What I Want Someone Who’s Overwhelmed with Their Mood Disorder to Know

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You have depression, or bipolar disorder. And on some days, you feel like you’re treading water—at best. You’re tired of struggling. You’re tired of regularly feeling tired. You’re angry that your to-do list just keeps getting longer and longer. You’re angry that you have to deal with so much darkness day in and day out.

Some days are just hard. Some days you feel so overwhelmed.

It is on these days that you probably feel like the only person on the planet who’s struggling with persistent symptoms.

Thankfully, you’re not. And thankfully, it will get better.

We asked individuals who live with depression or bipolar disorder to share what they’d like others who are feeling overwhelmed with these same conditions to know. Most of the individuals are speakers from This Is My Brave, a fantastic nonprofit organization that hosts live events and aims to “end the stigma surrounding mental illness through storytelling.”

Get treatment. T-Kea Blackman, a mental health advocate and speaker who lives with depression and anxiety, stressed the importance of seeing a therapist who can help you identify triggers, learn healthy coping tools, and set boundaries, along with a psychiatrist if you need to take medication. (For bipolar disorder, both medication and therapy are vital.)

Blackman emphasized not getting discouraged if the first or third medication you try doesn’t work, or the first or third therapist you see isn’t a good fit. “It can take time to find the right dosage and medication, and therapist for you.” This can be frustrating, but it’s common—and you will find the right help.

Focus on small victories. Sivaquoi Laughlin, a writer, blogger, and mental health advocate with bipolar II disorder, has good days, bad days, and sometimes great days. She underscored the importance of realizing that it’s OK not to be OK, and acknowledging small victories, which are actually “huge.”

Some days, those small victories might be getting out of bed and taking a shower, she said. Other days, they might be excelling at work and going to dinner with friends. Either way, it’s all important and worthwhile.

Forgive yourself. Fiona Thomas, a writer who has depression and anxiety, stressed the importance of not beating yourself up when you don’t do everything on your list, or when you have bad days. One of her friends always says: “Remember that your best changes when you’re not feeling well.”

Thomas, author of the book Depression in a Digital Age: The Highs and Lows of Perfectionism, suggested not comparing today’s output to your output from last year or last week. “It all depends on how you’re feeling mentally, and if you’re not 100 percent, then just do what you can—the rest will come later.”

Thomas also suggested doing one small thing every day that makes you feel better. This might be anything from drinking a few glasses of water to walking around the block to talking to a friend, she said. “There are so many ways to boost your mood little by little, and over time, they become habits and make you feel better without even really having to try.”

Do one enjoyable thing every day. Similarly, Laughlin encouraged readers to find one thing that brings you happiness, and try to incorporate that into your daily routine.

For Laughlin, it’s many “one things.” That is, she loves being with her grandson and her dogs, meditating, hiking, reading, and writing. “Start small and build upon it. Forgive yourself if you miss a day or days.”

Remember you are not broken. Suzanne Garverich is a public health advocate who is passionate about fighting mental health stigma through her work on suicide prevention as well as telling her story of living with bipolar II disorder. She wants readers to know that you “are not damaged, but [instead] so courageous and strong to live through and fight through this illness.”

Document your OK days. This way, “when you are having an off day or month or series of months, you can go back and remind yourself that you have felt differently,” said Leah Beth Carrier, a mental health advocate working on her master’s in public health, who has depression, obsessive-compulsive disorder, and PTSD. “You are capable of experiencing emotions other than the numb, black hole you reside in at the moment. There is hope.”

Surround yourself with support. “Surround yourself with people who can support you and find an online community who can relate to you, such as the Buddy Project or my community, Fireflies Unite,” Blackman said. She also noted that the National Alliance on Mental Illness offers free support groups.

Other online supports include: Psych Central’s forums, and Project Hope & Beyond and Group Beyond Blue–both of which were started by one of our associate editors, Therese Borchard.

Teresa Boardman, who has treatment-resistant bipolar disorder, attends weekly therapy sessions, but sometimes, she said, she needs more. “It’s OK to talk frankly with someone. I like to use the crisis text line because I do not have to break my cone of silence. Expressing yourself truly makes you feel less alone.”

Living with a mental illness can be hard. Acknowledge this. Acknowledge your overwhelmed, exasperated, angry feelings. Remind yourself that you’re not alone. And remind yourself that you are doing an incredible job, even on the days it doesn’t feel like it.

