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No. 11, Fall 2000
BC’s
Mental
Health
Journal
Mood Disorders
“Seamless Armour” by Bill Pope (full-colour original)
editor’s message
T he good news is that mood
disorders such as depres-
sion and manic depression are
affect the other.
While we move forward on these
mood disorders. We’ll look at
some of the things that
influence the development and
finally coming out of the clos- fronts, however, new challenges course of these illnesses, focus-
et. Prominent people such as are presenting themselves else- ing on the role of lifestyle and
BC’s Margot Kidder and Michael where. Mood disorders are be- health factors. We’ll also con-
Mental Wilson are sharing their expe- coming more common in our sider the range of approaches
Health riences with these conditions. young people and in the devel- that have shown success in help-
Journal
Jour nal
As a society, it’s becoming oping world. The incidence of ing people get back on their
easier to acknowledge the ill- suicide — which is often triggered feet. Finally, we’ll take a look
nesses’ presence in our midst. by serious depression — is be- at the relationship between
Going hand in hand with this coming a grave problem in the mood disorders, work, and cre-
increasing openness is a grow- elderly and is referred to as ativity. It is impossible for us to
is a quarterly publication
ing array of treatment alterna- “reaching epidemic levels” in address the full range of issues
produced by the Canadian Mental
tives that make a difference. Aboriginal peoples. Some of the connected to mood disorders.
Health Association, BC Division. It is
alternatives that are known to We do hope, however, that the
based on and reflects the guiding phi-
At the same time, we’re be- work, such as an approach known reader gains new insights into
losophy of the CMHA, the “Framework for
coming more aware of the in- as “cognitive behavioural thera- some of the facets of these con-
Support.” This philosophy holds that a
terconnections between mood py,” are not readily available to ditions.
mental health consumer (someone who has
disorders and issues of physi- the general public. Many of the
used mental health services) is at the
cal health, such as lifestyle, social influences on depression As is usual in this journal, we
centre of any supportive mental health
and with health conditions like (abuse, stress, and poverty, to also hope that the edition not
system. It also advocates and values the
heart disease and diabetes. name a few) are enormous, grow- only spreads understanding, but
involvement and perspectives of friends,
This emerging knowledge will ing problems that require a con- acts as a practical resource for
family members, service providers, and com-
undoubtedly help us improve certed societal effort over time. people who live with mental ill-
munity. In this journal, we hope to create
the prospects for dealing with ness and all those who care for
a place where the many perspectives on
both physical and “mental” dis- In this issue of Visions we’ll hear them. As always, we look for-
mental health issues can be heard.
orders as we recognize how first-hand about the experienc- ward to hearing your response.
each side of the “mental/ es of people who have struggled
The Canadian Mental Health Association
physical” coin can positively with and gained control over Eric Macnaughton
invites readers’ comments and concerns
regarding articles and opinions expressed
in this journal. Please e-mail us at Special thanks to Bill Pope whose painting Seamless Armour was selected for our cover.
office@cmha-bc.org or send your letter with Bill is a mental health consumer who lives in the Vancouver area. Bill’s artwork is also
your contact information to: featured on pages 37 and 41 and he has written an article as well (see page 40).
Visions Editor
CMHA BC Division
More artwork for this issue of Visions has been generously donated by Desneige McLean
1200 - 1111 Melville Street (see pages 12, 15, 27, 33, and 35). Desneige is a fourth year Visual Arts student at Simon
Vancouver, BC Fraser University. Her brother lives with a mental illness.
V6E 3V6
Thank you to Ken Hansen for his contribution of poetry (pages 35 and 42). Ken is a
Subscriptions are $25 for four issues. consumer from BC’s Sunshine Coast.
For more information on the journal or for
information about advertising and sponsor- Editorial Board Nancy Dickie, Jane Duval, Dr. Raymond Lam, Dr. Rajpal Singh
ship opportunities, call us at 688-3234 or Executive Director Bev Gutray
toll-free outside the Lower Mainland at Editor Eric Macnaughton
1-800-555-8222.
