Falling: Faces of Depression and Anxiety (by Clara Lieu)

Clara Lieu is an artist at Rhode Island School of Design.

She has this amazing gift of observation. For example, she has this series on her website (claralieu.com) called Waiting. Here is how she describes it.

I am interested in the contradictions found in waiting figures: even though these figures stand in very close physical proximity to each other, it seems apparent that there is a significant emotional distance between them. Each figure seems locked within their own existence, unaware and unresponsive to the other figures surrounding them. Yet simultaneously, waiting in a line creates a situation where the gesture of one figure leads directly to the next, creating a fluidity between all of the figures. I am engaged by the individual and group anxiety that seems to permeate such silent and still scenes.

So true. My first iPhone line was like that.



She also completed a very impressive series of drawings and sculptures called Falling. This series, unlike her others, are very personal, based on her own experience with depression.

She emailed My Three Shrinks to let us know about her work. I was so impressed that I asked her more about herself and the motivation to show such an intimate view of her anguish.

I developed depression and anxiety at a young age, and lived with the condition for most of my life before being diagnosed and treated just a few years ago. It was startling to see myself clearly for the first time, free from the disease. Only at that point did I have the emotional distance that allowed me to to be in position to address this subject artistically. I knew at that point that I felt an uncontrollable drive and compulsion to make the work.

"Falling" was an unusual project me for in that it was told from a very personal, intimate perspective unlike my previous projects, which approached the subject matter with an emotional distance. Depression is something that happens privately, behind closed doors; it's a secret that most people keep hidden and never talk about in public. Unfortunately here's still a social stigma associated with depression that causes people with depression to conceal their true emotions from others. On a broader level, I'm looking to open a dialogue about a topic that is rarely discussed openly by exposing my own personal experience. 

She goes on to describe this body of work:

"Falling" is a visualization of personal experience with depression and anxiety. The condition brought on frequent episodes where I felt emotionally and physically out of control. Unable to “release” myself from these episodes, I waited for the physical limitations of my body to end them. Recounting the affected years, I realize how accustomed I became to depression’s influence; many emotions and feelings belonged to it and not my own personality. After an extended, untreated struggle, a diagnosis brought relief, and the process of unearthing myself from the disease began. 

Her work can be found at claralieu.com.




Note: October 11 is National Depression Screening Day.       Get screened.

Podcast #68: Supermax, Health Exchanges, Statins, and e-Novels

Here's what we talk about:

• Clink talks about the burning issues in corrections, including a class action suit against a federal control unit prison in Colorado, filed by a civil rights organization.  Allegations include the idea that correctional officers were abusive and that mental health services were inadequate.  You can read more about this in Clink's article here.

Clink provides the following links:

1. For the lawsuit at: http://www.scribd.com/doc/97561358/Bacote-et-al-v-Federal-Bureau-of-Prisons on June 29, 2012.

2. For an article from The Atlantic:  http://www.theatlantic.com/national/archive/2012/06/an-american-gulag-descending-into-madness-at-supermax/258323/ on June 29, 2012.

• Roy talks about the Supreme Court decision to uphold the Affordable Care Act (aka ObamaCare) and talks about the Mental Health Parity Act and the delay in getting this clarified.  Roy believes there will be increased access to mental health care.   
  

•  Roy talks about Network adequacy and whether providers are actually available.  Here is his link to his article on Health Information Exchanges. 

•  Dinah talks about statins and depression and and reads from Emily Dean's blog on Evolutionary Psychiatry where she discuss statins and depression and violence and cholesterol.  The guinea pig pictured above has a fine lipid profile.

• Dinah  talks about her new novel : Home Inspection.                

        

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Is Depression Inherited?

I don't usually do the Sunday morning New York Times thing, but Dinah is away and doesn't have a laptop so she asked one of us to put something up about this for her.

Today on the New York Times, a piece entitled "Is Depression Inherited?"

The story, by Daphne Merkin, is about her lifelong struggle with depression and the role it has played in her life as a mother.

She was first hospitalized when her daughter was six months old and at least twice more after that during her child's adolescence. She talks about the guilt she felt when her daughter once ran into her bedroom and threatened to kill herself with a knife at the age of six. She worries that her child will learn her previous maladaptive ways of coping and end up dealing with a depressive disorder dealt her by a quirk of genetics.

She discusses the heritability of depression---about 40 percent---but qualifies this with the unknown factors of unexpected traumatic events and factors related to resiliency, like having loving and consistent parents.

In the end, genetics are not destiny and just being aware of the risk may be enough to protect the children of depressed parents.