What I Want Someone Who’s Overwhelmed with Their Mood Disorder to Know

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Small Things I Do Every Day to Manage My Bipolar Disorder

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Living with bipolar disorder can feel overwhelming. Maybe you’re tired of the ups and downs of different episodes—the soaring energy, the debilitating fatigue, the racing I-need-to-do-everything-and-I-need-to-do-it-now thoughts, and the dark, decelerated, bleak thoughts.

Maybe you’re exhausted from struggling with an especially stubborn and deep depression, which makes it tough to concentrate on anything, and feels like you’re walking through a river of waist-high molasses in a fog.

Managing bipolar disorder can feel overwhelming, too. What can make it much easier is getting effective treatment. Bipolar disorder is highly treatable—but a lot of people with the illness don’t get professional help.

Author Charita Cole Brown pointed out that “Of the estimated 5.7 million Americans living with the disorder, over 50 percent won’t seek treatment.” She wrote the memoir Defying the Verdict: My Bipolar Life “to reduce the stigma surrounding mental illness in general and bipolar disorder in particular. People need to understand how important it is to seek appropriate treatment.”

“My recovery is no anomaly,” Brown said. “By sharing my story, I want people to understand that mental illness is physical illness, therefore we must seek treatment as we would for diabetes or a broken arm.”

In addition to seeking treatment, there are small things you can do every day. Below, alumni from This Is My Brave share the small and significant ways they manage their bipolar disorder. This Is My Brave is an international nonprofit organization that hosts live events and publishes essays on their website written by people who are living with mental illness and living well.

Checking in. Amy Gamble is a speaker, executive director of NAMI Greater Wheeling, and a former Olympian. Every day and throughout the day, Gamble checks in with how she’s doing: “’Are my thoughts racing a little or do I just have a lot of creativity going right now?’ If I find I’m a little charged up or anxious, maybe even hypomanic, I take extra precautions not to make a lot of decisions.”

Gamble monitors her behavior, too. “I think about what is typical for me when I’m balanced. I am a very deep thinker and don’t typically make impulsive decisions. If I start acting on impulse, I reel myself back in. I don’t always notice a change in my behavior right away, but I monitor with hypervigilance.”

Suzanne Garverich also carves out time to pause and do a “self-inventory.” “I assess quickly how I am doing emotionally, physically, mentally, and spiritually,” said Garverich, a public health advocate who is passionate about fighting mental health stigma through her work on suicide prevention as well as telling her story. This helps her identify her needs—“before I go too far down the rabbit hole”—and meet them.

For instance, if Garverich determines that she’s feeling emotionally low and having dark thoughts, she figures out what she needs to do to “help me not go deeper into the dark thinking and depressive feelings.” She might call a friend or take a 10 to 15-minute walk. “It could be as simple as walking to the water fountain and drinking some water—just moving a muscle to change a thought. It could also be that I need to do some redirection of my thinking using my CBT and DBT skills…”

Having an effective bedtime routine. “The major thing I do is to make sure I get 8 hours of sleep a night,” Garverich said. “This really helps in keeping me balanced—sleep has a huge effect on my bipolar.”

To help herself get restful sleep, Garverich maintains a routine. Two to 3 hours before her bedtime, she stops doing anything work-related. She usually watches 30 minutes to an hour of TV. Then about an hour before her bedtime, she takes her nighttime medication, and gets into bed to read. Some nights she also takes a shower or bath.

“I also spend time before I go to bed breathing on my back and reviewing my day—seeing what I have done well, what I would like to improve, and if there is anything I need to share with anyone.”

She sets her alarm for the same time every morning. After she wakes up, she meditates in bed for 30 minutes. (More on meditation below.)

Practicing mindfulness and meditation. Gamble, also author of the book Bipolar Disorder, My Biggest Competitor: An Olympian’s Journey with Mental Illness, practices meditation, deep breathing, and mindfulness. “Staying in the present moment keeps me from getting down about how my illness has limited me.” (She also reminds herself that “everyone has something they are dealing with.”)

Every day Gamble listens to a playlist of her favorite meditation songs. “I put on my headphones and attempt to quiet my thoughts. I focus on slowing my mind down and paying attention to my breathing.”

Garverich also finds it helpful to practice deep breathing throughout the day, especially if she’s overwhelmed. For instance, at work, she usually takes a break and goes to the bathroom to take deep, slow breaths.