Staff Contributors Eric Macnaughton, Sarah Hamid, Jasmeet Bhullar,
The opinions expressed in this journal are
Barbara Bawlf, Carlene Daniel, David Wells
those of the writers and do not necessarily Design / Production Editor Sarah Hamid
reflect the views of the Canadian Mental Printing Advantage Graphix
Health Association, BC Division or its
branch offices. The Canadian Mental Health Association is grateful to the BC Ministry of Health which
has assisted in underwriting the production of this journal.
Guest Editorial ............................................................................................... 3
Background .................................................................................................... 4
2
CNTENTS
o Experiences and Perspectives ..................................................................... 8
Alternatives and Approaches ................................................................... 16
Mood Disorders and Health Issues .......................................................... 24
Depression, Creativity, and Work ............................................................. 36
Resources .................................................................................................... 44
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
guest editorial
Managing Mood Disorders
Robert
W
hile I was on MDA was started 18 years ago
vacation in a Robert Winram is the Executive by Ed and Vicki Rogers. Ed Winram
church far in the Director of the Mood Disorders had developed manic depres-
south of sunny Spain, I Association of British Columbia sion following surgery. The
watched a man washing his (MDA); he also lives with a mood illness came on so suddenly,
hands with invisible water. disorder himself. The Association he was particularly interest-
Over and over he washed al- has been around almost twenty ed in learning more about it.
most to his elbows, interrupt- years and has support groups all He attended a meeting at the
ing the washing only to make over BC for people with mood Canadian Mental Health As-
quick touches to his head. It and anxiety disorders and their sociation (CMHA) where he
seemed that he was praying friends and families. met people who were also
for relief from his obsessive- dealing with mood disorders.
compulsive behaviour — a He brought them together for
form of anxiety that can didn’t realize that my love of debilitating and frightening the first MDA meeting in the
accompany a mood disorder. sugar, soft drinks, and a par- when the mind ceases to basement of his home. From
What suffering! Non-stop he ticularly irregular diet had an work well. For some, this re- that first meeting, MDA has
washed, and I rededicated effect on my mood. Substance sults in an inexplicable, now grown to almost 50 sup-
myself to spreading the news abuse is often an issue, as generalized anxiety while port groups around the prov-
that there are solutions for people try to self-medicate, others, in the same situation, ince (for information, call
mood disorders. possibly drinking to get to develop anger. In a state of (604) 873-0103 or visit
sleep. Not being able to stop anger, it is very difficult in- www.lynx.net/~mda).
Managing mood disorders smoking, I stayed away from deed to recover one’s health.
has many components, and alcohol and drugs, as I felt I When people have overcome These illnesses are now bet-
there are a variety of strate- had such little control of my their anxiety or anger to the ter understood, and we have
gies that people use to dis- life as it was. point that they want to con- improved medications. Even
cover and maintain good tribute to society or those the arrival of the internet
health. In this edition of Even something as positive as around them, then they truly helps, as so much information
Visions , several points of exercise can, in illness, be are back on track. can be quickly located on
view, treatment styles, or overdone. When I was build- mental health issues. One site
roads to recovery are offered ing into mania, my exercise The most important part of that is of particular interest
for your consideration. In was so intense, so rushed my recovery was to develop is www.mentalhealth.com
Spanish, there is a word, that rather than bringing insight. I learned about the (see page 20). You can also
polyfacético, which means balance to my life, it fueled illness, its patterns, and check out the links section of
‘many faces.’ As there are the mania. Then, in depres- built support networks with CMHA BC Division’s web site
many types of depression and sion, when just getting out of friends and family. Eventu- at www.cmha-bc.org.
manic depression that can bed was the problem, the ally, I could “see” the mood
creep up on us, there are thought of regular exercise swings and the early signs. As the science behind recov-
many faces or facets of treat- seemed impossible. Then I would contact my doc- ery progresses, we still con-
ment and lifestyles that must tor and intervene before I was tinue to be burdened with the
also be attended to if we are Rebuilding social networks dealing with a full manic or stigma of mental illness that
to successfully manage these after manic or depressive ep- depressive episode. It takes keeps so many from realiz-
conditions. isodes takes time. In mania, I trust to work with others and ing that there are solutions.
