highly treatable.  If the first antidepressant doesn't work, you have to keep trying.  Another one will.  And that is true.  For about 60% of those who keep trying.  The success rate after two falls off dramatically.

They tell me that about 50% of those who have depression and get treatment will never get it again.  They have true single episode unipolar depression, and that is what they are treated for, with antidepressants if the doctor and/or patient are in a hurry, or with therapy and exercise if the doctor is enlightened and the patient is smart.

If you have to have a mood disorder, single episode unipolar is the one you want.  Meds work.  Therapy improves the quality of your life.  Exercise lengthens your life span, helps you lose weight, gives you more energy and probably improves your sex life, so you want to live longer, assuming you didn't blow your sex life away with those darn antidepressants.  And for that matter, it goes away with or without treatment in 6-18 months anyway.

But get treatment.  Because untreated single episode depression can turn into recurrent depression, at which point the meds won't work so well.  And because medication works, therapy improves the quality of your life, exercise lengthens your life span and all those other good things.

Now, think on this.  Almost everybody who comes into the doctor's office with symptoms of depression is diagnosed with single episode unipolar depression, the first time.  It's when they come in the second time, or when somebody peels them off the wall and drags them in, or the prison calls for an evaluation that the doctor considers another diagnosis, recurrent depression or bipolar I.  And you have to wait a few years, like 7-11 years, before they think about bipolar II.

John McManamy calls unipolar depression bipolar waiting to happen.  Maybe not.  You've got a 50/50 shot that your first episode of unipolar depression will be your last.  Especially if you get treatment for it.  Treatment loads the dice.  Assuming that the diagnosis is correct.

Forget the Diagnostic and Statistical Manual (DSM).  In the real world, a diagnosis of single episode unipolar means first mood disorder.  The significance of that fact will be considered next week, when we move from Tolerable to Bad and Downright Ugly.

photo of lecturer belongs to the Steklov Institute
picture of dice drawn by Steaphan Greene
both are licensed under the 
Creative Commons Attribution-Share Alike 3.0 Unported license.

Charts are my own creation.  You may copy them
if you give my name and the address of the blog.

Friday, July 23, 2010

OMG!!!That'sWhatTheySaid -- Failed Method/Successful Attempt

OMG!  it has been four months since I last gave an OMG! Award.  It's not that I don't keep finding excellent candidates.  It's just that I have been covering other major topics.  Plus, life just...

I am amazed and disappointed to give this month's award to for their July 22nd news release, Failed Suicide Method May Predict Likelihood of Successful Attempt.

First, let me introduce  From their website:

Health Central's mission is to empower millions of people to improve and take control of their health and well-being.
  • Our 35+ sites provide clinical resources and real-life support to those with life-changing conditions.
  • Our wellness resources and tools help people to live healthier, more fulfilled lives.
  • We are honored to serve over 12 million visitors each month.

Health Central addresses lots of different health issues, including mental health.  Often their information is excellent.  This time they missed the boat with this OMG Award-winning title to one of their featured articles.  They don't get points for originality.  They have repeated a much too popular -- what shall I call it?

Let me put it this way:

A twenty-seven year old woman is diagnosed with breast cancer.  Young women with breast cancer generally have a poor prognosis.  So she receives the most aggressive treatment available, including procedures that damage her body in ways that can be mended and other ways that cannot.  She undergoes intense pharmacological treatment using harsh chemicals that leave her sick, debilitated and at risk for other health complications.  Willing to try anything, she joins a support group, does mindfulness and visualization and changes her diet.

These measures eventually do work.  Her cancer goes into remission.  Her health is monitored carefully for a long time.  Just when she and her family begin to breathe again, she relapses.  Again, she opts for aggressive treatment, tries new drugs prescribed in off-label use, and again is left too weak to care for her children or leave the house.

This time, everybody's best efforts do not work.  She dies.

Does her doctor call that a success?  Does the preacher say she fought a long hard battle and finally succeeded?

Let me put it another way.