Connecting with others. “For me what is really important to achieve daily, to manage my illness and nourish my well-being, is feeling connected and not alone in my thoughts,” said Susie Burklew, who shared her story at the 2018 This Is My Brave show in Arlington, and co-produced the fall 2018 show. Eight years ago, for the first time, Burklew told her therapist that she thought she had a problem with alcohol. Her therapist suggested Alcoholics Anonymous (AA).

“I went to my first meeting that evening and I haven’t had a drink since. For the first time in my life I felt like I wasn’t alone. I connected and was inspired by people who had been through the same struggles and were living a happy life in recovery. I formed a strong network of people in AA and became comfortable opening up about my addiction to alcohol.”

For the past 6 years, Burklew has worked as a behavior specialist and counselor at a government residential rehab that specializes in co-occurring disorders.

Today, reaching out to someone on a regular basis—such as someone from her recovery network—helps her to stay in the moment, instead of getting “caught up in the stress of something that’s happened in the past or the fear of what’s ahead.”

Garverich connects with at least one person in her support system every single day. She might talk to this person over the phone, or they might simply text. Either way, this helps her know she’s not alone—something her illness wants her to feel, she said.

Sivaquoi Laughlin, a writer, blogger, and mental health advocate with bipolar II disorder, makes sure she spends time with her grandson and her dogs every day. “The energy from both provide me with a level of joy that I’m constantly yearning for.”

At the end of the day, Laughlin also sits down with her “16-year-old daughter and [we] discuss our day and name something good/great that happened. Even if it’s been a hard day or we haven’t had time to really connect, I make sure she knows that every day has a highlight.”

Engaging in art projects. “I undertake artistic projects daily. I am no good at it, but I can feel like I can breathe,” said Teresa Boardman, who has treatment-resistant bipolar I disorder with PTSD, OCD, suicidal ideation, and hypersomnia. Her latest project is a birdbath. “It is quite discombobulated that I decided to go with a steampunk theme. Now it is beautiful because I changed how I see it.”

Reducing the to-do list. Every morning, Laughlin lets her dogs out, and immediately makes a cup of tea. Next, she looks at the day ahead and jots down three things she’d like to accomplish. “They could be simple, such as returning a library book or dropping off dry-cleaning to bigger projects like organizing my closet or mowing the lawn. I’ve found that by committing to only three things, it keeps me from being overwhelmed and being triggered by ‘voices’ telling me I can’t do something.”

Boardman makes notes on her bathroom mirror of things she needs to do. For instance, she might list her exercise routine (e.g., 20 minutes of cardio, 20 minutes of yoga), and that she needs to take her morning medication and her evening medication. Boardman noted that she tries to work with her illness and its varying moods. After having over 20 electroconvulsive treatments (ECT), she realized she needed to take a different approach and embrace her illness.

It’s understandable that living with bipolar disorder can feel overwhelming and frustrating. But remember that there are 5.7 million Americans struggling alongside you. Remember that this illness, though difficult, is also highly treatable.

“Don’t give up hope,” Gamble said. “Things will get better, and you can learn how to manage the symptoms. They might not go away completely, but you can learn how it affects you. You can learn how to beat bipolar disorder.”

Small Things I Do Every Day to Manage My Bipolar Disorder

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Five Facts About Atypical Depression You Need to Know

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Despite its name, atypical depression is one of the most common types of depression, affecting between 25 to 40 percent of depressed people. Because the symptoms differ from those of typical depression, this subtype of depression is often misdiagnosed.

Atypical depression was named in the 1950s to classify a group of patients who did not respond to electroconvulsive therapy or to the tricyclic antidepressant Tofranil (imipramine). They did, however, respond to monoamine oxidase inhibitor (MAOI) antidepressants.

Some of the same treatments that work for classic depression work for atypical depression, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy; however, full recovery is more achievable when this type of depression is identified and addressed.

Here are a few facts about atypical depression you should know.

Fact One: Atypical Depression Usually Involves Mood Reactivity or Extreme Sensitivity

One of the distinguishing features of atypical depression is “mood reactivity.” A person’s mood lifts in response to actual or potential events. For example, she may be able to enjoy certain activities and is able to be cheered up when something positive happens — like when a friend calls or visits — while a person with classic major depression shows no improvement in mood.

On the flip side, a person with atypical depression also responds to all things negative, especially interpersonal matters, such as being brushed off by a friend or something perceived as a rejection. In fact, a personal rejection or criticism at work could be enough to disable a person with atypical depression. There is a long-standing pattern of rejection sensitivity with this kind of depression that can interfere with work and social functioning.