WhatsMyM3?

NBC-4 News Clip from Doreen Gentzler (May 16, 2012)

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.


WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

---

I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

Ketamine, Special K, and Depression

I just wrote a post over on Clinical Psychiatry News about the experimental use of ketamine (aka, rave drug "Special K") for instant relief of depression and suicidal ideation.

Please go over there to read it (link above), and feel free to comment there (sorry, registration is required but it's free) or here. I'd like to hear about providers who have used ketamine for their patients and from people who themselves have used it for depression.

Edit: find a list of clinical trials using ketamine for depression on clinicaltrials.gov.

NYT: When Lobotomy Was Seen as Advanced

This is an eye-opening essay about how lobotomies were used back in the day.
[posted via email]
From The New York Times:
ESSAY: When Lobotomy Was Seen as Advanced
New research indicating that Eva Perón was lobotomized not long before her death is a reminder of how enthusiastically this operation was once embraced.
http://nyti.ms/tRibGb

Would You Like Prozac With Your Latte?

The Guardian recently published this story about a longitudinal Harvard study of 51,000 female coffee drinkers followed over ten years. They found that there was a 20% lower risk of clinical depression in the women who drank four or more cups of coffee a day compared to non-drinkers. This is consistent with a previous study of 86,000 female nurses followed over ten years, where they found that the relative risk of suicide was reduced even for moderate to low coffee drinkers, defined as drinking two or three cups per day.

This is good news for me since I usually start my day with a half a pot before I get to work. (Yes, that much, really. No wonder Dinah sent me a link to this story and said, "You've gotta blog about this.")

The trick is, there may be a ceiling effect to all this: once you get to eight or more cups a day this risk of suicide starts to increase again according to one study.

Somewhat gratuitously, the Guardian article threw in reference to our "druggy society" and faulted the researchers for not considering other factors like social supports, involvement in religious groups or community activities, and even whether the women were drinking coffee alone or with friends:

"As the scientists will also tell you, neurotransmitters respond to everything: hugs, kisses, conversation, books, pictures, gardening, hunger, worry, rows, war – all raise or lower chemical levels."

Ah yes, clinical depression and suicide must be the result of not getting enough hugs or the fact that you haven't taken up gardening. Cringe-worthy health reporting, at its best. The reporter concludes:

"...supposedly scientific comments of this sort serve little purpose except to coax women into a state the doctors can then medicate."

Amazing. A simple study about caffeine and depression has somehow been morphed into another nefarous plot by evil Dr. Pillshrink.

Is This Depression?

Over on KevinMD, an anonymous doctor has post up called the Absence of Joy about his own problems with depression.  He writes:


For ten years I fought against the feeling that for long periods of time I was abnormally unimpressionable.  Not all the time, but certainly for moments. I was neither incredibly happy nor depressingly sad.  I put all this down to the stresses of making ends meet by moonlighting in ER’s, working impossible hours, studying for interminable exams, followed by the stresses of looming loan repayments, cash flow crises, parenting and marriage demands as my practice struggled to find its feet.

During moments of reflection I would question my condition, briefly consider depression as a factor, and then disregard it completely.  I was sleeping well.  I was not miserable.  Just stressed, like many of my colleagues.  Burn out was the diagnosis I chose for myself, and there seemed to be no easy option to deal with that.

But as the joy withdrew from my life, I was unable to identify the cause within.  I looked for other causes.  If the reason was not internal, it had to be external.  I found subtle fault with everyone around me, my wife, my kids, my career, my patients, my staff.  I considered changing my situation, leaving all of these, building another life, because this one did not appear to make me happy.
My wife saved me from myself.  Some ultimatums later, I was presented with a diagnosis of subclinical depression and began taking an SSRI.

He goes on to talk about how much better he feels and how much less labile his moods are.  He mentions things rolling off him like they'd roll off a duck's back, and of course we Shrink Rappers are big into ducks. 

So why am I writing about this blog post?  I think because I wasn't so sure I would have offered this patient medications.  Of course it's only a snapshot, and sometimes a recounting of symptoms on paper does not match the distress that a live person can convey, but the writer does not describe clinical major depression, what we think of as an illness.  He does a great job of describing existential angst, and makes no mention of whether he's had psychotherapy.  Perhaps he describes dysthymia (a low grade chronic depression that depletes the patient) but I wasn't totally sure.  I almost had the sense while reading that he's taking a happy pill that moves him to complacency. But the writer describes a huge relief, satisfaction with his outcome, and who am I to second guess? 