sometimes said things that give them permission to give Mental illness has alarming
We now have medications could not be called back. you their input. The self-help symptoms that we cannot
that are effective for most During a depression, I would model used by the Mood pretend to ignore, especially
people. These usually provide go months not answering Disorders Association of BC now that successful manage-
the starting point of recov- the phone, resulting in un- (MDA) helped me learn ment is such a reality.
ery. However, there are life- pleasant isolation. It took from others what my early
style issues that contribute months after each manic or signs might be. The sincerity We who have experienced
very heavily to successful out- depressive episode to mend of those at the support group good care and enjoy improved
comes. As I was not given a my broken social networks. meetings helped substantial- health need to end the silence 3
diagnosis for more than 25 ly increase my trust, as I re- by talking about our recov-
years, I had no understand- It’s not appreciated how much alized I wasn’t the only one ery openly and loudly — loud
ing of the ways my lifestyle damage is done to a person’s living with the challenges of enough that the message will
was aggravating my manic confidence by an episode of a mood disorder. be heard even in a small
depression. For instance, I mania or depression. It is so church in the south of Spain.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
BACKGROUND
Recognizing the Faces
of Major Depression
Raymond W. In part, this is because many patients present physical symp-
Lam, MD,
FRCPC
S
arah is a 23-year-old homemaker who feels she can’t cope
because she is so tired and fatigued. Roger is a 48-year-old
truck driver who feels bored with life. Alice is a 41-year-old
toms and the depression is missed. Table 1 shows the symp-
toms experienced by people with major depression. Many
lawyer who cries and feels suicidal. Maria is a 72-year-old people are like Alice in that they feel sad and blue and cry
potter with insomnia and disabling headaches.1 What do all during a depression. Others, like Roger, may not notice de-
Dr. Lam is a these people have in common? They are all suffering from pressed mood but will experience lack of interest in usually
Professor in the clinical depression, a medical condition that is often unrecog- pleasurable activities. Most patients have physical symptoms
Department of nized and untreated. like changes in sleep, appetite, and weight. Maria has insom-
Psychiatry at the nia and wakens early in the morning, unable to sleep. She also
University of Clinical depression, known as major depressive disorder or has no appetite and has lost 15 pounds over the past few
British Columbia major depression in medical terms, is the most common men- months. Sarah, however, experiences oversleeping and
(UBC) and is tal disorder and one of the most common medical illnesses in
Table 1: Symptoms of Major
Medical Director the general population. Major depression affects 1 in 7 people
of the Mood at some time in their life. At this moment, 1 in 25 people (4%), Depressive Disorder
and Anxiety or 16,000 people in British Columbia alone, suffer from clin-
DIAGNOSTIC SYMPTOMS
Disorders ical depression. The chances of having depression are twice ❑ Depressed mood
Program at as high for women as compared to men. A depressive episode ❑ Loss of interest
UBC Hospital can last from weeks to months (and sometimes, years). The ❑ Sleep problems (insomnia or oversleeping)
in Vancouver. direct medical costs of treating depression in Canada exceed ❑ Appetite problems (loss of appetite or overeating)
❑ Feelings of guilt
one billion dollars a year.