Fact Two: People with Atypical Depression Tend to Overeat and Oversleep

Instead of experiencing interrupted sleep and loss of appetite as people often do with typical major depressive disorder, people with atypical depression tend to overeat and oversleep, sometimes referred to as reversed vegetative features. It’s not uncommon for someone with atypical depression to gain weight because they can’t stop eating, especially comfort foods, like pizza and pasta. They could sleep all day, unlike the person with typical depression experiencing insomnia.

Oversleeping and overeating are the two most important symptoms for diagnosing atypical depression according to a study published in the Archives of General Psychiatry that compared 304 patients with atypical depression with 836 patients with major depression.

Fact Three: People with Atypical Depression Can Experience Heavy, Leaden Feelings

Fatigue is a symptom of all depression, but persons with atypical depression often experience “leaden paralysis,” a heavy, leaden feeling in the arms or legs.

According to Mark Moran of Psychiatric News, a depressed patient gave a graphic portrayal of his symptoms to researchers at Columbia University College of Physicians and Surgeons 25 years ago: “You know those people who run around the park with lead weights? I feel like that all the time. I feel so heavy and leaden [that] I can’t get out of a chair.” The researchers labeled the symptom “leaden paralysis” and incorporated it into the criteria of diagnosis of atypical depression.

Fact Four: Symptoms Usually Begin at an Earlier Age, Are Chronic, and Affect More Women

Atypical depression tends to begin at an earlier age (younger than age 20), and is chronic in nature. Michael Thase, M.D., Professor of Psychiatry at Perelman School of Medicine at the University of Pennsylvania, discussed atypical depression in a Johns Hopkins Depression & Anxiety Bulletin, where he said, “The younger you are in adult life when you start to have trouble with depression, the more likely you are to have reverse vegetative features. In other words, the likelihood that you’ll overeat and oversleep when depressed is dependent on the age at which you become ill.” This was the subject of a 2000 study published in Journal of Affective Disorders. The illness of the patients with early-onset of atypical depression looked entirely different from those diagnosed with a classic melancholic depression.

Atypical depression also seems to affect more women than men, especially women before menopause. “Ultimately, I see atypical depression as a subtype of depression that reflects the convergence of an early age of onset, female gender, and a chronic but less severe form of major depression throughout pre-menopause,” writes Dr. Thase.

Fact Five: Atypical Depression Often Coincides with Bipolar Disorder and Seasonal-Affective Disorder

Atypical depression is more likely to occur in people with bipolar disorder and seasonal affective disorder. A study published in the European Archives of Psychiatry and Clinical Neuroscience evaluated 140 unipolar and bipolar outpatients who had symptoms of an atypical major depressive episode. The prevalence of bipolar II disorder was 64.2 percent.

In another study published in Comprehensive Psychiatry, 72 percent of 86 major depressive patients with atypical features were found to meet the criteria for bipolar II disorder. There have also been studies reviewing the overlap between atypical depression and seasonal affective disorder, highlighting common biological links underpinning common symptoms.

Five Facts About Atypical Depression You Need to Know

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Medications That Can Cause Depression

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There is nothing more frustrating than when the cure is part of the problem. Because depression is prevalent in patients with physical disorders like cancer, stroke, and heart disease, medications often interact with each other, complicating treatment. To appropriately manage depression, you and your physician need to evaluate all medications involved and make sure they aren’t cancelling each other out.

A review in the journal Dialogues in Clinical Neuroscience a while back highlighted certain medications that can cause depression. The following are medications to watch out for.

Medications to Treat Seizures and Parkinson’s Disease

Many anticonvulsants have been linked with depression, but three medications — barbiturates, vigabatrin, and topiramate — are especially guilty. Because they work on the GABA neurotransmitter system, they tend to produce fatigue, sedation, and depressed moods. Other anticonvulsants, including tiagabine, zonisamide, levetiracetam, and felbamate have been associated in placebo-controlled trials with depressive symptoms in patients. Patients at high risk for depression should be monitored closely when prescribed barbiturates, vigabatrin, or topiramate. When treating Parkinson’s disease, caution should be taken when using levodopa or amantadine, as they may increase depressive symptoms.

Medications to Treat Migraines

In migraine patients at risk for depression, topiramate and flunarizine should be avoided when possible. A better option is acute treatment with serotonin agonists and prophylactic treatment with TCAs, as those medications could simultaneously address symptoms of both depression and migraine headaches.

