Category Archives: Depression

Introducing “Listening to Prozac”

Depression, Issues & Debates, Review - books movies series, Treatment Approaches
By Peter D. Kramer
By Peter D. Kramer MD

Last year I bought this book for RM5 from the Popular RM5 book fiesta (by now you probably have realized that I bought a lot of books there, and yes you’re right, I do spend time to go through those non-fictions and try to pick some treasure!). It is written by an American psychiatrist.

This is really a book that I’d strongly recommend, to … certain people, like me – who know quite a bit about psychopharmacology, but not enough, not much about their history – who have seen how all those drugs are used practically and in day to day life, but not read much about the facts and dark stories behind them. It is an old book I have to say, but I learnt so much about the older generation anti-depressants (tricyclic like Imipramine, Monoamine Oxidase Inhibitors which is not so common these days) and those that I’m so familiar with, i.e. the SSRIs (e.g. Prozac (Fluoxetine)!).

It made me think a lot about how those so-called legal drugs are prescribed, used and misused, how it can change a person from the inside (personality! how they see themselves all their lives simply changed after they started the medicine!), how vague the definitions of psychiatric diagnosis are, how tiny the difference between well and unwell could be etc etc. It may not be a book for everyone, I’m sure some might fall asleep reading it, but it’s probably the first time I’m reading such old book (published in 1993 -before I attended elementary school :P, some updates in early 21st centuries at the back) but still get so astonished and learnt so much!

Drug Use & Drug Abuse

Depression, Issues & Debates, Treatment Approaches,

More specifically, it is Psychiatric drug use VS Illicit drug abuse

If I have depression, or dysthymia, or an inability to experience pleasure (anhedonia), why do I need to take psychiatric drugs? I can take cocaine, amphetamine, heroin or opium too, they make me happy and feel high too. It reminded me of the patient who took his own life by jumping off from a building. He said gathering with his bunch of friends and taking those pills are his kind of pleasurable activities (case study here), just like women go shopping or people go gym. Yea, right, how about that? Take a few “pills” and I’m better?

Antidepressants like Prozac and Lexapro (the SSRIs) do not provide pleasure, it restores the capacity for pleasure. It is neither excitatory like cocaine nor satiating like heroin. The drug taker doesn’t crave Prozac and does not feel relief when it enters the system. The desired effect, a change in responsiveness to ordinary pleasures, occur gradually and is unrelated to the daily act of consuming the drug. So unlike cocaine which produces quick, strong but short-lasting “high”, people don’t “usually” get addicted to the SSRIs.

Drug addicts use stimulant drugs hoping to cope with intolerable feelings. Without medication, they may experience little enjoyment. Prescribed medication makes drug addicts who kick the street-drug habit feel less empty and better able to enjoy ordinary pleasures. For the addict, the hope is to enhance the ability to “postpone gratification”, something antidepressants may do by increasing the ability to imagine future pleasure. If and when ordinary pleasure becomes appealing (after a drug addict is treated with psychiatric medicine and begins to experience “ordinary pleasure”), it’s hoped that self-understanding and self-control will follow (no longer rely on illicit drugs to achieve “instant pleasure”).

So can we use anti-depressants (and some other medication) to treat stimulant drug addictions? I believe with a combination of behavioural therapies, and supports from the immediate family members, anti-depressants would work. But taking only anti-depressants without strong mental and motivation to quit and sufficient social supports is definitely not enough, not in long-term for sure.

Psychiatric Drug Abuse?

But anti-depressant drugs (focusing on SSRIs here) can also be abused. There are patients whose depression were treated with the SSRIs, once successfully weaned from the tablets, want to restart it, not because they are depressed, but because life seemed brighter when they were medicated. In psychiatry it’s a bit difficult to decide where treatment ends and depression starts again.. but doesn’t this seem a bit like taking illicit drugs? Same applies to people who take excessive anxiolytics (anti-anxiety drugs / tranquilisers) to make them calm and functional, how do we define when it’s legal psychiatric drug abuse?

