Thursday, 22 October 2009

Friends & Family: Understanding Depression

If one of your friends or a family member has depression, it can be a real struggle. Mental illness doesn't just affect the person with the illness, but everyone around them too. If you've never been there yourself, you will never completely get it. But there are some things I can tell you which may help you understand a little better, and some advice on how you can help.

Depression is neurological. When a person suffers from depression, their overall brain activity is significantly reduced, and this accounts for a lot of the symptoms which outsiders can find frustrating or confusing. So concentrating, paying attention, keeping up with a conversation, remembering to do things, etc, are suddenly completely overwhelming. It's like having the energy sucked right out of you. It's a neurological disturbance. It's essential to understand that.

There are no quick fixes. It's tempting, in this day and age, to think that somebody can take a pill and all's well again, but recovering from depression is like recovering from a really badly broken limb (as Jerod Poore points out at crazymeds). It's not like a sprain where you just need some ibuprofen and to keep the pressure off it. Your bones need to be re-set and then put in a cast for a while. You need some serious painkillers to get any sleep at all, and in the long-term you need lots of physiotherapy and follow-ups. Medication can help improve the symptoms of depression, but it's not a cure-all. For a severe or prolonged depressive illness it can take years to recover. It's okay to find this frustrating, but try not to take it out on the person who's depressed. It's not their fault.

Depression affects the way you think. Depressed thinking, by definition, is so negative that it interferes with a persons normal functioning. It happens in all sorts of situations and it becomes a downward spiral, where negative thinking causes negative behaviour. You withdraw from social situations because you think "what's the point? nobody likes me" and you stop doing things you used to love because you think "I'm crap at it anyway." None of this is rational or normal, but it's an unavoidable part of the illness.

You're not a therapist. Don't forget that you can't make it all better and you definitely can't be their therapist. The ill person has to tackle this themselves, with the help of a trained professional. You'll have a much easier time if you accept that. There are no magic words, and no advice you can give which will make it all better. Yes they may be being irrational, but it's not your job to point those things out. That stuff hurts coming from a friend in a way it doesn't coming from an impartial professional whose job it is. Literally, the most important thing for you to do is just be there. "It's okay. I'm here for you." That is honestly all it takes.

Be Supportive. So how do you support somebody who has depression? Let me show you something I wrote a few months ago when I was really low:
It's just so hard, because I look normal, so people forget that I have a disability. I wish just one person would not forget, and ask me how I am every now and then, or notice that I've not left my room for days. I really want somebody I can call to talk to when I feel low. Somebody who, once in a while, will just stay in wth me and watch movies. Put an arm around me and tell me it's okay.
It honestly doesn't take a lot. You don't have to put your own life to one side. Just call once a week to see how they are. Just that can make a world of difference, you have no idea. How happy you can make somebody just by taking the time to check in. If things are bad, and you live close enough, set aside one night a week to see them.

Procrastination. I just want to briefly mention this because I know it's been a problem for my friends and family. Letting things build up and not dealing with them until they get overwhelming is a classic symptom of depression. Especially in people who also experience anxiety (it's very common for depression and anxiety to go together). We're not lazy, we're just overwhelmed. Don't be too hard on us.

Look After You. You want to be supportive, and for that you are awesome. Seriously. It's not easy. I have had friends who were so depressed that they were completely exhausting to be around. You don't know how to help, nothing you say is right, and you don't even recognise them. They've become selfish, negative and constantly angry or upset. It's natural to feel overwhelmed, frustrated and confused. It's important that you look after yourself too. You are allowed to have boundries, and no matter how much your friend is hurting, s/he has to respect those boundries. If you feel overwhelmed or unable to deal with their problems, you get to say so. Find a helpline or a professional they can call instead. Your support is a gift and get to say how much you can handle, and when you've had too much.

To sum up: If you're concerned about somebody and you don't know what to do, don't panic. All it takes is "are you ok? Is there anything I can do?". If somebody says they are fine and they don't want to talk, then there's nothing you can do about it. You can't help somebody if they won't help themselves. If they tell you how they really feel, just listen, even if you can't relate, it still helps. Try to see the person underneath all the sadness. They may be acting totally differently, but the person you used to know IS still there underneath all of that. You might find if you just have a chat with them, make them laugh if you can, and make them feel comforted and loved, you can make a world of difference.

