Monday, October 13, 2008

Anatomy of a Depressive Episode

I originally posted this on Saturday, but I'm posting it again because I believe it's an important topic to discuss. My response to Kelly on Friday was about ways to try and deal with a depressive episode in the work environment. And my list of five recommendations was geared to trying to help her feel better as soon as possible in order to be productive at work.

However, Friday night when I was sleeping (I have many of my best ideas when I'm dreaming), I realized that in focusing on depression and work, I didn't discuss some of my other theories about the nature of depressive episodes. Thus, the reason for this post.

I believe that depressive episodes usually have some sort of triggering event. In my own history of more than 120 depressive episodes, this was always the case even when I wasn't aware of it. And the cause was usually stress.

So...what I recommend to everyone who is suddenly feeling worse and whose medication is no longer able to mask the symptoms is this:

1. Keep a mood chart (I've written about this many times and you can check my archive for my recommendations on how to do this). Try and figure out what is causing your current depression. Is it work-related stress? A relationship problem? A seasonal problem? A medical problem? etc.

2. If your medication has worked well in the past and suddenly isn't, what has changed? Have you added a different medication to the mix? Have you changed the dosage of what you're currently taking? Are you noticing symptoms that you haven't before? Or, do you just think that your medication is "pooping out," which does happen.

3. Is it a seasonal problem? No matter how well I'm feeling and how happy I am, I always have a problem in the fall. While I make it a point to spend more time outdoors and increase my level of exercise, for the past number of years I usually have to go back on Adderall, the one medication that works for me. And this year is no different. I'm on a very low dosage of Adderall, but without it, I can't wake up in the morning.

4. If you can determine the trigger(s), or even if you can't and need help to do it, it is undoubtedly a good idea to talk with a counselor or therapist. Or if you decide that the way you handle stress is a constant problem, then I would recommend yoga, meditation, gardening, deep breathing exercises, and/or playing a musical instrument (which for me makes a big difference).

5. Try not to panic. In past years, one of the biggest problems I faced when I could feel a depression on the horizon (and I could pinpoint it within three days) was that I panicked. I don't mean that in the sense of a panic attack (I've never experienced one). It was just that I'd undergone so many depressions and they had become so debilitating that I was terribly concerned whether I could survive another episode. I believe now that my anxiety about the advent of the depressive episodes undoubtedly heightened their impact.

These days I know that my depressions (and I hesitate to use the word because it's not truly a depression; it's just a lower level of energy) are caused solely by seasonal change. I'm sorry they occur, but they are easily treatable and may only last a few weeks or a few months.

I know that Adderall works for me, and I have no hesitation in taking it. Since I can tell when the depressions end, I can titrate off it quickly with no ill effect.

Also, I also know that Adderall does have certain behavioral side effects, which I try to monitor. My mood rises during the day. If I don't monitor my behavior, I tend to talk too much, but since I'm aware of it, I try hard to make sure I listen to others. Also, if I'm a bit too wound up, I take small breaks during the day, and play an instrument or breathe. I am too enthusiastic, which I also monitor (While I don't find this to be problematic, I have learned that others do). And that's about it.

Over the years I have eliminated all other behavioral problems, including spending too much money, trying to "save" people who are needy, and participating in too many activities.

So, I guess what I'm saying is that in my case, my wellness activities cannot prevent Seasonal Affective Disorder. And since bright lights and a dawn simulator don't work for me, nor do vitamins and alternative remedies, I take Adderall, knowing that it causes a low level of hypomania. But...even this isn't a problem because I try hard to monitor my behavior, and prevent behavioral patterns that have been problematic in the past.


robert said...

I have recently started reading your blog, which I find very grounding. Common sense advice, to the point, etc. My situation, and my Adderall dependance, is causing great suffering. I was addicted to drugs from the age of 16 to 24 (I am 53). Drugs worked so well in suppressing the trauma I felt with regard to my sexuality: I am gay, but at that time, it was not discussed, I didn't know what it was, and I felt completely defective. I got sober at 24, came out of the closet, and had a relatively happy life until the age of 38, when approximately 8 friends and my lover at the time died of AIDS. During those years leading up to 38, I suffered from depression, but I don't remember much about it. I know I tried some anti-depressants, but that's about all I remember.
So when all my friends died, I left AA, and eventually, five or so years later, was introduced to crystal meth, which was pandemic in the gay community. I became addicted to this drug, which I used for about 6 or 7 years.
In desperation to get off, I saw a pdoc who diagnosed me as bipolar and using meth to self-medicate ADD. Thus, I began my decent into the world of psych meds. I have been on at least 30 over the last 6 years. I have become, basically, a vegetable, unable to function. Prior to psych meds, and of course on crystal, I was a very high functioning human being, a civil rights attorney, artist, owned a gallery, real estate, etc. Now I am on SSDI and food stamps, and have great difficulty leaving the house.
Last December, realizing that this doctor diagnosed my as bipolar while I was addicted to meth (everyone shows signs of bipolar on meth) I decided that the drugs were my problem. I have successfully tapered and removed Lamictal and Risperdal from my cocktail. I am stuck with the Aderrall. The doctor had me on huge dosages, and, I have switched to other stimulants, but I can't seem to get off of them. I get to a low dosage, and become suicidal. My doctor is totally against me going off meds, but I believe that it's my only hope. Yet I just can't seem to get past this point of stimulant dependance. I'm thinking to go back on Lamictal, then go off the stimulants, then back off the Lamictal. Maybe this would work, I'm not sure. Any advice? I hate my stimulant addiction. I am hypomanic all the time, and hyper sexual. I abuse them, and they cause all sorts of problems. I'm so lost and don't know what to do. Thanks for being here. Robert

Wellness Writer said...

