Friday, December 1, 2017

DARN: A Simple and Effective Way to Increase Your Motivation to Change


DARN is an acronym which stands for: Desire, Ability, Reasons, and Need. These represent four types of self-talk that people contemplating change engage in (Miller & Rollnick, 2013). Use this approach to ask yourself evocative questions that tap into your intrinsic motivation. 

Desire: Desire is wanting to have something or wanting a change. Examples include, “I want to exercise more” or “I would like to eat healthy.” Ask yourself the following questions to elicit your desire to change.
  • What am I hoping to accomplish by this change?
  • How would I like for things to change?
  • How do I want my life to be different six months from now?

Ability: Ability is your perception of your ability to bring about the change. Questions to elucidate ability include:
  • How likely am I able to flex my schedule to incorporate this change?
  • What do I think I might be able to change in my daily schedule?
  • If I did decide that I wanted to add this change, how could I do it?

Reasons: Help yourself find the reason for change using the following questions:
  • What are some of the advantages of adding this change?
  • Why do I want to make this change?
  • What might be the good things about making this change in my life?

Need: Need signals a sense of urgency or importance for change and is elicited by questions below:
  • What needs to happen?
  • How urgent does the need for making this change in my life feel to me?
  • How important is it for me to make this change?
  
Example of a "DARN" Worksheet
D:  What do I want to change?
I want to exercise more.
A: How likely am I able to change?
I can add exercise to my daily routine as I have done it before.
R: Why do I want to make this change?
Exercise is going to improve my mood and improve my physical health.
N: How urgent or important is this change?
I need to do something soon to get back in shape and to get my energy level up.

DARN are the components of motivation and the stronger your DARN is, the more committed you are for changing your behavior.

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

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: The Guilford Press.





Monday, November 13, 2017

Anger Problems? Find the “Should” Behind Your Anger


We experience anger when our unrealistic demands, conceptualized in our minds as “should” or “musts,” are not met. Examples include, “I should work harder,” “People should treat me fairly,” “You must do what I tell you to do,” “I shouldn’t be angry,” etc. “Should” and “must” statements arise from either moralistic rules or perfectionistic demands that we hold ourselves and others to. Irrational should statements rest on your assumption that you are entitled to instant gratification. However, life being what it is, does not respect your “shoulds” or “musts.” Moreover, there is no law that says we should get what we want, any more than other people always get what they want.

How do you handle the “shoulds”?

1. Eliminate the words “should” and “must” when talking about expectations and replace them with “I hope,” or “I wish,” or “I prefer.”  For example, “I wish things were different,” “I hope I can do well, but I can tolerate not being perfect,” “I wish things were different,” etc. In contrast to a perfectionist philosophy, a preferential philosophy of desires, wishes, and hopes makes you approach situations with less fear of failing, makes you resort to less self-blame, and makes you more open and agreeable in other peoples’ eyes.

2. Become more accepting of reality and stop feeling entitled: A lot of your anger stems from you being unwilling to face the reality about yourself, other people, or the world. In the same vein, you have to set your expectations in line with reality. For example, you arrive at a hotel and find out that they don’t have the kind of room you had requested. You get angry because you feel that you are entitled to get what you had booked. The hotel reservation clerk tells you that there is a convention happening in the hotel and the kind of room you had requested is sold out. What are your choices?  You can either sulk or give the clerk your piece of mind. However, the room you had requested will not magically reappear and this will only add misery to your already frustrated state of mind. Or you can use some self-compassion to accept the reality, let go of the entitled mindset, and use your energy to problem-solve. A useful question to ask in a situation where your anger doesn’t change the outcome of the situation is, “What are the advantages versus disadvantages of holding on to my anger?”

3. Rethink your notions about fairness: Moralistic “shoulds” and “musts” are driven by your desire that you have to be treated fairly, that others have to be treated fairly, and that the world should be a fair place to live in. Thus, when you perceive unfairness or injustice in a situation, it leads to frustration and anger. There is nothing like “absolute fairness.” What appears fair to one individual may appear unfair to another individual. People have different moral, cultural, and social rules, which they use as a yardstick to judge a situation. Anger results in situations where you start believing that your rules are applicable to others and anyone not abiding by your rules are being unfair. Of course, there are generally accepted moral and ethical codes and the laws of the land that everyone has to follow. The rules that generally lead to conflict and anger are the more personal ones that you have created based on your past experiences and observations. To save yourself from getting frustrated and angry due to perceived unfairness, you need to broaden your definition of fairness to include what is fair to other people and to get rid of the concept of “absolute fairness.” Useful questions to ask yourself in situations where you perceive unfairness are below:

  • “Am I interpreting this situation as being unfair based on rules or standards that are mostly personal to me?”
  • “In what ways is the other person perceiving this situation differently than me?”
  • “Do I really need to feel this entitled?”
  • “Is this demand for fairness helping or hurting me?”
  • “Do I really have control over how others should think or behave?”
  • “Why must things be only as I expect them to be?”
  • “Am I perceiving this conflict situation as a personal attack on my worth or other things?
  • “Is my need to be in control making me angry and pushing people away?”