Monday, 19 October 2009

8 Tips For Students With Depression

Now that I am back at university, I have less time to blog. Sorry about that. But to make up for it I have compiled a list of things you really should do if you are a university student who suffers from depression. I hope you find it useful.

1. Register With a GP
Unless you're living at home while you're studying, you'll probably need to register with a local GP. It really is better to register with a practice as close to your university accommodation as possible, especially if you take medication and need regular prescriptions. Most universities provide students with contact information for near-by practices, but you can also search for a GP near you on the NHS website.

2. Get Referred to Local Psychiatric Services
Once you've registered with a local GP, it's a good idea to go see them as soon as possible and get them to refer you to local mental health services. You can also contact whoever was in charge of your care when you were at home, and ask them to write to your new GP and ask them to refer you. There are usually waiting lists, so do it sooner rather than later.

3. Meet Your Academic Contacts
All universities have a support service for students with disabilities, and it's a good idea to set up an appointment with them as soon as possible so you can ask them what they offer, and how you can access their services. Most academic departments also have their own tutors or advisors who you can go to if you have problems, so introduce yourself now and make sure they know about your condition (and bring medical evidence). It's good to have these contacts in place so that if you ever need an extension on a deadline or an exam concession, they can sort it out quickly without needing to ask questions.

4. Sign-Up For an Activity You Enjoy
Most universities have a 'Fresher's Fair' where you can find out all about the societies, sports and activities on offer. It's a really good idea to sign up for for one activity you know you will love, as an antidote to the stress of studying. Experimenting with new activities can help your self-esteem, and you might make your best friends there.

5. Buy Earplugs
If you live in a university halls of residence, trust me, you will need them at some point.

6. Avoid too much alcohol
Okay, I know it completely goes against the university stereotype and some people will think you're, like, totally uncool. However, large amounts of alcohol tend to have a chemically depressive effect on the brain. Which is a really, really bad idea when your brain is already chemically depressed. Having a couple of drinks is okay, but more than that and you could find yourself feeling extremely low, and since alcohol also makes you more impulsive, there's always the risk that you could act on suicidal thoughts. Cutting down on alcohol doesn't have to stop you socialising, just drink soft drinks, water or juice in between the alcoholic ones, so it doesn't add up to too much. If you're taking medication, always check with your doctor if it's okay to drink alcohol while you're on it.

7. Be Realistic
This is a tough one, but a very important one. Don't expect too much of yourself. There will always be some people who are more compatible with you than others, so you can't possibly get on really well with everybody. You can't read everything on your reading list. Read what you can, according to what you're going to write an essay about/talk about in a tutorial etc.

8. Apply for Disabled Student's Allowance
If you're a student and you have been diagnosed with clinical depression, or any other mental health problem, you could be eligible for Disabled Student's Allowance. DSA is a kind of government grant which helps fund extra support for disabled university students. It helps pay for any specific equipment or support you might need, like one-to-one support . You can download an application form by clicking on the link below. You'll also need a letter from a doctor or from your psychiatrist which explains that you have a diagnosed mental health condition, and how they think it might affect your studies. Click here to download an application form.

Thursday, 8 October 2009

The New Antidepressant In Town

Researchers are constantly looking for new, faster-acting, more effective antidepressants with fewer side-effects. And one new antidepressant in particular is starting to look pretty promising. It's called agomelatine (brand name Valdoxan) and it isn't quite like any other antidepressant on the market, because it doesn't affect the uptake of serotonin, noradrenaline or dopamine.

Agomelatine is a specific agonist of MT1 and MT2 melatonin, and to some extent it is also an antagonist at serotonin 5HT-2C receptors (as are SSRIs). Melatonin is a hormone produced by the pineal gland, which has an important role in the sleep-wake cycle ('circadian rhythm'). Abnormalities in circadian rhythms are highly prevalent in mood disorders, including depression, so agomelatine has many potential advantages for treating depression, because it may help regulate the sleep-wake cycle. This means it helps you sleep better, without sedating you and causing daytime sleepiness. Which is a big deal, considering many SSRI's and SNRI's cause insomnia, and therefore make sleeping problems worse.