There are people who feel more mentally sharp and agile, talk more fluently, and more socially confident when they are on anti-depressants, they continue to take it even when they don’t show any signs of depression at all. Unlike amphetamines which also make people more alert and productive but at the same time is addictive and causing paranoia, most of these SSRIs don’t lead to any significant side effects (and (if) any discomfort tend to go away after first few days). So does this make it morally and ethically fine to take anti-depressants to increase alertness, quickness of thought, and verbal and mechanical fluency, in the absence of illness?

 

P.S. SSRIs stands for Selective Serotonin Reuptake Inhibitors, which are newer drugs used to treat depression, but also work for OCD and anxiety disorders. Some commonly used in Malaysia include Lexapro (Escitalopram), Prozac (Fluoxetine), Zoloft (Sertraline), Luvox (Fluvoxamine).

N.B. This post focuses more on major and minor depression, dysthymia and anhedonia.

給年邁父母的愛

Clinical Case Studies, Depression

其實很多時候我還蠻擔心接到他老人家的電話的，雖然我心裡很敬重他，但更多的，是心疼。

他是個七十多歲的老先生，是診所多年的抑鬱病患者，情況時好時壞，目前吃著的抗抑鬱藥物更已經是最大劑量。老先生已經退休，平時都在照顧中風臥病在床的妻子，給自己還有老婆打點生活的大小事務，有個兒子但不同住，關係也不大好，見面總是吵架，兒子去年剛離婚，也沒爭取到孩子的扶養權。老先生自己的身體不怎麼好，有骨刺，嚴重起來自己也是痛得徹夜難眠。

害怕接到老先生的電話，是因為老先生住得遠，平時要是病情惡化了，心情鬱悶不已，就會給我打個電話請我幫忙舒緩。而因為藥物已經是最大劑量，又真的不想因為增加沒什麼作用的藥物導致老先生得承擔更大的經濟負擔，所以平時只能儘量和老先生聊聊天減少他不必要的操心。而事實上，老先生尚算樂觀開朗，就算心情很煩躁鬱悶，也很少掛個苦瓜臉哀聲嘆氣，而且老先生的抑鬱很大程度是環境和一些他個人無法控制的因素造成的，所以藥物最多只能稍微輔助，起不了太大的作用（雖然對一件事的詮釋完全歸於個人）。

我知道我不該這麼想，但因為在這行久了，看多了，我常不自禁擔心老先生會不會覺得自己身體不好，又要照顧老夫人，和兒子關係又差（而且兒子還有許多要他擔心的事），抑鬱一發作，生活沒意義沒樂趣，一時想不開就走了。每次想到這，都會慶幸自己偶爾可以幫上一點小忙，更會明白老先生能撐到今天，很多能量來自於對老夫人的愛與責任。少一點愛，少一點責任心都不行。說得難聽些，換作是時下的年輕人（如我，雖然我也不太年輕了…），肯定早就撐不下去逃避問題去了。是的，我總認為上一代的人比較堅強，有韌性，有毅力，較能在逆境中生存甚至向上；這一代在太多保護與遷就裏長大，比較任性，欠缺責任心和堅持。

我心疼他，同時也生氣他的兒子，脾氣不好，行為不好，也不盡孝心，見面就是和老先生吵架。其實我也和這獨子有過一次接觸，感覺他生活很多狀況也自顧不暇，所以責怪他的心理很矛盾，因為其實兩父子顯然都很關心對方，有問題都不敢告訴對方怕對方操心，大概又是同樣的火爆脾氣，兩人說不上兩句就吵架了。

其實說穿了，很多老人家都一樣，寧可對外人聊心事講問題，也不要不敢對自己的家人自己的孩子說，因為孩子總是忙，因為孩子已經很累了，因為不要孩子擔心操心，因為和孩子說太多最後都變吵架，因為怕孩子嫌自己煩自己嘮叨（甚至怕孩子把自己送進老人院）… 每次和老先生的接觸，都會提醒我要對爸媽更好一些，更體貼他們一些（然後回家就忘得七七八八！）

P.S. 這是我第一用中文紀錄臨床個案（Clinical Case Studies），主要是因為我心裡有很多感受想用中文抒發；所以可能要請讀者體諒這文章可能寫得不太順暢（還要磨練磨練）

Is it Depression or Depressive State in Bipolar Disorder?