❑ Low energy
❑ Poor concentration
The social and physical costs of clinical depression are signif- ❑ Psychomotor disturbance
icant. A large study sponsored by the World Bank and the (feeling slowed down or agitated)
World Health Organization ranked the global burden of all ❑ Thoughts about suicide
medical diseases according to the combined mortality and
disability caused by the disease. In 1990, major depression ASSOCIATED SYMPTOMS (symptoms which may
ranked fourth worldwide in combined disability, outranking accompany depression)
❑ Anxiety
heart disease, stroke, and AIDS. In fact, the only conditions ❑ Low self-confidence and self-esteem
that outranked depression were those experienced mainly by ❑ Cognitive distortions (negativity, pessimism)
Third World countries including infec- ❑ Dependent behaviour
tions, diarrhoeal diseases, and perinatal ❑ Hallucinations
“Faces of Depression” (NMHA 1993 video cover)
❑ Delusions
(i.e., before and after childbirth) mor-
❑ Sensitivity to criticism
tality. This study also estimated that de- ❑ Irritability
pression will rank second worldwide by
the year 2020.
overeating during her depression along with carbohydrate
The most serious consequences of de- cravings and weight gain. Some patients feel physically and
pression include death by suicide. One mentally slowed down, while others feel agitated.
person commits suicide in British Colum-
bia each day, and most people who are Feelings of hopelessness, helplessness, and worthlessness are
suicidal are clinically depressed. also common when people are depressed. They often think of
death and may have thoughts about suicide. There are many
Clinical depression can also worsen the myths about suicide that flow through our culture and are still
outcome of medical conditions. For example, your risk of dy- held by some health professionals. One myth is that asking
ing after a heart attack is four times greater if you are clinical- about suicide makes it worse. This is not true. Most people,
ly depressed. Depression is a greater risk factor for predicting like Alice, are relieved when they are asked about suicidal
death after heart attack than a history of smoking, previous thinking and find out that it is a common depressive symptom
4 heart attacks, and poor heart function. (also see page 31). that can be treated.
Many associated symptoms are found in major depression but
Symptoms of Depression
are not part of the formal diagnostic criteria. Roger experi-
Unfortunately, major depression is often unrecognized and ences anxiety and has cognitive distortions where his think-
untreated even when people are seeing health professionals. ing becomes very negative and pessimistic, as if he is seeing
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
background
the world through a depressive filter. Alice became indecisive impulsive, reckless behaviour such as spending money or get-
in her court work, and her self-confidence and self-esteem ting into needless arguments.
fell. In severe cases, patients may be psychotic, losing touch
with reality. They may have hallucinations (perceptual dis- We also differentiate subtypes of depression, including pa-
turbances such as seeing things or hearing voices) or delu- tients with “psychotic” depression (with hallucinations or
sions (false fixed beliefs such as feeling responsible for wars delusions), “atypical” depression (with overeating, oversleep-
going on in the world). Maria was very distressed because she ing, and mood reactivity), and “seasonal” depression (with
heard voices telling her that she was evil and that she de- depressive episodes only in the winter). Distinguishing bipo-
served to die. lar disorder and these depressive subtypes is important be-
cause they have specific and different treatments.
Diagnosis of Depression
Causes of Depression
With all these different types of symptoms, it is not surprising
that clinical depression is sometimes difficult to recognize. The causes of clinical depression are not known, but it is clear
Screening questionnaires such as the Beck Depression Inven- that there is a complex interaction between psychological
tory can be helpful. This widely used, self-rated, 21-item scale and neurobiological factors. Genetics play a role as clinical ___________
helps to identify people who may be depressed, but by itself depression can run in families, and the chance of having a Footnote
cannot be used to diagnose a clinical depression. Research has clinical depression is increased if a family member also has 1
shown, however, that two simple questions can be as sensitive the condition. However, it is not yet possible to predict who in All names
and case
as a screening questionnaire: “Have you been feeling sad or the family will develop depression. Many studies show bio- histories are
depressed?” and “Have you lost interest in your usual activi- logical changes in the brains of people with clinical depres- fictitious and
ties?” By regularly asking these two questions, many clini- sion, especially in neurotransmitters, the chemicals involved represent an
amalgamation
cians will be able to identify patients with a clinical depression in transmitting signals between neurons. Disturbances are of patient
who might ordinarily be missed. found with serotonin, noradrenaline, and dopamine, the main stories.