4. Avoid the “common sense” trap: Another reason why you may resort to “shoulds” and “musts” is that you perceive that it is common sense for you or others to think and act in certain ways in certain situations. This notion of common sense is a cousin of the notion of fairness in that what appears common sense to some may appear non-sense to others. The definition of common sense according to the Merriam-Webster dictionary is “sound and prudent judgment based on a simple perception of the situation or facts.” The problem here is that this “simple perception” varies amongst individuals, which then leads to a variety of “sound and prudent” judgments. Therefore, common sense isn’t that “common” as you may think. Hence, the next time when you are getting angry because somebody didn’t do what was “common sense,” pause and reflect if you are falling for the common sense trap.

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


Sunday, October 22, 2017

Procrastination in Depression: The Motivation Myth


Procrastination is putting off things for another day, or doing things which are not productive as an excuse of not doing what is important. Dr. Wayne Dyer (1995) in his book, Your Erroneous Zones, provides the rationale behind procrastination as a thought process which is something like this: “I know I must do that, but I am really afraid that I might not do it well, or I won’t like it. So, I will tell myself that I will do it in the future, then I don’t have to admit to myself that I am not going to do it. And it is easier to accept myself this way.” This temporary avoidance gives you a quick relief from the anxiety associated with a task, which then reinforces this behavior. We all have procrastinated at one time or the other, but in depression, procrastination becomes more complex due to the self-defeating attitudes of perfectionism (“I can do things only if I can do them perfectly”), hopelessness (“My low motivation and low energy levels are never going get better”), and fear of failure or criticism. Of all the reasons why people with depression procrastinate, perhaps the most common is the lack of motivation. 

People with depression who procrastinate tell themselves, “Once I start feeling better and my motivation has improved, I will do X, Y or Z.” And then they wait for the day when they are in the right frame of mind with the right amount of energy and motivation to get things done. Unfortunately, that day doesn’t arrive and nothing gets done. This then increases frustration and disappointment, which increases the severity of depression in these individuals. The more severe depression further reduces energy level and motivation, which makes doing things that have been put off even less appealing. This vicious “amotivation” cycle continues to wreak misery in the lives of people with depression.

You can break this amotivation cycle by challenging the commonly held belief that motivation precedes action (Burns, 1999). In real life, the opposite is true – action precedes motivation. When you do something toward achieving a goal, no matter how small it is, you feel good about your actions, which in turn enhances your self-confidence. This then makes you even more motivated to do what you started off with. Therefore, don’t put the cart before the horse with your “waiting for motivation” attitude and get yourself into the action mode. This doesn’t mean that you will only rest after you have finished the task you have been putting off. It just means that you will do whatever is the least amount of effort that takes to start the process of completing the task, pat yourself on the back for what you have done, build on your gains, recognize your enhanced sense of self-efficacy (your ability to do things) and motivation, and then do more. This action + motivation + reward yourself + more action = success is the life equation that will help you break the amotivation cycle and overcome procrastination.

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

Burns, D. D. (1999). Feeling good: The new mood therapy. New York, NY: Avon Books.
Dyer, W. W. (1995). Your erroneous zones. New York, NY: Harper Paperbacks.


Thursday, September 7, 2017

How to Find the Right Mental Health Provider for Depression?