Certain headache medications like Excedrin that list caffeine as an ingredient can also worsen anxiety.

Heart Medications

The link between blood pressure medications and depression has been well established. By affecting the central nervous system, methyldopa, clonidine, and reserpine may aggravate or even cause depression. Beta-blockers like atenolol and propranolol may also have depression side effects.

Although low cholesterol has been associated with depression and suicide, there is no clear link between depression and lipid-lowering agents.

Antibiotic and Cold Medications

Although most antibiotics used to treat infections are unlikely to cause depression, there have been some cases in which they induce symptoms. Anti-infective agents, such as cycloserine, ethionamide, metronidazole, and quinolones, have been linked to depression.

Over-the-counter cold medications like Sudafed that contain the decongestant pseudo-ephedrine can contribute to anxiety.

Antidepressants and Anti-Anxiety Medication

Sometimes medications to treat depression and anxiety can have a reverse effect, especially in the first few weeks of treatment. There have been reports of Lexapro, for example, worsening anxiety, however it usually subsides after the first few weeks. Anecdotal evidence suggests that Wellbutrin may also cause anxiety.

Cancer Medications

Approximately 10 to 25 percent of cancer patients develop significant depressive symptoms, however, given that so many medications are involved in treating cancer, it can been difficult to pinpoint the culprits. Vinca alkaloids (vincristine and vinblastine) inhibit the release of dopamine-ß-hyroxylase, and have been linked to irritability and depression. The cancer drugs procarbazine, cycloserine, and tamoxifen are also considered to induce depression.

One report cited depression in 16 percent of carmustine-treated patients, and 23 percent in those receiving busulfan when employed as part of the treatment for stem cell transplants. The antimetabolites pemetrexed and fludarabine have been reported to cause mood disturbances. Some hormonal agents to treat breast cancer have also been associated with depression, including tamoxifen and anastrozole. Finally, taxane drugs such as paclitaxel and docetaxel have been linked to depression.

Oral Contraceptives and Infertility Medications

Oral contraceptive medications have long been associated with depression. In a study published in the British Medical Journal, of the group of women taking oral contraceptives, 6.6 percent were more severely depressed than the control group. GnRH agonists (such as leuprolide and goserelin) can have depression side-effects in some people. In one study, 22 percent of leuprolide-treated patients and 54 percent of goserelin-treated patients suffered from significant depressive symptoms. Clomiphene citrate, a selective estrogen receptor modulator used to induce ovulation, has also been associated with depressed mood.

Medications That Can Cause Depression

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Does Calling Depression an Illness Worsen Stigma?

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I plead guilty to expounding on the biochemical vulnerabilities and abnormalities in neural wiring of depression to make the case that it is a legitimate illness alongside lupus, breast cancer, or psoriatic arthritis. I thought I was doing a good thing by quoting experts like Peter Kramer, M.D, who believes that because depression can be associated with the loss of volume in parts of the brain, it is the “most devastating disease known to mankind.”

My intention, like so many other mental health advocates I know, was to use science as a tool to lessen stigma. But is that really effective?

Proof of the Madness

I am relieved by clinical reports that explain why my efforts at cognitive-behavioral therapy aren’t enough to correct certain behaviors or thoughts — that brain imaging reveals the breakdown in normal patterns of processing that impedes the ability of depressed people to suppress negative emotional states and that high levels of activity in the amygdala part of the brain (the fear center) persist despite efforts to retrain thoughts. I would rather know that depression involves a problem in the wiring pattern of my brain than to know I simply wasn’t trying hard enough.

I get excited about the progress of finding genomic biomarkers for different types of mood disorders and about twin studies that show if one twin developed depression, the other twin also suffered from depression in 46 percent of identical twins. I am delighted that experts have found a common genetic mutation associated with a person developing clinical depression when faced with traumatic events in his or her life because it means that I’m not making this stuff up, that genetic variations exist that increase a person’s vulnerability to depression and other mood disorders.

No illness, please.

But apparently, people want their distance from those with illnesses or defined diseases. According to some research, concentrating on the biological nature of mood disorders can actually worsen stigma.

In his article, “Hyping biological nature of mental illness worsens stigma,” Patrick Hahn cites several studies that have shown public attitudes toward those who suffer from mental illness have worsened with the promotion of bio-genetic theories. One was a German study that found that between 1990 and 2001, the number of respondents who attributed schizophrenia to hereditary factors increased from 41 to 60 percent. In the same report, an increased number of respondents said they didn’t want to share a building, job, or neighborhood with a schizophrenic.