But the really big thing which makes agomelatine exciting is the lack of side effects. Unlike SSRI's and SNRI's, it does not cause weight gain, sexual dysfunction or withdrawal symptoms. It has no discontinuation syndrome. That is a big deal. Weight gain and sexual side-effects are the two main complaints people seem to have about SSRI's, and it's a big reason some people stop taking them. And trying to come of an SSRI can really suck. Not to mention how bad the discontinuation can get for venlafaxine.

As with any new antidepressant, its efficiacy is questionable. It has, however, demonstrated superior efficacy to sertraline in one study, and fluoxetine in another. In other studies, it had a higher efficiacy than placebo, especially for treating severe depression, and a lower rate of relapse. As with many antidepressants, some studies showed no difference between agomelatine and placebo. It's worth noting that those studies also showed no difference between the active controls (paroxetine and sertraline) and placebo.

If agomelatine really works, with such a good level of tolerability, it's definitely a very exciting step forward in antidepressant treatment. It was released in the UK in July this year, so watch this space.

Sunday, 4 October 2009

Antidepressants: 10 Things You Need To Know

1. What Antidepressants Are
Antidepressants are drugs which are used to treat clinical depression, although many of them are approved for use in other conditions as well. There are five main types:
  1. Tricyclic Antidepressants (TCAs)
  2. Selective Serotonin Re-uptake Inhibitors (SSRIs)
  3. Noradenaline Re-uptake Inhibitors (NRIs)
  4. Multiple Re-uptake Inhibitors
  5. Monoamine Oxidase Inhibitors (MAOIs)
There are also miscellaneous antidepressants which don't fit into any of those categories. Apart from depression, antidepressants may be used for severe anxiety disorders and panic attacks, obsessive-compulsive disorder, eating disorders, post-traumatic stress and chronic pain.

2. How We Think They Work
It's not known for certain how antidepressants work, but most of them are thought to work by inhibiting the reabsorption of certain chemicals in the brain. For those of you who know nothing about the brain, let me run you through a couple of basics. The brain is made up of about 10 billion brain cells, or 'neurons'. Each one connects to about 10,000 others, but they don't actually touch one another. They are separated by small gaps called synapses. This is my fantastic diagram of two brain cells:

Brain cells communicate with each other by releasing chemicals called neurotransmitters, which other brain cells respond to. These chemicals are then either broken down or re-absorbed, because otherwise your neurons would be soaking in chemicals all the time, and they wouldn't be able to respond to other neurons any more. The most common antidepressants slow down the reabsorption of certain neurotransmitters, so that your neurons get longer to respond to them. That is why they are called 're-uptake inhibitors'. The three main neurotransmitters involved in depression are thought to be serotonin, noradrenaline and dopamine. SSRI's work on serotonin, NRI's work on noradrenaline, Multiple Reuptake Inhibitors work on two or more of the three and Tricyclics work on all three.

MAOI's work a bit differently; they slow down a chemical called Monoamine Oxidase, which breaks down neurotransmitters. The effect, however, is the same. Your brain cells get to soak in the right chemicals for longer.

3. Not Everyone Needs Medication
Antidepressants should not be used for treating mild depression for two reasons:
  1. Recent research shows that if you're not severely depressed, antidepressants don't work any better than placebos.
  2. While the placebo effect can be useful, antidepressants have risks and side-effects, so for those with mild to moderate depression, the risks basically outweigh any potential benefits.
Here's the deal. Most people with mild or moderate depression can be treated with therapy, regular exercise, a good diet and a support group. Some people ask for medication straight away because they're looking for a quick fix, which is a dumb idea because antidepressants are not happy pills. You still need to do all those other things even if you are on medication. But there are those who do all the right things and don't feel any better. In that case, medication may be a valid option.