Dear Robert,
Wow! I almost don't know where to begin. But first, welcome to my blog. Thank you for sharing your story, and thank you for your kind words about my blog.

I certainly empathize with your situation, and I am truly sorry for the losses you have experienced.

Yes, I would agree it's ridiculous to diagnose someone as bipolar who is on other drugs. It would have made far more sense to have waited until you had kicked your crystal meth habit.

But, I also need to tell you that I don't know anything about drug addiction or recovery. So, you need to understand that before I share my thoughts.

One of the reasons I can take Adderall is that I neither enjoy taking drugs nor do I abuse them.

The reason this is important is that my psychiatrist knew I would take the lowest possible dosage and titrate off it as soon as I was able to.

So, every year, I only take it when my depressions hit, and I go off it when they are over. Even if I take it for four to five months, I can go off it within a day (to prevent a hypomania) and I have no need for it whatsoever. I do not feel suicidal nor do I have any withdrawal symptoms whatsoever.

I realize this is fairly unique. It is quite possible that my biochemistry is different than others because I only take 10-20 mg of Adderall and for the last three years, I have never had to "up" the dosage.

If I take too much I don't feel well. I don't have any of the symptoms or "desires" you do, I just get a terrible headache and feel nauseous.

A number of years ago, I was taking 80 mg, because it had seemingly pooped out. But even on that high dosage, it didn't work.

Evidently others have far greater problems titrating off stimulants. I have also taken Concerta and Stattera, but neither worked.

One blog you should check out is Beyond Meds, which is listed under Bipolar Blogs. Gianna knows much more about this subject than I do. And she also knows about resources for people who are trying to get off stimulants.

Robert, I believe we are all "wired" differently. From what I have read, stimulant withdrawal is difficult for most people.

While I'm not medically qualified to tell you whether Lamictal can help, I can tell you that during the last 15 years, I tried it three different times (a total of 18 months) and it never worked for me. Thus, going off it wasn't a problem for the same reason.

I guess my best suggestion is that you check out Gianna's blog, and see what suggestions she can provide.

I do know it takes a long time for all these medications to work their way out of our systems.

In my case, after I had gotten off everything except Adderall and Ativan (for sleep at night although I no longer take it), it took four years to regain my mental acuity.

And as you know, if you've read other posts, I'm very big on pursuing a host of other wellness activities.

Best of luck!


Mariposa said...

I've been limping the past days, and glad to make it here again...the past days has been a struggle...and since that is what this post is about let me share what I realized for the past 10 years to be my triggers...

(1) It can be a seasonal problem. I have allergic rhinitis and is too sensitive to weather changes...and this get worst as I progress through years...and this triggers my down moments since once I do not feel well...everything goes to the spiral down. A simple cold can keep me in bed for days...and will make me lose momentum in whatever it is that I am doing...makes me irritable...and well, there is always that feeling of helplessness for being "sickly".

I have learned to counter that by being extra careful with my health everytime the weather changes...I always make sure to bring an umbrella with me...get enough sleep...take vitamins and eat well. Also, getting regular massages helps me get by with whatever faigue my body has to go through which makes my system prone to illnesses....

Dealing with this part is quite achievable especially with a help of a doctor and a nutritionist.

(2) Relationship (especially at work.)

I will say it out loud here as I can't seem to discuss it openly in my site, people near me do cause me stress! Damn if they know I have BP...damn if they don't, afterall these are not the people who are really supposed to care for me. These are the people at work who makes backbiting and unfair competition their thing...

Just Sunday evening I learned from a friend how some people at work whom I got used to trust and worst, whom I have helped so much went out of their way saying bad things about...hearing things like those make every fiber of my being twist!

I am trying so hard not to mind...not to care...and I still have yet to master that art of managing pain from I took a leave from work yesterday. See? It still affected me...though my foot still hurts...that wasn't really the reason why I did not work...I was not so ready to face those people yet...

But now I am fine. Not so fine...but fine-fine. :)

I made this post A Note to Myself to remind myself of one thing...I cannot please peple...and again, their loss not mine...

This is way better already compared to my past behavior...but I'm hoping for that day when I can just shrug my shoulder and say...ummm okay...without any remorse...without feeling any pain.

Maybe you can help me?

Maybe I should stopped becoming too emotionally involved? Maybe I should stop trusting? But is that not what life is all about?!

Susan...thanks for giving my this window to let go what I feel right you the floor back now...LOL

Wellness Writer said...