In the U.S. the General Social Surveys of 1996 and 2006 say pretty much the same. As the neurobiological explanation of mental illness gained approval, there was an increase in the number of people who didn’t want to be closely associated with someone with a mental illness, not as a co-worker, neighbor, friend, or in-law.

Extreme versus Sick

Hahn explains the two ways of looking at mental illnesses:

We could regard them as more extreme versions of the despondency, fear, wrath, or confusion that we all experience, as perfectly understandable reactions to overwhelming abuse and trauma. Or we could regard them as brain diseases, probably genetic in origin, requiring the sufferer to take powerful mind-altering drugs, quite likely for the rest of her life.

One approach emphasizes our common humanity, and the other seems to regard the sufferer as a mere biological specimen. One approach invites us the consider the societal and economic factors that lead individuals to feel despondent, fearful, wrathful, or confused, and to think about ways of changing them, while the other seems to regard society as basically sound, but unfortunately plagued by those individuals with faulty genes or guilty brains who can’t fit in.

I see room for both perspectives. While I regard some of my symptoms as exaggerations of the human condition — allowing me to explore the societal and psychological causes — I also recognize when my despair falls into the category of illness, an assessment that offers me a kind of relief — to know that my brain scans look different than the average Joe’s, and that there is a reason therapy and meditation and all my other efforts can’t fix it.

Embracing All Illness

Mood disorders are thorny and different from other biological illnesses in that some of their symptoms can be experienced by persons who are not diagnosed with them and their symptoms can overlap with a variety of conditions. For example, a person without major depressive disorder can feel lethargic, sad, and irritable.

But I’m not going to let the complicated nature of depression stop me from promoting research about biomarkers or genetic studies. I firmly believe that depression and all mood disorders need to be understood in their biological context. In my perspective, if the stigma increases with the acceptance of the bio-genetic model, then we need to work harder at embracing everyone who is ill, whether they have cancer, lupus, or depression.

Does Calling Depression an Illness Worsen Stigma?

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8 Reasons Why Your Depression May Not Be Getting Better

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You’ve been to four psychiatrists and tried over a dozen medication combinations. You still wake up with that dreadful knot in your stomach and wonder if you will ever feel better.

Some people enjoy a straight path to remission. They get diagnosed. They get a prescription. They feel better. Others’ road to recovery isn’t so linear. It’s full of winding bends and dead-ends. Sometimes it’s entirely blocked. By what? Here are a few impediments to treatment to consider if your symptoms aren’t improving.

1. The Wrong Care

Take it from the Goldilocks of mental health. I worked with six physicians and tried 23 medication combinations before I found the right psychiatrist who has kept me (relatively) well for the last 13 years. If you have a complex disorder like I do, you can’t afford to work with the wrong doctor. I would highly recommend that you schedule a consultation with a mood disorders center at a teaching hospital near you. The National Network of Depression Centers lists 22 Centers of Excellence located across the country. Start there.

2. The Wrong Diagnosis

According to the Johns Hopkins Depression & Anxiety Bulletin, the average patient with bipolar disorder takes approximately 10 years to receive the proper diagnosis. TEN YEARS. About 56 percent are first diagnosed incorrectly with major depressive disorder, leading to treatment with antidepressants alone, which can sometimes trigger mania.

In a study published in the Archives of General Psychiatry, only 40 percent of participants were receiving appropriate medication. It’s pretty simple: if you’re not diagnosed correctly, you won’t get the proper treatment.

3. Non-adherence to Medication

According to Kay Redfield Jamison, Ph.D., Professor of Psychiatry at Johns Hopkins University and author of An Unquiet Mind, “The major clinical problem in treating bipolar illness is not that we lack effective medications. It is that bipolar patients do not take these medications.” Approximately 40 to 45 percent of bipolar patients do not take their medications as prescribed. I’m guessing the numbers for other mood disorders are about that high. The primary reasons for non-adherence are living alone and substance abuse.

Before you make any major changes in your treatment plan, ask yourself if you are taking your meds as prescribed.

4. Underlying Medical Conditions

The physical and emotional toll of chronic illness can muddy the progress of treatment from a mood disorder. Some conditions like Parkinson’s disease or a stroke alter brain chemistry. Others like arthritis or diabetes impact sleep, appetite, and functionality. Certain conditions like hypothyroidism, low blood sugar, vitamin D deficiency, and dehydration feel like depression. To further complicate matters, some medications to treat chronic conditions interfere with psych meds.

