A Primer on Depression and Bipolar Disorder

II. MOOD DISORDERS AS PHYSICAL ILLNESSES

C. Treatment of Depression and Bipolar Disorder (cont.)

There are a number of practical issues to be faced when taking psychiatric medications. Like all medications, psychiatric drugs have side effects. Many of them are inconsequential, some are more serious. For example, with the antidepressants, it is common to experience a dry mouth. Sometimes this is so serious as to prevent one from speaking, and a drink of water doesn't solve the problem because what is needed is saliva produced by the body. This one has been a problem for me because when I was a professor, I gave lectures. I solved the problem by chewing sugarless chewing gum when I felt the dryness start. It's a bit vulgar in appearance, but I simply explained to my students why I did it, and they accepted it. Lithium can have two troublesome side effects. One mentioned above is that it often causes small-muscle tremor. I remember a period of time when I could not drink tea because I couldn't lift the cup from the table to my mouth without spilling it all over the table. Tremor was especially troublesome for me because it got so bad that I simply could not write; this seriously interfered with my daily professional activities. My doctor told me there was another drug to control the tremor, but I decided not to take any drugs that I didn't have to; eventually the tremor went away, seen only under extreme stress, and even then only a little. A more serious side effect of lithium is that if its concentration in your bloodstream gets too large it can damage your kidneys. This problem can be avoided by having blood tests to measure the lithium level in your blood. Typically this will be done fairly frequently (monthly or maybe even weekly) when you first start lithium, but later, if your level is pretty constant, your doctor will check it maybe every 3 months. Similar remarks apply to Depakote. Finally there is the very serious problem lithium caused me during rehabilitation from my auto accident: the margin between the therapeutic and toxic levels of lithium in the bloodstream is small. And because I became dehydrated while in the hospital, my lithium blood-level soared way above the toxic level, and induced the terrible coma I have described above. With Depakote, the known therapeutic range is about a factor of four, and the highest dose is still much below toxic. Thus compared to lithium, there is an enormous safety factor. In my case, I take almost the minimum dose, so I never expect to have any trouble with it.

It is crucial to take your medications exactly as your doctor prescribes. Do not ``experiment'' with changing the dose on your own. Sometimes it is hard for people to remember whether or not they have already taken a pill that day, but it is vital not to take too many or too few. I beat the problem of an aging memory by using the small compartmented pill dispensers available in drug stores. They usually have seven compartments labeled with the days of the week, so one can tell immediately whether the correct number of pills have been taken. It must also be stressed that you should never stop taking your pills all at once (``cold turkey''); to do so shocks the nervous system, and could precipitate a very severe psychiatric episode. If your doctor agrees that you should give up on a medication, always ramp the dosage down slowly over several days. For someone like me this is probably useless advice because it seems plain that I will be on my medications for the remainder of my life. One other note is that it is important to realize that, like most medications, psychiatric drugs can be lethal if taken in large quantity. If you are very seriously depressed, your psychiatrist may not give you more than a few days worth of your medication: a sublethal dose. This does not imply a lack of trust on the doctor's part, but rather a well-placed concern. Later, when you are back to normal, he/she will probably let you have them by the bucketful if you want.

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Last, a word about cost. Psychiatric medications can be cheap or quite expensive. For example, lithium is very inexpensive, which is one reason it is widely prescribed. Antidepressants, especially the modern SSRIs, are more expensive. As is Depakote. I personally think they are cheap compared to the benefit I derive from them (my life), but for someone on a small and/or fixed income, such costs can be very hard to bear. The cost can often be reduced by using generic drugs. For example, if one buys generic desipramine, which is much cheaper than the brand-name Norpramine, the monthly bill can be reduced by almost a factor of three. In many cases medication costs will be covered by insurance: my group policy pays for all but a relatively small copayment for each prescription. To be sure, many people don't have any insurance at all, especially if they have a history of mental illness. This is a severe social problem that must be faced and solved!

A final remark about meds: I cannot stress too strongly that the success rate for controlling depression and bipolar disorder with medication is quite high. We don't have perfect ``cures'' yet, but we are clearly well along the right track.