A right match between you and your mental health provider is key to your wellness and recovery from depression. If you are looking for a therapist, the most important thing to inquire is if they use evidence-based psychotherapy to treat depression. Cognitive-behavioral therapy (CBT) and Interpersonal psychotherapy (IPT) are two modalities of psychotherapy that have the most evidence to support their first-line use for treating acute depression (Parikh et al., 2009). There is some evidence to suggest that CBT may be more effective than IPT in individuals with severe depression, but the two are comparable for treating mild and moderate depression (Luty et al., 2007). In addition, ask the prospective therapist the following questions:

  • “How did you get your training in CBT or IPT?” You are not looking for a therapist whose only training was a weekend workshop.
  • “How much experience do you have with these approaches?”
  • “What are your professional credentials?”
  • “What kind of methods would be used during the therapy?”
  • “How often would I have to come in for therapy?”
  • “How long would the treatment last?”
  • “How would you assess that I am getting better?”
  • “Are you a provider for my insurance plan?”
  • “If I were to pay out-of-pocket, could a reduced fee be worked out?”
It not necessary to seek a therapist who is only trained in CBT or IPT. Other modalities of psychotherapy that are shown to be effective in depression include behavioral activation, mindfulness-based cognitive therapy (MBCT), cognitive-behavioral analysis system of psychotherapy (CBASP), problem-solving therapy (PST), and psychodynamic psychotherapy (the latter has less evidence compared to other therapies) (American Psychiatric Association, 2010; Parikh et al., 2009).

If you are going to see a psychiatrist, some of the questions as mentioned before would also be applicable here. In addition, you may want to ask them the following questions: 
  • “What is your philosophy behind prescribing medications for depression?”
  • “How do you objectively assess if the medication is working?”
  • “How do you monitor for side effects?”
  • “What do you do in case of side effects?”
  • “How long would I have to take the medication?”
  • “Would I be able to come off the medication if I wanted?” “How?”
  • “Would you check if the prescribed medication interacts with my other medications?”
  • “How would you be communicating with my primary care physician or therapist?”
  • “Will I have access to more urgent services if I am not doing well?”
Some of the above questions may be more appropriate for the first session with the psychiatrist, especially if you are unsure about taking medications.

Questions to ask yourself after your first visit with the mental health provider
Following your first session with a mental health provider, you will have a good feel if you and your mental health provider are a good fit. Ask yourself these questions to ascertain if the provider meets your expectations or values (Copeland, 2001; Pies, 1991):
  • Was the provider courteous?
  • Did the provider interact with you in a manner that conveys warmth?
  • Did the provider create an atmosphere of empathy, concern, and acceptance?
  • Did the provider take a reasonably complete psychiatric and medical history (the latter more relevant for a psychiatrist) or suggested and/or made a referral to a physician, if indicated?
  • Did the provider make it easy to communicate?
  • Did the provider make a good eye contact with you?
  • Did the provider permit you to finish your statements?
  • Did the provider use a vocabulary suited to your education and style?
  • Did the provider listen to and explore your feelings before offering interpretations?
  • Did the provider show interest in you and in what you say?
  • Did the provider appear knowledgeable about depression?
  • Did the provider appear knowledgeable about the treatment you are seeking (medication or psychotherapy)?
  • Did the provider give you tools and resources to get better, but also encouraged personal responsibility for getting better? A good therapist guides you in the right direction, but doesn’t do the homework for you to reach your goals.
  • Did the provider explain your diagnosis and prognosis?
  • Did the provider discuss available treatment options (including types of medications for psychiatrists)?
  • Did the provider give a rationale for the chosen treatment?
  • Did the provider mention the duration of treatment and frequency of appointments?
  • Did the provider explain how they would assess improvement?
  • Did the provider involve you in arriving at a shared decision regarding your treatment?
  • Did the provider give you their contact information or other resources in case of any emergencies?
  • Did the provider ask you at the end if there was anything else that needed to be discussed?
  • Did you feel a sense of hope and optimism following your interaction with the provider?

One of the best predictors of how well you will do in therapy is the strength and quality of the relationship between you and the therapist (Bieling & Antony, 2003; Horvath et al., 2011). This relationship entails you trusting your therapist, seeing them as empathic, and also believing that you and the therapist are working on the same goals. Another factor that predicts success of treatment is the competence of the therapist. Research shows that efficacy of cognitive therapy appears to depend to a considerable extent upon the competence of the therapist and you are more likely to acquire cognitive therapy skills if your therapist adheres to concrete cognitive therapy techniques (Hollon, 2011; Webb et al., 2012). You are not obligated to continue seeing a provider who is not a good match for you. Sometimes this is evident in the first session, but should become clear in three to four sessions. Waiting longer than that to switch therapists can be taxing and time consuming.