Sometimes you need to work with an internist or primary care physician to address the underlying condition in tandem with a mental health professional.

5. Substance Abuse and Addiction

According to the National Institute on Drug Abuse (NIDA), people who are addicted to drugs are approximately twice as likely to have mood and anxiety disorders and vice versa. About 20 percent of Americans with an anxiety or mood disorder, such as depression, also have a substance abuse disorder, and about 20 percent of those with a substance abuse problem also have an anxiety or mood disorder.

The depression-addiction link is both strong and detrimental because one condition often complicates and worsens the other. Some drugs and substances interfere with the absorption of psych meds, preventing proper treatment.

6. Lack of Sleep

In a Johns Hopkins survey, 80 percent of people experiencing symptoms of depression also suffered from sleeplessness. The more severe the depression, the more likely the person will have sleep problems. The reverse is also true. Chronic insomnia creates a risk for developing depression and other mood disorders, including anxiety, and interferes with treatment. In persons with bipolar disorder, inadequate sleep can trigger a manic episode and mood cycling.

Sleep is critical to healing. When we rest, the brain forms new pathways that promote emotional resilience.

7. Unresolved Trauma

One theory of depression suggests that any major disruption early in life, like trauma, abuse, or neglect, may contribute to permanent changes in the brain. According to psychiatric geneticist James Potash, M.D., stress can trigger a cascade of steroid hormones that likely alters the hippocampus and leads to depression.

Trauma partly explains why one-third of people with depression don’t respond to antidepressants. In a study recently published in Scientific Reports, researchers uncovered three subtypes of depression. Patients with increased functional connectivity between different brain regions who had also experienced childhood trauma were categorized with a subtype of depression that was unresponsive to selective serotonin reuptake inhibitors like Zoloft and Prozac. Sometimes, then, intensive psychotherapy needs to happen alongside medical treatment in order to reach remission.

8. Lack of Support

A review of studies published in General Hospital Psychiatry assessed the link between peer support and depression and found that peer support helped reduce symptoms of depression. In another study published by Preventive Medicine, teens who had social support were significantly less likely to become depressed after experiencing work or financial stress in early adulthood than those without support. Depression was identified among conditions affected by loneliness in a paper published in the American Journal of Public Health. Persons without a support network may not heal as quickly or as completely as those with one.

8 Reasons Why Your Depression May Not Be Getting Better

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What Do I Do When My Antidepressant Stops Working?

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Approximately 25 percent of patients with major depressive disorder (MDD) experience a recurrent depressive episode while on an adequate maintenance dose of antidepressant medications, according to a 2014 metanalysis published in Innovations in Clinical Neuroscience. The clinical term for this medication poop-out or antidepressant tolerance is antidepressant treatment (ADT) tachyphylaxis. While psychiatrists and neuroscientists don’t know exactly why this happens, it could be due to a tolerance effect from chronic exposure to a medication.

I address this topic because I have experienced antidepressant poop-outs myself, but also because I often hear this concern from persons in my depression communities: What do I do when my antidepressant stops working?

The following strategies are a blend of clinical suggestions from the metanalysis mentioned above and other medical reports I’ve read, as well as my own insights on recovering from a relapse.

1. Consider all reasons for your relapse.

It’s logical to blame the return of your depressive symptoms on the ineffectiveness of a drug; however, I would also consider all other potential reasons for a relapse. Are you in the midst of any life changes? Are your hormones in flux (perimenopause or menopause)? Are you experiencing loss of any kind? Are you under increased stress?Did you just start therapy or any kind of introspective exercise? I say this because I experienced a relapse recently when I starting intensive psychotherapy. While I am confident it will lead to long-term emotional resiliency, our initial sessions triggered all kinds of anxiety and sadness. I was tempted initially to blame the crying and emotional outbursts on ineffective medication, but soon realized that my pills had nothing to do with the pain.

Watch out especially for increased levels of stress, which will commonly drive symptoms.

2. Rule out other medical conditions.

Another medical condition can complicate your response to medications or contribute to a worsening mood. Some conditions that are associated with depression include: vitamin D deficiency, hypothyroidism, low blood sugar, dehydration, diabetes, dementia, hypertension, low testosterone, sleep apnea, asthma, arthritis, Parkinson’s disease, heart disease, stroke, and multiple sclerosis. Get a thorough check up with a primary care physician to rule out any underlying condition.