Dear Mariposa,
It sounds like you've got the seasonal problem under control. I think it's great that you realize it and are so proactive with it.

My sense is, and correct me if I'm wrong,that it might exacerbate the problems at work. Do you feel the same way--to the same degree--about co-workers during other seasons? Just something to think about.

In terms of people hurting your feelings, let me share a few thoughts.

1. I have often felt that one of the reasons my feelings get hurt--is that when I'm hypomanic I'm so giving. I feel so strongly about the people I care about in life, and give so much of myself.

Then, when I'm "normal" or slightly depressed, I am always disappointed that others don't reach out and help me the way I've helped them.

That may just be a part of being "bipolar." However, I've never read about others feeling this way.

What I've ultimately realized is that many other people don't feel as deeply and never will, and so it's an unrealistic expectation to expect it.

2. Another possibility is that there are those of us who are just "more sensitive" than others. We are more aware of our own feelings, and thus more vulnerable when others are "mean, petty, back-biting, etc."

I used to think that I could change myself so I wouldn't feel that way. But, I truly can't.

What I can do is to recognize that I'm sensitive, and that perhaps the people who are hurting my feelings truly don't realize it.

If it's possible, I try and let people know by saying something like, "I really don't like gossiping about others. It makes me feel bad." Or "In case you didn't realize it, what you said just hurt my feelings, and I wanted to let you know that."

But, the problem with disclosing it is sometimes that like disclosing bipolar disorder, there are people who do try and take advantage.

I'm not sure if any of this is helpful. But, I think this topic may be one we need to explore further.


Mariposa said...

Susan, you nailed it there!

Yes, the seasonal thing get to affect sometimes, but since I am aware of it...I get to "getby".

You are also correct on discussing how we get to be so giving and all when we are manic...amazingly...I have not taken a closer look at that.

It's also true that it could have that some people are just more sensitive than others...and I am one of them.

However, the triggers do not come from my set of I usually love to give and I don't expect any be honest. The triggers is when people treat me "badly". And I can have a long list of what I consider as I guess it's being too sensitive.

On the other hand, I'd like to note that this only happens in the workplace as people around me (not from work) are fact I doubt if they suspect if I am BP or if I have some challenges of sort.

I also agree that telling people you're BP is a very crucial decision...I have resolved it with my doctors and counselors before that people who can't help me become better don't need to know. So only my family and my bf knows...and they don't treat me as one...which I feel so thankful for. I don't want people to stop listening to my reasons nor to pay too much attention to my rants and all just because they see that as part of an illness.

I made it known to my bf so he knows that in times when I get to be so high and down, it's not his doing and that I don't mean any harm...and it's not that I have gone cold or anything.

I guess you are right, this will be a good topic to discuss further...specially the behavioral aspect...and also, "trusting". Will that only adds to the triggers or help ur get depends of course...but could be very interesting to talk about...

Wellness Writer said...

Thanks for your take on this. It's these kinds of questions where I think we truly can help each other by discussing our behavior and tips we've learned to handle it.

I think it may be interesting to compare what we consider "treating me badly" means to us.

I promised to write about wellness this week, but next Monday, I'll write about this entire topic and see what kind of response we get.


kara said...

Hey Susan...

I've read your previous post about mood charting and then saw you mentioned it again here. It's something I MUST begin doing, but I just can't get it down. My pdoc and I have gone over it for at least the past year...and I've started many mood charts, but then get frustrated b/c I feel so bogged down--like I don't know what to include and what to leave out. I do believe, as you, that it would be highly benefical...but can't come to a definitive conclusion on what to chart and what not to chart so I just quit midway through.

Any suggestions?!?


Wellness Writer said...

I thought I wrote a series on mood charts, but I don't see it in the labels. I'll check later tonight and get back to you.


Wellness Writer said...

Dear Kara,
I found it. The mood chart series is listed under Bipolar Mood Charts and goes from 6/23/2008 to 6/27/2008. Hope it helps. Let me know if you have any questions.


Tamara said...


Great post!

As I have just discovered (again, because I have known it before but forget) my depression (and yes that is too strong of a word) can be set off by my feeling a bit down. Then I think I have to deal with it and power through it while outwardly pretending I am fine. This causes the mood to dip even lower. As soon as I quit trying to hide my true feelings and let others in then it immediately improves.

Wow, that was awkwardly worded but you probably understand.

I do still take amitriptyline to sleep. It is the only drug I take but without it I don't sleep near enough and that can bring on a bit of hypomania.

I so agree with journaling and mood charting. Once you truly learn your own rhythms then it is much easier to keep balanced.


Wellness Writer said...

Dear Tamara,
Yes, it is important to say, "I'm feeling a little bit down today," and just enjoy that so many people care.

For many of us, it may be difficult because we spent so many years trying to hide the depressions because they were a problem at work, or our friends and family members were sick of hearing about it, or we didn't want pity. Rather, it was just a statement of fact.

What's so interesting about mood charting and journaling is that they're both such critical elements of wellness, and yet so few people seem to do them.



kara said...

Thanks Susan!

Wellness Writer said...

You're welcome Kara!