Five essential requirements for a successful treatment by a professional
There are five general principles that underlie any successful treatment, particularly for psychotherapy (Pies, 1991):

  1. The satisfaction of being understood: All human beings have a strong desire to be understood at an emotional and intellectual level and without this need being met, it is unlikely that any treatment is going to succeed.
  2. The release of emotional tension: This is also called “catharsis” and may bring about a relief, though sometimes temporary, by “getting things off your chest.”
  3. The pleasure of self-expression: Putting a name to your feelings gives you a sense of satisfaction about your ability to organize sometimes vague and chaotic inner experiences. 
  4. Acceptance by the provider: Acceptance doesn’t mean that your provider will or should accept everything you say or do. What it means is that despite your shortcomings, your provider treats you with respect and as a worthwhile person.
  5. Increase in self-esteem: Your self-esteem and self-confidence will grow during treatment as you master more and more problems.
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 (2010). Practice guidelines for the treatment of patients with major depressive disorder (3rd ed.). Arlington, VA: American Psychiatric Association.

Bieling, P. J., & Antony, M. M. (2003). Ending the depression cycle. Oakland, CA: New Harbinger Publications, Inc.

Copeland, M. E. (2001). The depression workbook (2nd ed.). Oakland, CA: New Harbinger Publications, Inc.

Hollon, S. D. (2011). Cognitive and behavior therapy in the treatment and prevention of depression. Depression and Anxiety, 28, 263-266.

Horvath, A. O., Del Re, A. C., Fl├╝ckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-16.

Luty, S. E., Carter, J. D., McKenzie, J. M., Rae, A. M., Frampton, C. M, Mulder, R. T., & Joyce, P. R. (2007). Randomised controlled trial of interpersonal psychotherapy and cognitive-behavioral therapy for depression. British Journal of Psychiatry, 190, 496-502.

Parikh, S. V., Segal, Z. V., Grigoriadis, S., Ravindran, A. V., Kennedy, S. H., Lam, R. W., & Patten, S. B. (2009). Canadian network for mood and anxiety treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. Journal of Affective Disorders, 117, S15-S25.

Pies, R. W. (1991). Psychotherapy today: A consumer’s guide to choose the right therapist. St. Louis, MO: Manning Skidmore Roth.

Webb, C. A., DeRubeis, R. J., Dimidjian, S., Hollon, S. D., Amsterdam, J. D., & Shelton, R. C. (2012). Predictors of patient cognitive therapy skills and symptom change in two randomized clinical trials: the role of therapist adherence and the therapeutic alliance. Journal of Consulting and Clinical Psychology, 80(3), 373-381.

Wednesday, July 5, 2017

What Depression is Not


When one is feeling low, it doesn’t necessarily mean that one is going through the throes of clinical depression, i.e., major depressive disorder. There are several conditions that may mimic clinical depression but don’t reach the severity or pervasiveness of the former condition or are symptomatically distinct. It is important to recognize these so that one may not unnecessarily get prescribed medications or started on psychotherapy as some of these conditions are time limited or may remit on their own. At the same time, some of these conditions such as complicated grief may need specialized therapy. Conditions that resemble depression but are not depression include the following:

Sadness: Depression is more than the normal pangs of sadness one gets when experiencing a stressful situation. Depression is a more pervasive and persistent change in your mood along with changes in your physiological functions such as sleep, appetite, and energy level. Although stress can trigger a depressive episode, not everyone faced with stress becomes depressed. And, sometimes depression can occur without any specific triggers and may not respond to changes in environment (the so-called endogenous depression), which differentiates it from sadness. Moreover, while sadness can disrupt your day-to-day functioning, the effect of depression is more significant, though some researchers believe that this criterion is not clinically meaningful to distinguish sadness from depression (Wakefield et al., 2010). In contrast to sadness, depression is associated with a pattern of negative or distorted thinking which perpetuates the symptoms (Burns, 1999).

Bereavement: Bereavement and depression have a complex relationship. 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.
Certain symptoms may help one distinguish when bereavement may have transformed into depression (American Psychiatric Association, 2013). These include persistently sad mood that doesn’t improve with changes in environment, lack of pleasure, feelings of worthlessness, pessimistic or self-critical ruminations, and suicidal thoughts related to negative feelings about self.

