Tuesday, July 26, 2016

Is it Grief or Is it Depression?


Grief and depression may have some overlapping symptoms such as sadness, crying, fatigue, reduced concentration, and sleep and appetite disturbances. However, grief and depression are not the same. Grief is a normal reaction to a loss whereas depression is a clinical condition. Other distinguishing features between grief and depression are as under (American Psychiatric Association, 2013; Shear, 2012):  
  • Although in grief, individuals feel sad and are tearful, the predominant mood in grief is a feeling of emptiness and loss, whereas in depression, the depressed mood is persistent and there is an inability to anticipate happiness or pleasure.
  • Bereaved people feel sad because they miss a loved one, whereas individuals with depression feel sad because they see themselves and/or the world as inadequate, flawed or worthless.
  • Self-esteem is preserved in grief, whereas depression is usually characterized by feelings of worthlessness and self-loathing.
  • Feelings of guilt in grief are related to one’s perception of failing to say or do something before the person died (e.g., not seeing the deceased person more frequently or not being able to mend a relationship before the person died). In depression the feelings of guilt are associated with irrational thoughts of taking excessive personal responsibility or that one doesn’t deserve to fare better when others are suffering.
  • In grief positive emotions occur as frequently as negative emotions as early as a week after a loved one dies whereas in depression, these emotions are rare.
  • Depression biases one’s thinking in a negative direction, but grief does not.
  • Depression inhibits one’s capacity to relate to other people’s intention and to care about them. In grief, the desire to be with others and appreciation for the efforts of others is preserved.
  • In grief, suicidal thoughts about death or dying are related to the themes of “being with” or “joining” the deceased, whereas in depression these thoughts are triggered by underlying themes of worthlessness, hopelessness, feeling that one is undeserving of life, or inability to cope with the pain of depression.
If an individual has suffered a recent loss and they are not sure if their grief has evolved into depression, then using the above distinguishing pointers would be helpful. However, be mindful that depression can still occur in context of bereavement. The Diagnostic and Statistical Manual of Mental Disorders – fourth edition, text revision (DSM-IV TR) excluded depressive symptoms occurring up to a couple of months after a loss as being a sign of a major depressive episode (American Psychiatric Association, 2000). However, depression arising after a loss of a loved one is no different compared to that arising due to a job loss or recent divorce or “out of the blue” (Pies, 2014). Moreover, not diagnosing depression during grief can potentially divest such people from getting timely help; professionals may defer treatment until symptoms persist or become more severe. In tandem with these observations, the DSM-5 doesn’t consider bereavement as an exclusion for diagnosing depression.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Pies, R. W. (2014). The bereavement exclusion and DSM-5: an update and commentary. Innovations in Clinical Neuroscience, 11(7-8), 19-22.

Shear, M. K. (2012). Grief and mourning gone awry: pathway and course of complicated grief. Dialogues in Clinical Neuroscience, 14, 119-128.


Tuesday, July 19, 2016

Problem Solving: A Proven and Simple Way to Treat Depression




If you are human, you will have problems. Having problems means that you are normal and solving them means you are a happy normal! Genuine problems such as not being able to pay your bills on time or not knowing how to go about furthering your education are best addressed by problem-solving and not by cognitive techniques such as challenging your irrational thoughts. Problem-solving therapy is an effective treatment for depression, but has received little attention as most popular books on self-help of depression heavily rely on cognitive-behavioral techniques (Kirkham et al., 2015). The problem-solving steps are described next (Martell et al., 2010; Nezu et al., 1989).
 

Problem-solving steps


1.     Define the problem in clear and specific behavioral terms, i.e., what specific behavior needs to be addressed or changed. You will be able to generate better solutions for a specific problem such as, “I have been postponing paying my bills for last two weeks and feel overwhelmed whenever I try to do that” versus the vague problem, “I can’t get anything done.” To get the specifics of a problem, describe it in terms of: Who? What? When? Where? Why? and How?

2.     Define your goals in addressing the problem – what is your desired outcome? Goals are often stated beginning with the phrase, “How can I …?”

3.     Brainstorm possible solutions to the problem. When brainstorming solutions, generate as many solutions as possible, don’t analyze or judge the possible solutions at this stage, and think in terms of both broad strategies and focused tactics. However, be aware that when you are feeling depressed, it is a challenge not to prematurely judge a solution negatively due to your underlying negative irrational thoughts (e.g., “This is never going to work,” or “Yes, but…” rejection of a solution). Also, a judgmental stance engendered by depression curbs creative thinking. If you are drawing a blank, then use the following strategies to stimulate your brain into thinking about more solutions:
  • Think about an individual you know personally who you admire and respect or someone from the world of movies, books, or current events. Next, ask yourself, “How would he or she approach this problem? What actions would this person take if faced with the same problem?”
  • Close your eyes and imagine yourself in the problematic situation. Imagine yourself successfully coping with the problem. Think of what you would say and do to deal effectively with the situation.