A middle-aged man has heart disease.  He gets regular medical attention, takes all his meds, monitors everything he is supposed to monitor, changes his lifestyle, even his job to reduce stress.

Nevertheless, he has a heart attack, in fact, several heart attacks.  Each time he is rushed to the hospital, where emergency personnel work their butts off to save him.  He is transferred to ICU, then to a regular bed, then to rehab.  His family posts frequent status reports on facebook, and his church prays for him every week.

Does anybody say he failed?  That he wasn't serious about these heart attacks of his?  When he returns to church or the golf course, do they turn their faces, afraid they might say the wrong thing and provoke another attack?  One that might be successful?

Mental illness is physical illness.  It has a mortality rate, just like cancer and heart disease.  We struggle desperately for years and undergo every treatment we can find and tolerate, trying to survive our illnesses.  Death by mental illness is not a success.  It is a tragedy.  Survival is not a failure.  When somebody has to be rushed to the hospital and manages to fight his or her way back to life, it is a hard won victory celebrated in heaven.  It ought to be celebrated on earth.  This person deserves a party.  With balloons.  And a cake.

Now let me pause to discuss the content of the article with this outrageous title, because the article does give important information.

The article reports research into the prognosis of suicidal individuals according to the method of self-harm they originally use.  The numbers are astounding.

Those whose initial act of self-harm takes the form of hanging, suffocation or strangulation have the poorest prognosis.  Of those who survive, 85% of them die at their own hand within a year.  They do not get it out of their system.  They die.  Within the year.  85% of them.

Those who jump, or use a firearm or drowning are at a moderately lower risk of subsequent death (69-78%, as reported in the original research.)  Those who use poisoning, overdose or cutting have the lowest risk of completed suicide with in year (25-36%.)

These figures hold true when controlling for diagnosis and for sociological factors.

That said, the single greatest risk factor for death by suicide is a previously survived episode.  Nobody gets it out of their system.

These findings have implications for aftercare.  Just as the most aggressive treatment is warranted for younger women with breast cancer and out of shape persons with heart disease, those whose original method of self-harm is hanging, strangulation or suffocation need the most intensive follow-up, monitoring and treatment.

Again that said, one potentially harmful consequence of this report is that those who use less lethal means, such as cutting or poison, may be dismissed as not serious, as engaging in attention-seeking behavior.

Yes, cutting and overdose are attention-seeking behaviors.  They are the serious attempts of seriously ill people to get serious attention for their serious condition.

Cutting and overdose have serious health consequences.  They are the methods used most often by Latina and African-American girls, who have less access to health care and mental health care anyway.  The consequences of not receiving the attention that these girls plead for are first, brain and liver damage, and then further deterioration of their lives, including dropping out of school, substance abuse, being continued victims of violence at their own hand or that of family and acquaintances, continued poor health choices and early death on account of all of the above.

If you turn your face from anybody who commits a potentially fatal act of self-harm by any means, you become the Scribe who turned his face from the man who was mugged, beaten and left for dead on the road to Jericho, because you count your agenda more important than that person's life.

As I said, this would be an unintended consequence of this article, and one that the author seek to avoid: However, "although use of more lethal methods of self-harm is an important index of suicide risk, it should not obscure the fact that self-harm in general is a key indicator of an increased risk of suicide," Hawton wrote.

Back to the OMG! Award.  I am on a Mission from God.  It is my mission, in whatever years I have remaining of my own life, permanently to eradicate the use of the word successful in the same sentence as the word suicide, and to eliminate the scandalous naming of survival as failure.

So I plead for your help.  I plead, when you hear a grieving friend or family member say that their loved one who died of mental illness was successful in the attempt, I plead that you tell that person, kindly and gently, Suicide is not a choice; it happens when pain exceeds resources for coping with pain.  I am so sorry for your loss, and so sorry that your loved one has lost the battle.

I plead that you, whenever you hear health care professionals refer to a failed attempt, that you feel and that you express your shock and horror at the words.  I plead that you confront them, and urge then to examine the hostility toward their patients and clients that lie beneath their words.