Complicated grief: Another condition called complicated grief or as the DSM-5 calls it, the “persistent complex bereavement disorder,” also mimics depression. In short, this is characterized by preoccupation with the deceased or the circumstances related to death, feelings of disbelief or numbness, excessive avoidance of reminders of the loss, a desire to die in order to be with the deceased, social withdrawal, and persistence of other intense and impairing symptoms of acute grief beyond the socially and culturally accepted norms (American Psychiatric Association, 2013; Shear, 2015). Complicated grief differs from depression as it an extension of the normal grieving process and usually lasts more than a year while depression is a clinically diagnosable entity. Approximately, 7% of grieving individuals develop complicated grief. Women and those with preexisting mental illness, substance use, trauma history, limited social support, and multiple recent losses are more at risk of complicated grief (Simon, 2013). Screening tools such as the Inventory of Complicated Grief can help people with prolonged grief arrive at a proper diagnosis (Prigerson et al., 1995). Although, antidepressants have been used to treat complicated grief, it is best treated with focused psychotherapy.

Adjustment disorder with depressed mood: Stressors – breakups, job loss, marital conflict, natural disasters, or life changes such as school, illness, marriage, divorce, retirement, etc. – can cause a heightened emotional or behavioral reaction in some people. If you experience low mood, tearfulness or feelings of hopelessness within three months of a stressful situation and these symptoms subside after the stressor is over, the diagnosis is more likely to be adjustment disorder with depressed mood (American Psychiatric Association, 2013). Compared to depression, adjustment disorder always has a clear precipitating event, is time limited, and never meets the full criteria for depression. Psychotherapy is the mainstay of treatment for adjustment disorder with depressed mood.

Premenstrual syndrome and premenstrual dysphoric disorder: Premenstrual symptoms, starting a week before the onset of menstrual cycle, range from mild physical or behavioral symptoms in premenstrual syndrome to marked mood changes – irritability, crying spells, depression, and anxiety – in premenstrual dysphoric disorder. The latter is also characterized by changes in sleep, appetite, lack of interest, difficulty concentrating, increased sensitivity to rejection, and physical symptoms such as feeling of “bloating,” breast tenderness or swelling, or joint/muscle pain. The symptoms in premenstrual dysphoric disorder are severe enough to interfere with normal functioning. However, unlike depression, the symptoms subside after the onset of menses and don’t represent an amplification of pre-existing depressive symptoms (American Psychiatric Association, 2013).

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page. To find out if you have clinical depression, check this blog post.


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.

Burns, D. D. (1999). Feeling good: The new mood therapy. New York, NY: Avon Books.
Pies, R. W. (2014). The bereavement exclusion and DSM-5: an update and commentary. Innovations in Clinical Neuroscience, 11(7-8), 19-22.

Prigerson, H. G., Maciejewski, P. K., Reynolds III, C. F., Bierhals, A. J., Newsom, J. T., Fasiczka, A., Frank, E., Doman, J., & Miller, M. (1995). Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65-79.

Shear, M. K. (2015). Clinical practice. Complicated grief. The New England Journal of Medicine, 372(2), 153-160.

Simon, N. M. (2013). Treating complicated grief. The Journal of American Medical Association, 310(4), 416-423.

Wakefield, J. C., Baer, J. C., & Schmitz, M. F. (2010). Differential diagnosis of depressive illness versus intense normal sadness: how significant is the “clinical significance criterion’ for major depression? Expert Review of Neurotherapeutics, 10(7), 1015-1018.


Tuesday, June 27, 2017

What is Treatment-Resistant Depression?


With strategies such as Transcranial Magnetic Stimulation (TMS) and Ketamine becoming more prevalent for treatment-resistant depression, it is helpful to take a look at what this entity really means. Not everyone who is being referred for either TMS or treatment with Ketamine may have "true" treatment-resistant depression and then there is what is called "pseudo-resistance."

In simple terms, treatment-resistant depression implies that depression has not reached sufficient remission after an adequate treatment. Remission is defined as clinical improvement with few signs of depression still remaining and a lower likelihood of subsequent exacerbations. About 15% of people with depression may eventually develop treatment-resistant depression (Berlim & Turecki, 2007). Treatment-resistant depression has been variously defined, but the most commonly accepted definition is as below (Souery et al., 2007):

A person with depression is considered to have treatment-resistant depression when consecutive treatments with two antidepressants from two different pharmacologic classes, used for a sufficient length of time at an adequate dose, fail to produce significant improvement. This is further elaborated below:
  • Two different pharmacologic classes means antidepressants having different mechanisms of action. For example, Selective Serotonin Reuptake Inhibitors (SSRIs) versus Serotonin Norepinephrine Reuptake Inhibitors (SNRIs).
  • An adequate length of time is an antidepressant trial lasting at least 4 weeks.
  • An adequate dose is the minimum effective daily dose recommended in the drug package insert.
  • Significant improvement is a score of less than 17 on the 17-item Hamilton Depression Rating Scale.
There are several problems with this definition of treatment-resistant depression. First, it assumes that switch from one class of antidepressant to another may be a more effective strategy than switching within the class. Second, it doesn’t talk about the role of psychotherapy. Third, it is silent on functional improvement and improvement in quality of life and relies only on clinical improvement to define treatment-resistance. Nevertheless, this is the most accepted definition of treatment-resistant depression.