Basic & General, Bipolar Disorder, Depression

I’ve previously written about patients with Bipolar Disorder taking only anti-depressant medication (see here for Case 1 & Case 2). As presented in these cases, quite often hypomania and mania do not lead to doctor visits, whereas usually people in depressive state will seek help, which then means that anti-depressant medications will more likely to be considered and used initially. But after a period of treatment, just like the teacher in Case 2 who thought she had recovered but all the colleagues and headmistress found her so hyper, and the man in Case 1 who refused to stop anti-depressants as they made him feel so strong, empowering and elated, these drugs could go all wrong without proper follow ups and assessments.

Anti-depressants (SSRI, Selective Serotonin Reuptake Inhibitor) such as Prozac, Lexapro, Luvox, Zoloft are some commonly used medications for anti-depressant. Sometimes they also work for anti-anxiety and treatment for obsessive compulsive disorders. When bipolar is involved, an antidepressant taken without the protection of a mood stabilizer can potentially induce mania or hypomania, and worsen the course of the illness.

So if the family members or the patient suspects that the depression is actually part of a bipolar disorder (based on patient’s presentation and past experience), it’s very important to make aware to the psychiatrist or attending clinician, so that a mood stabiliser can be used first. Even if the mood stabiliser cannot control the depressive state, it can be used in conjunction with anti-depressants, as a “protective shield” from switching to manic stage (though still, no guarantee, only reducing the chance).

Also, it usually takes at least 2 to 3 weeks for mood stabilisers and anti-depressants to kick in, and a much longer period till it becomes fully effective, sometimes seeing no effects may suggest that you need to be patient and in a month or so you will feel very different, while other times it could also suggest that you are not taking the right dosage, and this is to be judged by psychiatric doctor.

N.B. This is written by a psychologist based on her experience working with patients in psychiatric clinic (and some research); if in doubt please consult your doctor. 

本文写的是抑郁症 (depression) 与躁郁症 (bipolar disorder or manic depressive disorder) 里的忧郁的区别. 大部分时候, 狂躁 (manic) 的人都不会寻求医疗帮助, 都是在抑郁的阶段 (depressive state) 去看医生, 这样一来, 医生很可能就会用抗抑郁药物 (anti-depressant). 可是就如 案例 1 里的男人吃了抗抑郁的药不肯停下来, 因为它让他觉得很强大兴奋和 案例 2 里的老师在接受抗抑郁药物一段时间后以为自己好了不再老是悲伤哭泣, 但身边的校长老师都觉得她情绪过度高昂近乎狂躁.

所以如果家人或者病人本身, 根据过去的经验与病人的表现, 怀疑病人目前的忧郁是狂躁的一部分而不是单纯的抑郁病, 就一定要和医生讨论, 可先用情绪稳定剂治疗 (mood stabiliser), 避免单纯的应用抗抑郁药物 (anti-depressants) 而把病人推向狂躁 (mania).

值得一提的是, 大部分抗抑郁药物 (antidepressants) 和情绪稳定剂 (mood stabilisers) 都至少需要两到三个星期才展现效果, 并需要更长时间才更完整地见效. 所以要是一开始完全不觉得情况有改善, 一是你需要更多耐心, 在大概一个月后你的感觉会改善许多, 二是病人的药物分量不够, 这则需要专科医生的判断.

备注: 本文的作者是一名心理学家 (psychologist), 内容是依据与精神科病人工作的经验与研究所写. 如有任何疑问请寻求专业医疗帮助.

A supposed-to-be successful and inspiring insurance agent

Clinical Case Studies, Depression

He became a millionaire in his early 30s, although primarily an insurance agent, he was known with his skills in investing. He had a wife and a daughter. They went on holidays all over the world every year.