neurotransmitters regulating mood and emotion. There are
To make a medical diagnosis of major depression, at least 5 of also many hormonal abnormalities and disturbances in the
the 9 major symptoms must be present for at least two weeks. biological function of sleep and circadian rhythms (the daily
These symptoms must also cause significant distress and/or rhythms generated by the biological clock in the brain).
result in impairment in functioning at work or with relation-
ships. Other medical conditions that can have depressive symp- There is also much evidence that psychosocial factors are im-
toms (Table 2), prescription medications, and alcohol or portant. Early parental loss, social isolation, personality style,
substance abuse must be ruled out before making the diagno- and stressful life events can all increase the risk of developing
sis. The normal process of bereavement is also excluded, al- a clinical depression. For example, Roger began to be de-
though extended periods of grief may turn into something pressed after a recent separation from his wife, while Sarah is
meeting the criteria for a major depressive episode. struggling with marital and parenting stress.
We classify people with a depressive disorder separately from Unfortunately, for an individual person, it is not usually possi-
those with bipolar disorder (formerly called manic-depres- ble to identify a single cause of depression. However, it is still
sive illness). People with bipolar disorder experience manic important to identify biological, psychological, and social fac-
episodes at some time in their lives in addition to having de- tors that may be contributing to the clinical depression be-
pressive episodes. During a manic episode, people with this cause specific treatments can be targeted in each of those
disorder are uncharacteristically euphoric (or irritable), hy- domains. For example, antidepressants can be used for bio-
peractive, grandiose, and distractible. They speak very rapid- logical factors, psychotherapeutic approaches can be used for
ly, have racing thoughts, and have less need for sleep. In severe psychological factors, and occupational or marital therapy can
cases, they will also experience psychotic symptoms, some- address social factors. Later on in the issue, we’ll return to the
times believing they have special powers like telepathy. stories of Sarah, Roger, and Maria, and look at the treatment
During the manic episode, they have poor judgment and show alternatives that they’ve found helpful. (see page 16)
Table 2: Some Medical Conditions with Depressive Symptoms
NEUROLOGICAL CANCERS CARDIOVASCULAR ❑ Hypo/Hyperthyroidism
❑ Alzheimer’s disease / ❑ Brain ❑ Heart failure ❑ Uremia
other dementias ❑ Pancreas ❑ Myocardial infarction
❑ Huntington’s disease (heart attack)
OTHER
❑ Migraine headaches
INFLAMMATORY ❑ AIDS/HIV 5
❑ Multiple Sclerosis
❑ Irritable Bowel Syndrome METABOLIC AND ENDOCRINE ❑ Chronic Fatigue
❑ Parkinson’s disease
❑ Systemic Lupus ❑ B12 or iron deficiency Syndrome
❑ Stroke
Erythematosis ❑ Cushing’s Syndrome ❑ Chronic pain
❑ Diabetes ❑ Fibromyalgia
❑ Hypocalcemia
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
background
When it Rains, it Pours:
The Co-Occurrence of Depression
and Other Mental Illnesses
Carlene
T
he importance of co- as they seem to be closely re- feelings of
Daniel occurring mental ill- lated. Depressive symptoms hopelessness ANXIETY
a
nesses has sparked the such as lack of energy, loss of and helplessness.