I don't usually inform people that they are winners of the OMG!!That'sWhatTheySaid Award.  Following what I have urged you to do, I will inform Health Central of their award.  Right now. 

Friday, July 16, 2010

Mood Charts -- Why Bother?

Last week I discussed two barriers to using mood charts, the complexity of some charts and the life styles of those with mood disorders.  I also suggested strategies to overcome these barriers.  Perhaps today's post should have come first.  Given the difficulties -- why bother?

The chart I use is here, the same destination linked to Mood Charting on the left side of the blog, under RESOURCES ON MENTAL ILLNESS.  The second page puts my remarks in context.  The first page was written for doctors.  This post will make all that verbage user friendly.

So let me tell you about my experience and why I am still at it.

The essential point is to understand your illness better, so you can manage it better.  These are things I have learned from my chart:

First, my cycles have a certain shape, and not the one I might expect from the information out there.  The typical description of Bipolar I and Bipolar II suggest a few weeks or so of high, followed by a few months or so of low, and a break between of whatever length your meds promise you, until the cycle begins again.

Me -- I go through two or three cycles a month.  They call that rapid cycling, or rather ultrarapid cycling.  And within these cycles, I ricochet several times a day between high energy anxiety/urgency and medium to severe depression, followed by a few days of mild depression, and then repeat -- with seldom a break.  They call that ultradian cycling (within the day.)

Bipolar II is not diagnosed properly if it initially presents with ultradian cycling.  Prozac, et al sped up my cycles.  We did finally piece together earlier, longer periods of hypomania that confirmed the diagnosis -- so I started being treated for the right disease!  (Bipolar II is seldom diagnosed until after antidepressants make it worse.)  I have kept track on my chart and confirmed the pattern.  It is clearly a cycle, with cycles within the cycle.

Now when I am cycling so fast that I need a helmet, I can reassure myself that a break is coming within days, not months.  Okay, the break is still depression, but not whale shit on the bottom of the ocean depression, which is an improvement.  Plus, now I can describe the course of my disease to my therapist and psychiatrist, and whether the last adjustment of meds changed anything.  Instead of treating the symptom du jour, they can address the pattern.  Ditto with side effects -- when I record them, I have evidence, not just impressions about whether they are subsiding or getting worse.

The chart also helps with my experiments.  By tracking a particular self-care strategy in relation to a particular symptom over time, I observe patterns and detect what really works.  Does alcohol or abstinence from it affect my mood?  Is my consumption changing with the trend of my mood?  Does exercise affect my sleep?  My anxiety?

We have so little control of brains that cannot self-regulate and regularly puts us on the roller coaster.  We have only some control over our exposure to whatever sets us on the ride.  We can control our self care strategies, like, don't eat a chili dog, tub of popcorn, fried dill pickle on a stick and funnel cake before getting on that roller coaster.

Perfection is not necessary, and its pursuit is probably harmful.  But relative consistency over time will tell us if a particular strategy works.  If it does, then it is worth the effort to maintain it.  My current experiment with alcohol tells me that my usual half a beer at lunch doesn't seem to matter, while a double martini at night is a disaster that night and into the next day.   I am trying to work up courage to try abstinence from sugar.  I'm not sure I want to know the results.

Of course, during your experiment you have to maintain your regular self care behaviors.  If you trade your daily beer for double hot fudge sundaes, you contaminate the results.  Not to mention your body.

One more why bother mood chart issue -- relevance.  Does it make sense for your own version of your mood disorder?

Early on I realized that my chart was missing something.  It didn't fit the way I experience my moods.  The foundation of the chart is high and low moods.  So the chart assumes the popular perception, that bipolar means that people have times when they feel great, and do crazy things because they feel too great. 

That is euphoric mania or hypomania.  And I used to have that.  We finally figured out I don't have recurrent depression by teasing out past euphoric episodes.  I used to be charming, the spark of the room.  I got crazy amounts of work done between my whale shit episodes.  My mind jumped from one thing to another, connecting more dots than anybody else in the state ever even saw.  It was fabulous.  I did not complain to my doctor.