Severe depression is different. If you're so depressed that you spend hours lying in bed trying to get up the strength to get up and make a cup of tea, it's pretty pointless for somebody to tell you that you need to get some exercise. That's the kind of depression where you need medication straight away.

4. They Don't Work Straight Away
Some people respond almost immediately to antidepressants, but others may not notice any difference for up to a month after they start taking, or six weeks for fluoxetine (Prozac). If there's still no response after about six to eight weeks, that's when it's time to try a different drug.

5. Side-Effects
Common side-effects when you start an antidepressant are: dry mouth, nausea, headaches, sleepiness or insomnia, weight gain and constipation or diarrhoea. These effects are usually temporary and they should pass in a few weeks. SSRI's can make you anxious at first and they can sometimes cause longer-term problems with weight gain and with your sex drive. Tricyclics can affect your blood pressure, and MAOI's can have serious and potentially fatal interactions with certain types of foods. If you are prescribed an MAOI, your doctor will tell you which foods to avoid. Always read the patient information leaflet for the full list of side-effects before you take an antidepressant.

6. Suicide Risk
All antidepressants carry an increased risk of suicide. Therefore it's very important that anybody who is starting an antidepressant is carefully monitored by a doctor, and that they report any suicidal thoughts immediately. It's a good idea to keep a list of phone numbers you can call in a crisis, and this should include your doctor or therapist or a crisis team. The risk of suicide associated with antidepressants is a lot higher in children and teenagers.

7. Alcohol
Generally speaking, it's best to avoid alcohol if you're taking an antidepressant. A few drinks here and there or a glass of wine with your meal is usually okay, but some combinations should not be mixed with alcohol at all. Ever. So ask your doctor first. Large amounts of alcohol also tend to make you more depressed, which can further increase your risk of suicide in the first few weeks of treatment.

8. Physical Dependency
When you've been taking an antidepressant for a while, your brain gets used to the chemical changes the meds cause. Although antidepressants aren't addictive in the true sense of the word, some people experience withdrawal symptoms when they stop taking their medication especially if it's an SSRI, and even more so if you stop taking them abruptly. Withdrawal from reuptake inhibitors can cause severe fatigue, headaches, nausea, vomiting, chills, dizziness, shaking or tremors, insomnia, electric-shock like sensations, vertigo, confusion and suicidal thoughts, plus "brain shivers". These symptoms are collectively known as SSRI Discontinuation Syndrome, but multiple reuptake inhibitors which affect serotonin can also cause this. Don't try to come off your medication on your own. You need to gradually reduce your dose over time to avoid withdrawal effects. Also, some drugs leave the body very quickly so even if you only miss one dose you can experience withdrawal symptoms. It's important to take your meds at the same time every day (or however often your psychiatrist or pharmacist told you to). Getting a pill organiser is a good idea.

9. Sometimes They Stop Working
SSRI's and other reuptake inhibitors can work really well at first and then suddenly stop working. It's known as the 'poop-out' effect. I kid you not, that's what doctors call it. It usually just means you need to switch to another medication in the same class, so don't panic if you find your medication suddenly stops working. Luckily, if you take a break from an antidepressant then start taking it again, it will often work as well as it did when you took it the first time. So if you find two SSRI's that work well for you, but they tend to quit working after a while, you can cycle between the two of them for as long as you need to.

10. Antidepressants Are Not A Cure
For people with severe depression, medication can be a very important part of treatment. It can be the difference between being completely incapacitated, and being able to engage in therapy, being able to go for a walk etc. But antidepressants aren't a magic cure. They don't suddenly make everything okay. Severe mental illness can't be fixed overnight. It usually takes months or even years of treatment to reach some sort of stability where you can get back to your life as it was before you became ill. And non-drug treatments are just as important for people who take medication as they are for those who don't. Doctors, patients, friends, family etc often expect medication to make the problem go away straight away. Some people will even wonder why you can't just "snap out of it" already. It doesn't work like that. Recovering from a serious depressive illness is like recovering from major surgery. It takes time, and the right treatment.

Just a reminder: I'm not a doctor and this is not a replacement for proper medical advice. You should always consult the patient information leaflet for a medication before taking it.