4.      Weigh pros and cons for each solution.
  • “How likely is it that this solution would help me reach my goal?”
  •  “What bad things could happen if I pick this solution?”
  •  “What is the likelihood that I can implement this solution in its optimal form?”

5.     Pick one solution and implement it. Sometimes a combination of solutions may work better as they complement each other.

6.     Evaluate the effectiveness and make changes to your approach, if needed.

7.     If the problem is not resolved, then do one of the following troubleshooting strategies:

  • Reset your goals as they may not be realistic.
  • Break the problem down into smaller chunks. 
  • Think of more possible solutions.

Becoming a master problem-solver comes with practice. You may want to write down the problem-solving steps on an index card as a reference to deal with minor or major problems. In addition, it is essential to integrate your new behaviors into a routine in order to have an enduring impact of the problem-solving exercise.


Tips to improve problem-solving skills

Following tips will enhance your problem-solving skills (Nezu et al., 1989):

·         Recognize that problems are part-and-parcel of life.

·         Many individuals have common types of problems and you are not alone.

·         Approach problem-solving with a rational, realistic, and positive attitude.

·         Don’t avoid facing a problem. Solving problems breaks the vicious cycle of problems leading to depression leading to more problems.

·         Work on smaller problems and build yourself up for the bigger ones.

·         There is no such thing as the perfect solution. Pick the best solution that works for you.

·         Stop and think before picking a solution – the first idea may not always be the best!

·         You have the ability to change your solution whenever you want.

·       If you cannot solve a problem after trying the troubleshooting strategies, then seek help from someone who is more knowledgeable or trained to deal with your situation. For instance, consult a financial advisor if you are not able to solve your financial problems after repeated problem-solving attempts.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Kirkham, J. G., Choi, N., & Seitz, D. P. (2015). Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry, Oct 5. doi: 10.1002/gps.4358.

Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. New York, NY: The Guilford Press.

Nezu, A. M., Nezu, C., & Perri, M. G. (1989). Problem-solving in depression: Theory, research, and clinical guidelines. New York, NY: John Wiley & Sons, Inc.


Tuesday, July 12, 2016

Self-Management: A Practical and Proven Way to Treat Depression

What is self-management?

You probably have heard the term “self-help” and may have also read a few self-help books. Most self-help books on depression focus on acute treatment of depression based on a particular model of therapy, usually the Cognitive-Behavioral Therapy (CBT). While the self-help approach tries to address a condition using a focused treatment modality over a short period of time, self-management is learning new ways to manage an illness over a longer period of time. In other words, self-management is using the resources and learning the skills to “positively manage” an illness (Lorig et al., 2006). Lorig and colleagues (2006) further elaborate on self-management; it is a “management style” wherein you are a positive self-manager who not only uses the best treatments provided by healthcare professionals, but also approach your illness in a proactive manner on a daily basis, leading to a more healthy life. For example, good self-managers of diabetes, besides taking medications, educate themselves about diabetes, learn to recognize symptoms of low or high blood sugar, monitor their blood sugar levels regularly, eat healthy and avoid foods that may destabilize their diabetes, exercise to maintain their weight, and seek professional help if their blood sugar levels are staying above or below their normal range. The same strategies can be used to self-manage depression.


What are the key components of self-management?

The key components of self-management include the following (Barlow et al., 2002):

1.      Information:
·         Educating self and family members/friends about depression.

2.      Medication management:
·         Taking medications as recommended by your provider.
·         Overcoming barriers to adherence to medications.

3.      Symptom management:
·         Using various strategies (e.g., cognitive, behavioral, mindfulness, etc.) to manage symptoms of depression.
·         Self-monitoring of symptoms using validated assessment tools.
·         Managing concurrent symptoms of anxiety and/or substance use.
·         Using techniques to deal with frustration, fatigue, pain, and isolation.
·         Managing sleep.
·         Managing symptoms of medical conditions that may be associated with depression.
·         Relaxation.
·         Using strategies for preventing relapse of depressive symptoms.

4.      Life style:
·         Exercise.
·         Overcoming barriers to exercise adherence.
·         Holidays.
·         Leisure activities.
·         Nutrition and diet.

5.      Social support:
·         Family support.
·         Relationships with peers and friends.

6.      Communication:
·         Assertiveness.
·         Communication strategies (e.g., with mental health professionals).

7.      Others:
·         Accessing support services.
·         Creating action plans.
·         Decision making.
·         Goal setting.
·         Problem solving.
·         Career planning.
·         Spirituality.

Unfortunately, most of the available self-help books on depression fall short of covering a majority of these essential ingredients of self-management. Depression cannot be treated by one-size-fits-all strategies as suggested by many of these books.