Thus far I have mentioned only medication. There is an alternative treatment for extreme depression, used when other methods have failed or when there is an urgent need to achieve results quickly (e.g. the victim has tried to commit suicide). This is known as electroconvulsive therapy, or ECT for short. ECT generally has a bad image with most people, probably because of grim portrayals of ``shock therapy'' they have seen in old movies. As it is employed today, ECT is a simple, painless, safe technique which is astonishingly effective in breaking severe depression. To prepare for a treatment the patient is given a muscle relaxant (to avoid damage when muscular contraction occurs in response to the mild electric current applied), and is partially sedated to relieve anxiety. Then a low-power electric current is directed into the brain for a carefully controlled period of time (seconds). When the patient recovers from sedation, he/she feels no pain, and typically has no memory of the procedure. Usually several treatments are given over a short period of days. No one knows in detail why this method works at all, let alone so well. One can speculate that perhaps the applied current disrupts totally the existing pattern of electrical activity within the brain, and forces it to start all over from the beginning in the correct pattern, much like pressing the ``reset'' button on a PC. The worst side effect of the method is a temporary loss of memory. Usually short-term memory is affected more than long-term memory. Most people recover most or all of the lost memory over a period of time, but some suffer some permanent memory loss.

I would like to close the discussion of treatment with a few words about fighting back. If you have the misfortune to experience a deep depression, at first you will feel as if a large truck has run over you. You may be extremely unhappy, confused, apathetic, exhausted, and feel helpless. As your therapy makes progress, you should begin to feel better. But it is not enough to leave it up to the pills and your physician. People get better faster when they are not just passive, but instead actively resist. The point is that, if you let it, the illness will destroy any enjoyment you might get in your life. Just as surely as you would resist someone trying to injure or kill you physically, it is essential that you resist the ravages of depression. A very typical pattern of recovery is that the victim begins to experience a gentle lifting of his/her mood, day by day, week by week. Unfortunately it often happens that along this long-term rise one will experience a number of temporary ``dips'' back downward to a lower mood level. When this happens, the victim often feels as if he/she has just plummeted all the way back down to the bottom, and begins to doubt the efficacy of the therapy, and may begin to despair (``Will this never end?!''). Eventually one learns to trust what is going on, and to understand that the setback is only temporary -- a day or two. But this kind of backslide can be very demoralizing, and it is important to have methods you can use to fight actively the discouragement and mental paralysis that might ensue. Thus it is very important for you and your physician to consult, as early into treatment as possible, about what you can do to make yourself feel better. For example: exercise programs; meditation; keeping a journal; community service; participation in activist groups; socializing with family and friends; participation in church activities. I have used all these methods to very good effect. Daily jogging keeps the body fit, and better able to fight on your side than if it is out of shape.

In 1986 I learned a couple of meditation techniques, and found them both restful and a source of insight; by accident I discovered that I could completely eliminate episodes of very severe anxiety I occasionally had by meditation (I threw away the tranquilizer!). My journal allowed me to compare how I felt currently with how I felt days and weeks before; even though I might be feeling rotten at the moment, I had clear evidence (in my own handwriting) of how much worse I had felt then, and how much progress I had really made. Nothing can make a person feel better about him/herself than giving some time, effort, and love to a group or project that will benefit needy people in the community. I don't like the prospect of nuclear war; helping anti-bomb activist groups was stimulating, thrilling sometimes, and improved my self-esteem. And socializing with family and friends need be only what it always is: fun! These are only examples; your job is to make up a list of things that will work for you, of things that you can actually do. Then do them! One final thing to consider is using cognitive therapy to restructure how you feel about yourself and your surroundings. For some people this technique produces amazingly good results. It is fully described in David Burns's excellent book Feeling Good listed in the Bibliography.

A final word: one should never forget that after a severe incident of depression or bipolar disorder, one is, at best, only in remission; it is not a cure. It is therefore essential to stay in contact with one's psychiatrist, so that he/she can monitor one's behavior through regular observation. You need to work out a definite timetable for regular visits; I personally recommend that they should be no less frequent than once a month, but this a question to be worked out with your doctor.

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