reni
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majority (79%) of people who common in both depression at this point
schi
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Coordinator of at some point in their life are tia. A study done in 1998 by depression 109876543210987654321
the Open Mind diagnosed with more than the Stockholm Gerontology comes about
Media Watch one mental illness. Depres- Research Centre found that a secondarily (i.e., as a result
program at sion is no exception, as it is mood disorder (e.g., dys- of developing schizophre- panic disorder, obsessive-
CMHA BC often diagnosed along with thymia, bipolar disorder) was nia), or whether depression compulsive disorder, pho-
Division. She is other disorders. While we diagnosed in nearly 12% of is an integral part of the bias, post-traumatic stress
going into her don’t know conclusively at the participants with demen- schizophrenic illness. It is disorder, and generalized
third year at this point why these disorders tia. The study concluded that clear, however, that depres- anxiety disorder. Each of
Simon Fraser occur together, it is clear that the prevalence of major sion in schizophrenia must be these disorders has specific
University, the presence of co-occurring depression is higher in peo- recognized, particularly in characteristics ranging from
studying disorders increases the ple with dementia than in the early phases of the ill- fears of public places or re-
psychology and complexity of a person’s treat- those without. In many cases, ness, as the combination of petitive checking behaviours,
communications. ment and the potential sever- the presence of depression these two illnesses puts the to spontaneous overwhelm-
ity of their mental health significantly affects the de- person at a much greater risk ing panic attacks. Although
condition. Below, we’ll look velopment of dementia, espe- of suicide during the first they are all different from one
at some disorders that may cially when dementia begins years of developing schizo- another, anxiety disorders
occur with depression: de- at an early age. phrenia. To deal with this tend to trigger reactions that
mentia, schizophrenia, anxi- problem, researchers at the are out of proportion to the
ety disorders, and eating Clarke Institute of Psychia- actual situation.
Depression
disorders. try are developing a form of
and Schizophrenia
cognitive behavioural thera- Major depression appears to
Schizophrenia is a mental ill- py (CBT) to deal with depres- have an integral relationship
Depression
ness which can be recognized sion in people who have been with anxiety disorders. Over
and Dementia
by a mixture of symptoms newly diagnosed with schiz- 30% of people who suffer
Dementia is a category of dis- including cognitive and ophrenia (see ‘Related Re- from clinical depression have
orders characterized by the emotional distortions that sources’ on opposite page). also had at least one episode
development of several cog- infringe on a person’s ability of an anxiety disorder in their
nitive deficiencies which to communicate, pay atten- The following quote, from a lifetime. The most common
impair a person’s social or tion, and produce coherent person who lives with both depressive symptoms that are
occupational functioning. thoughts and speech. Depres- depression and schizophre- experienced when suffering
Examples include memory sion is now being recog- nia, illustrates the need to from an anxiety disorder are
impairment, deterioration of nized as a common feature of deal with both issues: “The fatigue, insomnia, and con-
language, and impaired abil- schizophrenia. Recent stud- medication cleared my psy- centration difficulties. Re-
ity to carry out everyday ac- ies have shown that a sub- chosis but it didn’t do any- searchers are currently
tivities like combing one’s stantial rate of depression thing for the depression…I debating how and why anxi-
hair. The most common cause (40-50%) has consistently asked to go on Prozac even ety and depression are relat-
of dementia in Canada is been found in people with though they told me I didn’t ed. Some people view major
Alzheimer’s disease, which schizophrenia. Depressive need anything, and when I depression as secondary to
accounts for about 60% of symptoms are so similar to [finally] did I felt like a total- anxiety, or something that
6 cases. some negative symptoms of ly different person.” happens as a result of having
schizophrenia that they can particular anxiety disorders.
Research illustrates the dif- be difficult to distinguish. It may also be that anxiety
Depression
ficulty in separating the Symptoms of both disorders occurs as a symptom of de-
and Anxiety
symptoms of dementia from include withdrawal, lethar- pression.
the symptoms of depression gy, emotional numbness, and Anxiety disorders include
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
background
Although the causal relation-
ship between depression and
anxiety has not been con-
excessive exercise. From an-
other angle, the effects from
a serious eating disorder,
Different Kinds
firmed, it is clear that when
they occur together, consum-
ers experience more severe
such as malnutrition or ex-
cessive fatigue, can intensify
the severity of depressive
of Depression
symptoms and may have to symptoms. Some scientists
(“depressive reaction” or “exogenous”)
work harder and take a dif- believe that the relationship Normal Depressed Mood and Grief
ferent approach towards re- between the two disorders Depression can be a natural reaction to losses in life. What
covery. One person who has may be due to common genet- makes these reactions normal is that people eventually re-
normal but potential
experienced with both ill- ic factors that influence the cover on their own — even after the death of a loved one. If
nesses describes her experi- risk of suffering from both symptoms persist, a person could have a clinical depression
ence of recovery: “For me, it depression and anorexia. and should call a doctor.