In his mid thirties, he got depressed and suicidal, due to stress of work and some other problems. He attempted suicide several times, buying ropes to hang himself, overdosing himself on drugs but was always found early enough to save his life. Perhaps this wasn’t how his life meant to be.

His family took him to temples, hoping that the power of religion could help him to recover. They were told that the money he’d earned was “dirty money” (money obtained unlawfully or immorally). So by instructions, he went to China and donated almost all his money to the temples. At this point, the wife left him. He got even more depressed, he didn’t recover donating his money away.

Recommended by friends, he seek professional help and came to see psychiatrists. After weeks of medications and a course of ECTs, he got better. On the following years, his condition was maintained with medication. He would come to see doctor once he felt unwell. He rebuilt his career and became wealthy again. He even supported his ex-wife financially, although he also soon got married with another woman. Over the years he had had another 2 courses of ECT at times of difficulty.

He even went on press to talk about mental illness. He shared his stories including his suicidal attempts and helped raising the mental health awareness in the public, telling others not to discriminate them, but also encouraging those with mental illness not to give up, motivating them to seek help actively, telling them it’s recoverable, and they have the opportunities to lead a normal and fulfilling life just like him and anyone else!

He wasn’t just a normal successful insurance agent, but also one of the most motivating and inspiring speakers in the town.

Years later, in his mid 40s, he got into some troubles. This time he didn’t come back to see doctor, he checked himself in a hotel, jumped off from the window of the washroom in his hotel room. There ended his colourful short life.

People may think someone as motivating as him couldn’t and shouldn’t end his life that way, but it’s based on a true story. When the illness hits, it really hits, no matter who you are and what you are. Perhaps for cases like this, maintaining on medication and education on relapses are utmost important, including educating patient’s immediate family.

Can we allow a severely depressed patient to make the decision?

Clinical Case Studies, Depression, Issues & Debates

She’s gone, on Tuesday (more about this patient here: Depression & ECT).

As written on my previous post (link above), she underwent a course of six ECT and got much better. During the past year, she did voluntary work, travelled around (to South Africa, Japan etc). Every time she came back for follow up and saw me in the clinic, she had this big wide smile on her face, including the last time I saw her, last week.

Past few weeks she’d been calling me a lot, since her house renovation, which put her under some pressure. Then slowly all her negative thoughts came back. Lacking drives, lying down a lot, negative and suicidal thoughts, all returned, like how she was before the course of ECT last year, despite the increase of her anti-depressants.

She started to ask if she should come for another course of ECT. We kept helping and supporting her, and supporting her extended family to support her. Last week she asked again. And finally the consultant psychiatrist had also agreed that she should undergo ECT. When she was told that she could have it, she became hesitant and indecisive again. So she came for consultation and was told that she could take her time to think about it, and if she wanted it, she could call us and we’d arrange it (of course we also arranged what she should/could continue doing every day).

Few days later she rang me in the clinic, telling me she’s feeling much better, just did voluntary work in the temple. She was feeling quite positive and thought she’d make it. So much relief in me.

Few days passed and I was busy. This morning I heard from her cousin. She was gone, with medicine and half a bottle of herbal liquor. When they found her (the patient lived alone in KL, her family couldn’t reach her on phone all weekend long and came all the way from Malacca to see her), she was still conscious, but with white foam coming out from her mouth. They called the ambulance. But the patient refused to get into the ambulance. The medical staff said it’s against the law to force someone into the ambulance, so they left! The patient went back to sleep later and …”rests in peace”, as the way her cousin put it.

Is it right for us to leave the decision of whether to do ECT with her? Should we be the ones who make the decision for her? Could we be the ones?

Is it right for the ambulance staff to leave, just because the person refused to? Despite knowing that she most probably need a stomach washout, is it right that they let her make the decision herself?

Is she capable to make these decisions? She’s severely depressed, despite the medication, could she judge and reason then decide?

Practically I’ve always been told that we can’t really make any decision for patients, all we can do is to explain the options, treatments and procedures to the patients and family (if applicable). But how if they’re single and suicidal, with not much familial support? Are there exceptions? Can we push them to go for ECT?