What is Pseudo-Resistance?
Before you jump the gun and diagnose yourself with treatment-resistant depression, first rule out if this is pseudo-resistance. About 60% of people initially classified as having treatment-resistant depression may actually have pseudo-resistance (Berlim & Turecki, 2007). The causes of pseudo-resistance are below (Berlim & Turecki, 2007; Souery et al., 2006):  

  1. Inadequate dosing of the antidepressants: This may be due to staying at a low dose of the antidepressants because of initial side effects that have subsequently abated. Other causes could be drug interactions that are making the antidepressant less effective or an individual having rapid metabolism of the antidepressant. 
  2. Inadequate duration of the antidepressants: Switching medications too soon and concluding that a given medication is ineffective also contributes to pseudo-resistance.
  3. Inadequate adherence: Not taking the antidepressants as prescribed due to side effects or forgetting to take them accounts for about 20% of scenarios that are considered treatment-resistant depression.
  4. Improper diagnosis: This includes:
  • Failure to diagnose an underlying bipolar disorder.
  • Failure to diagnose psychotic symptoms associated with depression.
  • Failure to diagnose melancholic depression. Melancholic depression is a more severe kind of depression characterized by loss of pleasure in all, almost all activities, no emotional response when something good happens, a profound sense of despondency or despair, depression that is worse in the morning, early-morning awakening, appearing markedly slowed down or agitated, poor appetite or weight loss, and excessive or inappropriate guilt (American Psychiatric Association, 2013).
  • Failure to diagnose co-occurring anxiety or personality disorders.
  • Failure to identify underlying medical conditions that may be associated with depression such as hypothyroidism.
If you haven’t responded to a couple of trials of antidepressants, it may be worthwhile to explore the above possibilities in collaboration with your antidepressant prescriber.

What are the Risk Factors for Treatment-Resistant Depression?
While there is no definitive cause as to why some people with depression will develop treatment-resistant depression, research does demonstrate certain risk factors that predispose one to develop treatment-resistant depression. These include the following (Souery et al., 2007):
  • Co-occurring anxiety disorders, particularly panic disorder and social phobia.
  • Having suicidal thoughts during the current episode of depression.
  • Greater severity of depressive symptoms.
  • Presence of melancholic symptoms of depression (described before).
  • History of recurrent episodes of depression.
  • More than one psychiatric hospitalization in the past.
  • Age of onset of depression before 18 years.
  • Non-response to the first antidepressant in one’s lifetime.
  • Co-occurring personality disorder.
Being aware of these risk factors helps an individual plan ahead for treatment as treatment-resistant depression may require a combination of medications or other non-pharmacological strategies.

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.

Berlim, M. T., & Turecki, G. (2007). Definition, assessment, and staging of treatment-resistant refractory major depression: a review of current concepts and methods. Canadian Journal of Psychiatry, 52, 46-54.

Souery, D., Oswald, P., Massat, I., Bailer, U., Bollen, J., Demyttenaere, K., Kasper, S., Lecrubier, Y., Montgomery, S., Serretti, A., Zohar, J., & Mendlewicz, J. for the Group for the Study of Resistant Depression (GSRD) (2007). Clinical factors associated with treatment resistance in major depressive disorder: results from a European multicenter study. Journal of Clinical Psychiatry, 68(7), 1062-1070.

Souery, D., Papakostas, G. I., & Trivedi, M. H. (2006). Treatment-resistant depression. Journal of Clinical Psychiatry, 67(suppl 6), 16-22.



Friday, April 21, 2017

When Feeling Depressed, Don’t Defend Your Vulnerabilities with Anger


Anger, irritability, and frustration may not be the core symptoms of major depression in adults, but almost 50% of people with major depression experience these symptoms (Fava et al., 2010; Judd et al., 2013). In addition, irritability may be the main presentation of mood in children and adolescents with depression. Having irritability and anger while being depressed is a double whammy. Overt irritability and anger during an episode of major depression is associated with greater severity of depression, longer duration of the episode of depression, poorer impulse control, a more chronic and severe long-term course of depression, higher rates of lifetime substance use and anxiety disorder, and greater psychosocial impairment (Judd et al., 2013).