Empower Yourself with Self-Management


Healthcare is moving toward a model of client-centered care. In this model, clients are partners in decisions related to their healthcare and collaborate with their healthcare providers to prioritize and set goals and choose interventions for their illness.  In this context, self-management strategies prepare you to be an active player in your own treatment rather than being a passive recipient. With self-management, you assume the primary responsibility of your treatment, though with support from your provider and your social network.

Self-management techniques enhance your confidence and give you a sense of control in dealing with depression. Depression can make you doubt your capability for dealing with stress or sometimes even mundane day-to-day stuff.  Learning self-management skills is an antidote to these negative feelings and enhances your self-efficacy. Self-efficacy is your belief that you are capable of making changes to your life to accomplish a desired goal and is a key ingredient for the success of any self-management program. In other words, self-efficacy means that the stronger you believe that you will succeed in performing a task, the more likely you will attempt to finish that task.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA


REFERENCES


Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: a review. Patient Education and Counseling, 48, 177-187.

Lorig, K., Halsted, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. (2006). Living a healthy life with chronic conditions (3rd ed.). Boulder, CO: Bull Publishing Company.



Friday, July 1, 2016

You Asked: What is Bipolar Depression?

A bipolar depression is a depressive episode occurring in context of bipolar disorder. When diagnosing depression, it is imperative to first exclude an underlying bipolar disorder. This is because the medication treatment for bipolar depression differs from that for “unipolar” depression. People with bipolar disorder have manic or hypomanic episodes. These are periods of persistently elevated or irritable mood along with feelings of grandiosity, decreased need for sleep, talkativeness, racing thoughts, increase in sexual drive, increased goal-directed activity, or excessive involvement in risky or impulsive activities.

Individuals with bipolar disorder spend around 40% of the symptomatic time being depressed (Judd et al., 2002). Moreover, people with bipolar disorder are more likely to seek help when they are depressed. Therefore, it is not uncommon for bipolar depression to be misdiagnosed as unipolar depression or major depressive disorder. The consequences of such a misdiagnosis may result in treatment with antidepressants, some of which can cause mood episodes to occur more frequently in people with bipolar disorder (Hirschfeld, 2014). Pointers that suggest a possibility of bipolar disorder are as below (Goodwin & Jamison, 2007; Hirschfeld, 2014):

  •  Family history of bipolar disorder.
  •  Earlier onset of depression (early 20’s).
  •  Multiple past episodes and psychiatric hospitalizations.
  •  Seasonal mood episodes.
  •  Switching into mania or hypomania on antidepressants.
  •  Depressive episodes characterized by increased sleep, increased appetite, and weight gain.
  •  Depressive episodes mixed with hypomanic or manic symptoms.
  •  Depressive episodes with psychotic symptoms such as delusions or hallucinations.


If you have been diagnosed with depression and notice one or more of the above features, complete the Mood Disorder Questionnaire (MDQ), which is available on the Depression and Bipolar Support Alliance website (http://www.dbsalliance.org) or can be googled. The MDQ can correctly identify almost 75% of people with bipolar disorder and also correctly screen out 90% of people who don’t have bipolar disorder (Hirschfeld et al., 2000). Consult your mental health or primary care provider for a more comprehensive assessment if you screen positive for bipolar disorder on the MDQ.

Depression with mixed features: Sometimes people with depression may experience some manic/hypomanic symptoms, but never a clinical manic or hypomanic episode. In such cases, the most likely diagnosis is major depressive disorder with mixed features (American Psychiatric Association, 2013). Recognizing mixed symptoms in context of depression is important as they are a risk factor for future bipolar disorder and make depression less responsive to antidepressants (Hu et al., 2014). 

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.



HARPREET S. DUGGAL, MD, FAPA


REFERENCES:

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Goodwin, F. K., & Jamison, K. R. (2007). Manic-depressive illness: Bipolar disorders and recurrent depression (2nd ed.). New York, NY: Oxford University Press.

Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the mood disorder questionnaire. American Journal of Psychiatry, 157(11), 1873-1875.   

Hirschfeld, R. M. (2014). Differential diagnosis of bipolar disorder and major depressive disorder. Journal of Affective Disorders169(S1), S12-S16.

Hu, J., Mansur, R., & McIntyre, R. S. (2014). Mixed specifiers for bipolar mania and depression: highlights of DSM-5 changes and implications for diagnosis and treatment in primary care. Primary Care Companion for CNS Disorders, 16(2), pii: PCC.13r01599. doi: 10.4088/PCC.13r01599. Epub 2014 Apr 17.

Judd, L. L., Akiskal, H. S., Schettler, P. J., Endicott, J., Maser, J., Solomon, D. A., Leon, A. C., Rice, J. A., & Keller, M. B. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59(6), 530-537. 

Written by a board-certified psychiatrist and an international expert on self-management of depression, this blog focuses on proven scientific methods of treating depression that go beyond medications and traditional therapy. It discusses elements of healthy lifestyle, positive psychology, relationships, values, strengths, communication, and wellness. The content of the blog is not to be construed as treatment advice.

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