I miss euphoric hypomania.  I thought I was in the zone.  Turns out it was a rip tide.

Dysphoric hypomania is the ugly stepsister in my story.  Nasty, nasty, nasty.  All the dots that my mind connects point to impending doom.  My highs are irritation, on edge, walking down the street trying the shake the anxiety out through my hands, scratching my arms to distract my racing mind.  Nasty, nasty, nasty.

See, I don't call that high.

So I have changed my chart.  I still track mood, because my meds are designed to deal more with depression than with mania, and depression is a mood.  But now I also keep track of high and low energy.  High energy can cover the loud, animated, notstop conversation with my seatmate in the plane, the desperation to do some task that won't let me sleep at night while I go over and over and over the exact order of the steps I need to take, and what my wife calls spinning, when I rush so fast from room to room, trying to do so many things that I can't do any of them, to be followed hard by frustration and shame.

I sure would like to get a handle on those symptoms.  The first step is to track them  Then I can construct my experiments.  When I get my new chart converted into a visual (with up and down lines) I'll post it under MENTAL HEALTH RESOURCES.

So that's why I record my moods on a chart that I keep as a bookmark by my bedside: to convince myself that what I think about my disease really is true, to supply better information to my care providers, and to do experiments on self care strategies and symptoms, so that I can manage this thing better.  Not cure it, but manage it.  Because I want to live with it, and by that I mean, live.

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Thursday, July 8, 2010

Calling All Mood Charts

A few months ago, I posted this video description of my mood chart, calling it "Bipolar II with a touch of PTSD."

I also asked readers' experiences with mood charts, and promised a report.  Such as it is, here it is.

First, a mood chart is a basic tool in recovery, a way to record visually how your moods vary from day to day, or within a day for you lucky ultradian cyclers.  There are a variety of charts out there that vary by the features recorded. The chart can be paper or digital.  And yes, there's an app for that.

The chart I use keeps it simple. I record my mood each day, high or low, scale of 1-3, plus sleep, drug and alcohol consumption and meds taken or not.   I add two extra features, anxiety and irritation, again on the 1-3 scale.  These are basics.  When my meds change, I scribble little notes about side effects.  One page covers the whole month.

You can get fancier.  I registered to use the DBSA (Depression and Bipolar Support Alliance) "Wellness Tracker."  They have all kinds of moods to track, and side effects, too.  I was well into the third screen, saw the fourth coming, with no indication of an end in sight, when I realized I would never follow through on a daily basis, and quit.

So the first barrier to using mood charts is complexity.  Success will be supported by keeping it simple.

Readers identified follow through as another difficulty.   My bipolar readers said their lives are not regular enough to do the daily entry.  A reader with simple depression credits her brother for her success.  He set up a computer-based chart that pops up on her screen at a certain time every night.  You can buy the program here.  Of course, that still doesn't work for people who aren't on the computer the same time every night.

The second barrier is life style.  Success is supported by finding the right niche in your daily schedule that is regular, and associating the chart with that.  You could put your chart on the bag of dog food, on top of your meds, your bathroom mirror, your pillow, whatever -- some place you see at more or less the same time daily.  I think night time is best, the better to remember what happened that day inside my fevered little brain.  But whatever works.  I managed my seven month stretch of nearly daily recording (okay, May was a lost month) by sticking the chart in my bedtime reading.

A third issue has become apparent to me over time.  Is it relevant?  Does it record the information you need?

Well, what do you need?  Another way of putting it -- why bother?

Why bother -- What a great place to break until next week!

 This photo was taken by WillMcC and is licensed under

Thursday, July 1, 2010

Nationalism and Patriotism -- For the Love of My Country

There is nothing funny about nationalism. Nationalism does not laugh at itself.

Patriotism, on the other hand, is like family. The Muppets are patriotic. Even those who don't speak English.