Just thought it might make for some good conversation here on Shrink Rap.  Do check out the whole post over on KevinMD by clicking here.

Video Report: Deep Brain Stimulation for Psychiatric Disorders? : Clinical Psychiatry News

Look, it's our friend, Ben Greenberg!
Hi, Ben.
Ben is an expert on Deep Brain Stimulation. We like him.

Suicide, Brains, and Football

In yesterday's New York Times, Alan Schwarz wrote about the tragic suicide of football player Dave Duerson this past week. Schwarz notes that prior to shooting himself, Duerson texted family members that he wanted his brain examined for Chronic Traumatic Encephalopathy, a condition we've discussed before in our post Brains, Behavior, and Football.

Schwarz writes:

Doctors, N.F.L. officials and even many players denied or discredited the links between football and such brain damage for months or even years. The roughly 20 cases of C.T.E. that have been identified by groups at Boston University and West Virginia University were almost always men who had died — most with significant emotional or cognitive problems — with no knowledge of the disease. Now, for the first time he knows of, Stern said, a former player has killed himself with the specific request that his brain be examined.

I'm left to wonder, did this former football player have this problem? Sometimes depression alone causes memory problems and sometimes people with depression worry that they have Alzheimer's disease, or any number of other illnesses for that matter. Treating the depression may help the memory problems, and may alleviate the fears of other illnesses. And we don't know much about the Chronic Traumatic Encephelopathy induced by repeated head injuries: is the course of the dementia altered by early intervention with medications? Does the depression respond to the usual treatments for mood disorders? Could Mr. Duerson have been saved, at least for a while?

Here's an article on the treatment of chronic brain injury with hyperbaric oxygen in animal models:
http://www.hbot.com/first-successful-treatment-of-chronic-traumatic-brain-injury

And here's an emedicine article on treatments for repetitive brain injuries (not necessarily specific to CTE) with medicine recommendations, but no mention of antidepressants or medicines to slow the course of dementia:
http://emedicine.medscape.com/article/92189-treatment

Here's a medscape article on CTE and dementia:
http://www.alzheimersreadingroom.com/2010/08/causes-of-dementia-chronic-traumatic.html

And, finally, here's a shout out to my friend and med school classmate Robert Morrison, M.D., Ph.D. whose paper for our public health class was published in JAMA back in 1986 as a state of the art review of boxing and brain injury: http://jama.ama-assn.org/content/255/18/2475.short

Is it worth it in the name of sports?

Could I ask a huge favor of the next football player who considers suicide? Instead of completing the act, could you have your depression treated and then write about the results? It would be an enormous contribution. Sure, it would be an anecdote, and not a controlled trial, but perhaps it would add something to the field. And we'd be happy to publish your story here on Shrink Rap.

My heart goes out to the family of Dave Duerson.

Is Depression on the rise?

GP's tend to deal with a lot of depression and anxiety (and I'm not talking about our own... who tends to us? Another question. Another post).

Is there more depression and anxiety in the 21st century or are we just getting better at recognising it?

The middle of the 20th century saw the rise in early recognition and treatment of psychiatric illnesses. In fact, most of the stigmas surrounding psychiatry, psychologists and psychological drugs were put to bed in the late 70's and early 80's. The rise of Freud and Mommy-consoling. They were heady days.

Back to the present – something is definitely up. It feels like at least 1 out of every 3 patients I see is on some type of an antidepressant or mood stabiliser. I used to have a professor who joked that lithium should be put into the water. Quick, painless alleviation of most of our problems. Imagine a world where the traffic driver is too stoned to cut you off. Wait. They are stoned. And still cut us off? Well, I did say “most” of our problems.

I see at least 3 people per week who arrive complaining of stress, an inability to cope – and of the opinion that medication (not psychological treatment) will help.

Has life really become more stressful in the 21st century? Dual incomes? Pressure for women to succeed and men to become more nuturing? Or have our parents not prepared us properly for the big bad world. Are we, as modern human beings, getting less and less capable of dealing with situations and just getting in with life?

Why do more and more people feel that they have to take medication (and/or drugs) to deal with the everyday stuff? Maybe it has something to do with the fact that everytime you pick up a YOU magazine, you're confronted with pretty looking people advising you seek out your doctor for the latest in smiley medication.

A lot of questions – and not too many answers I'm afraid.

Perhaps we should spend more time teaching stress management in schools? Or organisational skills... teach our children to be more efficient, manage money better, be more emotionally available?

Then maybe our next generation won't have to be permanently medicated to be happy and functional...