When feeling depressed, you may be masking your more vulnerable feelings of hurt, guilt, shame, grief, or fear with anger or irritability. Depression causes the emotions that make you feel more vulnerable not come to the surface as you are uncertain on how to express them without feeling worse. However, it is important to focus on these hurtful emotions as anger may be manifesting as a secondary emotion because other primary emotions have not found expression. Underlying these hurtful emotions are irrational thoughts that can be challenged and replaced with more rational thoughts. For example, a person loses a parent, but due to life circumstance such as birth of a child, his normal grieving process is interrupted. A few months down the road, he starts getting irritable and snappy with his family and coworkers, feels tired most of the time, experiences insomnia, doesn’t enjoy pleasurable things as he used to, and is losing weight. It is likely that in this situation, the unresolved feelings of guilt related to interrupted grief are manifesting as depression, which is now presenting with irritability and anger. Thus, if this person were to focus only on ways to manage anger, it would only serve as a Band-Aid, while the deeper emotional problems related to guilt and grief would remain unaddressed. Therefore, when you are feeling depressed and also experiencing anger, ask yourself the following questions:

“If my anger were to talk to me, what would it tell me about my deeper feelings?”
“In what way does this situation hurt me?”
“Am I using anger to protect myself from other more vulnerable emotions?”
“Is there an underlying fear that is driving my anger?”
“Is there something I feel guilty or ashamed about this situation that is making me angry?”

Once you have identified the true emotions underlying your anger, then try to identify any fixed beliefs or assumptions associated with these emotions that you may be harboring. In the previous example, the person may be harboring the belief that he hasn’t been a good son to his parents, although there may not be any evidence to support that belief. Thus, identifying and challenging the irrational thoughts associated with the real feelings of hurt and not the proxy feelings of anger will pave the way for reducing both anger and depression.

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


REFERENCES
Fava, M., Hwang, I, Rush, A. J., Sampson, N., Walters, E. E., & Kessler, R. C. (2010). The importance of irritability as a symptom of major depressive disorder: results from the national comorbidity survey replication. Molecular Psychiatry, 15(8), 856-867.

Judd, L. L., Schettler, P. J., Coryell, W., Akiskal, H. S., & Fiedorowicz, J G. (2013). Overt irritability/anger in unipolar major depressive episodes: past and current characteristics and implications for long-term course. JAMA Psychiatry, 70(11), 1171-1180.


HARPREET S. DUGGAL, MD, FAPA




Tuesday, April 4, 2017

What You Need to Tell Family and Friends When You are Feeling Depressed



Family and friends are your immediate support system. Individuals with depression may avoid sharing their symptoms with their family or close friends due to the perceived stigma. Some don’t share their feelings to avoid being a burden on others and then there is this fear of being perceived as weak and needy. Unless you have a very critical and judgmental person who is not accepting of depression as an illness, your family and friends would appreciate your efforts to reach out and be candid about your depression. It is important that you educate your family about depression using scientifically-based information. Local chapters and websites for organizations such as the National Alliance on Mental Illness (NAMI) and the Depression and Bipolar Support Alliance (DBSA) have information for family members and friends regarding depression. Information about depression is also available at the National Institute for Mental Health website. You also have to advocate for yourself in how you want to be treated when going through the throes of depression. Literature on depression shows that criticism, hostility, and an attitude of emotional overinvolvement can lead to more chances of depressive symptoms returning (Hooley et al., 1986). Some pointers in this direction are listed below (Langlands et al., 2008):
  • Emphasize to your support system that depression is no body’s fault but is an illness, which is treatable and has a good prognosis.
  • Your family and friends need to know that there is a fine line between what constitutes a concern and encouragement and what amounts to “controlling.” Use examples to define these behaviors for your family so that they are aware when their way of supporting you may be making you feel worse.
  • Share with your family and friends the traits you are hoping for them to display in their interactions with you such as being empathetic, non-judgmental, respecting your individuality, and being supportive and appreciative of your strengths while also guiding you if you need more support.
  • Advise your family and friends to refrain from using critical labels such as being “weak,” “lazy,” “faking,” “selfish,” and “attention seeking.” Depression is not a character flaw as promoted by these labels.
  • Educate your family about recognizing early signs of depression so that they can assist you in getting timely help and also at the same time respect your decision if you don’t want to seek help.
  • Educate your family about situations when you are not comfortable discussing your symptoms and need more space.
  • Emphasize that you want people to be genuinely caring and not just say all the “right things.”
  • Inform your support system that when you are really feeling down, saying things such as “get over it,” “snap out of it,” “put a smile on your face,” “get your act together,” or “lighten up” are not helpful and may even backfire.
  • Tell your support system that when you approach them with a problem, you may be only reaching out for a person who can listen and empathize with you and that you are not necessarily seeking a 'cure' or a 'solution' to your problems.
Depression can make it difficult for you to initiate any kind of social contact. Use the following dialogue with your friend or social support person to educate them about this pattern (Ilardi, 2009):
“I really want us to get together more often, but because of the depression, I might have trouble taking the initiative sometimes. Would you be willing to stay on me about it – to call me anytime you haven’t heard from me in a while, and to insist that we set something up?”