Make sure to test for a MTHFR gene mutation, how you process folate, which can definitely affect antidepressant results. If you experience any elevation of mood with your symptoms of depression, be sure to discuss those with your doctor. More than half of people with bipolar disorder are misdiagnosed as clinically depressed and don’t receive the proper treatment they need, including a mood stabilizer.

3. Take your medication as prescribed.

Before I list some of the clinical suggestions, it’s worth mentioning that many people don’t take their medication as prescribed. I would like to plead innocent here, however, I acknowledge that there are too many evenings when I forget to take my pills.

ccording to a 2016 review in the World Journal of Psychiatry, about half of the patients diagnosed with bipolar disorder become non-adherent during long-term treatment, a rate similar to other chronic illnesses. Some psychiatrists assert that the real problem isn’t so much the effectiveness of medications as much as it is getting patients to take medications as prescribed. Before switching up your medication, ask yourself: Am I really taking my meds as prescribed?

4. Increase the current antidepressant dose.

Increasing the dose of an antidepressant is a logical next course of action if you and your doctor determine that your relapse has more to do with a medication poop-out than anything else. Many patients take too little medication for too short period of time to achieve a response that can last. In a 2002 review in Psychotherapy and Psychosomatic, doubling the dose of Prozac (fluoxetine) from 20 to 40mg daily was effective in 57 percent of patients, and doubling the 90mg from once weekly to twice weekly was effective in 72 percent of patients.

5. Experiment with a drug holiday or lowering the antidepressant dose.

Since some medication poop outs are a result of a tolerance built up from chronic exposure, the metanalysis recommends a drug holiday among its strategies for tachyphylaxis, however this needs to be done very carefully and under close observation. In some patients where the symptoms are severe, this is not a feasible option. The length is of a drug holiday varies, however the minimum interval required to restore receptor sensitivity is typically three to four weeks. This all seems counterintuitive, however, in some studies, like the one by Byrne and Rothschild published in Clinical Journal of Psychology, decreasing the dosage of an antidepressant led to positive results.

6. Change your drug.

Your doctor might want to switch medications, either to another drug in the same class or to another class. You may need to try several medications to find one that works for you, according to the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study, the largest and longest study ever conducted to evaluate depression funded by the National Institute of Mental Health (NIMH).

If the first choice of medication does not provide adequate symptom relief, switching to a new drug is effective about 25 percent of the time. It might make sense to introduce a drug that has an entirely different mechanism of action in order to regain the response blunted by the drug tolerance of the one you’re on.

The transition between meds needs to be handled carefully. Typically it’s better to introduce the new drug while tapering off the old, not to quit it abruptly.

7. Add an augmentation drug.

According to the STAR*D study, only one in three patients in the first sequence of monotherapy (that is, taking one drug) achieved remission. Meta-analyses of antidepressant trials of nonchronic patients with major depressive disorder report remission rates of 30 to 45 percent on monotherapy alone. Augmentation drugs considered include dopaminergic agonists (i.e. bupropion), tricyclic antidepressants, buspirone, mood stabilizers (lithium and lamotrigine), antipsychotic medications, SAMe or methylfolate, and thyroid supplementation. According to STAR*D, adding a new drug while continuing to take the first medication is effective in about one-third of people.

8. Try psychotherapy.

According to a 2013 Canadian Psychology Association report, mild to moderate depression can respond to psychotherapy alone, without medication. They found that psychotherapy is as effective as medication in treating some kinds of depression and is more effective than medication in preventing relapse in some cases.

Also, for some patients, the combination of psychotherapy and medication was more beneficial than either treatment on its own. According to a study published in the Archives of General Psychiatry, adding cognitive therapy to medication for bipolar disorder reduced relapse rates. This study examined 103 patients with bipolar 1 disorder who, despite taking a mood stabilizer, experienced frequent relapses. During a 12-month period, the group receiving cognitive therapy had significantly fewer bipolar episodes and reported less mood symptoms on the monthly mood questionnaires. They also had less fluctuation in manic symptoms.

It’s normal to panic in the days and weeks your symptoms return; however, as you can see, there are many options to pursue. If the first approach doesn’t work, try another. Persevere until you achieve full remission and feel like yourself again. It will happen. Trust me on that.

What Do I Do When My Antidepressant Stops Working?

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