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


Hooley, J. M., Orley, J., & Teasdale, J. D. (1986). Levels of expressed emotion and relapse in depressed patients. British Journal of Psychiatry, 148, 642-647.

Ilardi, S. (2009). The depression cure. Philadelphia, PA: Da Capo Press.

Langlands, R. L., Jorm, A. F., Kelly, C. M., & Kitchener, B. A. (2008). First aid for depression: a delphi consensus study with consumers, carers and clinicians. Journal of Affective Disorders, 105, 157-165.





Thursday, March 16, 2017

The “ABCDE” Behaviors that Derail Relationships When You are Feeling Depressed


The acronym “ABCDE” refers to certain types of communication behaviors that increase conflict and marital/intimate relationship distress. These behaviors get heightened when one is depressed as depression rekindles negative irrational thought patterns such as all-or-none thinking, overgeneralization,  jumping to conclusions, blowing things out of proportion, taking things personally, disqualifying positives, and negatively labeling self or others. Here's what you need to avoid during communication with your partner (Beach et al., 1998; Christensen et al., 2014; Starr & Davila, 2008):

Accusation: Accusations usually are “You always …” or “You never…” statements. Accusations may have some kernel of truth in them, but that gets exaggerated and dramatized by the heat of the argument. Accusations lead to counteraccusations and defensiveness and takes away the focus from one’s own shortcomings and also from resolving the conflict on hand.

Blame: Individuals may blame their partner’s actions for a problem or blame their mental illness, moral weakness, or personal inadequacies for the problems the couple is facing. For example, “If you had taken those medications, then we would have been able to go on this trip.”

Coercion: People use coercion to force their partners to do what they want by making demands, threats, nagging, criticizing, complaining, and inducing guilt. The partner at the receiving end gives into the coercion as they want peace and this reinforces the behavior of the coercive partner. However, over time the receiving partner may get used to this coercion and ignore the demands of the coercive partner, which may result in the latter escalating their coercive tactics, eventually leading to more marital discord.  

Defensiveness: Defensiveness is the usual reaction of a partner on the receiving end of accusation or blame, but only adds to the argument and conflict. Defensiveness really amounts to saying, “The problem isn’t me, it’s you.” The innocent victim stance is not an uncommon variant of defensiveness (Gottman & Silver, 2015). The user of this stance often whines and sends the message, “Why are you picking on me? What about all the good things I do? There’s no pleasing you.”

Excessive reassurance seeking: Excessive reassurance seeking is repeatedly requesting reassurance from your partner that you are lovable and worthy. Examples include, “Do you still love me?” or “Am I a good person?” or “Are you going to stay with me?” Excessive reassurance seeking wears out your partner and they start feeling burdened, frustrated, and helpless and their reassurances start getting tinged with irritation. This then leads to either true or perceived rejection that develops, maintains, and worsens depression and with higher levels of depression, the demands for reassurance also increase, thus creating a vicious cycle (Allen, 2006).


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



Allen, J. G. (2006). Coping with depression: From catch-22 to hope. Washington, DC: American Psychiatric Publishing, Inc.

Beach, S. R. H., Fincham, F. D., & Katz, J. (1998). Marital therapy in the treatment of depression: toward a third generation of therapy and research. Clinical Psychology Review, 18(6), 625-661.

Christensen, A., Doss, B. D., & Jacobson, N. S. (2014). Reconcilable differences (2nd ed.). New York, NY: The Guilford Press.

Gottman J. M., & Silver, N (2015). The seven principles for making marriage workNew York, NY: Harmony Books.

Starr, L. R., & Davila, J. (2008). Excessive reassurance seeking, depression, and interpersonal rejection. Journal of Abnormal Psychology, 117 (4), 762-775. 



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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