seems the anxiety and de-
pression were quite separate. As noted above, when other Adjustment Disorder with Depressed Mood
I had anxiety (but no depres- disorders occur along with Life is full of changes; coping with them can be difficult.
sion) from a young age right depression, it tends to in- Many people feel overwhelmed until they can get things
into my teens … and then the crease the severity of a per- under control. If they can’t or don’t, they instead become
depression hit. The depres- son’s mental health condition, persistently gloomy, angry, and unable to cope. If these symp-
sion was so severe that it end- compared to one disorder toms occur without a life change or they are out of propor-
ed up giving me amazing occurring alone. By recog- tion to the change, then call a doctor.
perspective. I went from car- nizing this co-occurrence,
ing about petty little things however, we can better un-
in my anxious states to just derstand the nature of an in-
being concerned about mak- dividual’s disability and are Chronic Mild Depression (known as dysthymia)
Just like it sounds, dysthymia is a low-level depression that
clinical depressions (usually “endogenous”)
ing it through the day. Going in a better position to help the
through depression actually person make a full recovery. always seems to be there. It may or may not have a triggering
ended up being the best cure life event.
for my anxious tendencies.”
Major Depression
Again, like it sounds, when someone says they are “seriously
Depression and ______________
depressed,” this is what they mean. You can suffer a major
Eating Disorders Selected References
depression and not feel blue. Very often, major depression
Anorexia nervosa and bulim- Forsell, Y. (2000). “Predictors for strikes without any triggering loss; 15% of people with ma-
depression, anxiety and psychotic
ia nervosa are two of the most symptoms in a very elderly popu-
jor depression attempt or commit suicide.
prominent eating disorders lation: Data from a 3-year follow-
in Western society. Anorexia up study.” Social Psychiatry “Double” Depression
Epidemiology, 35(6): 259-63. Dysthymia coupled with a major depressive episode.
nervosa is characterized by
excessive over-exercising Levy, A.B. et al. (1989). “How are
and an immense fear of gain- depression and bulimia related?” Bipolar Disorder (Manic Depression)
American Journal of Psychiatry, This illness involves major depressive episodes alternating
ing weight. Bulimia nervosa 146(2): 162-9.
is characterized by habits of with high-energy periods of manic activity, which are often
binge eating followed by A full list of references consulted is characterized by risky behaviour, irritability, rapid speech
available upon request.
purging or other methods and thought, and “delusions of grandeur,” e.g., feelings that
to prevent weight gain. The one has special powers or can accomplish amazing feats.
Related Resources
connection between depres-
sion and eating disorders is Depression and Anxiety. A cyber-
Seasonal Affective Disorder (SAD)
becoming increasingly evi- journal more for the clinically-
dent. minded, but a useful resource Often called “winter blues,” SAD is a real psychophysical
time-specific clinical
nonetheless. Most of the volumes reaction to a lack of sunlight in winter. It is a mild or major
are accessible online at www3.
Depression has been shown interscience.wiley.com/cgi-bin/ depression that develops in late fall and clears up in early
depressions
to be a contributor to the jtoc?ID=38924 spring.
development of an eating “Treating Depression in Schizo-
Post-partum Depression
disorder, as depressive symp- phrenia.” A description of a pro-
toms influence a person’s gram being developed at the Centre This kind of depression occurs in the weeks or months after 7
for Addiction and Mental Health giving birth to a child. Due to hormonal fluctuations as well
feelings of self-worth. Low using cognitive behavioural thera-
self-worth (especially poor py for people in the early stages of as the new challenges of dealing with a baby, about two-
body image), in turn, is one schizophrenia or a psychotic illness. thirds of women feel a transient sadness; 10-15% become
www.camh.net/CLARKEPages/ clinically depressed.
of the main risk factors for schizophrenia/depression_in_
binge eating, purging, and schizophrenia.html
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
EXPERIENCES AND PERSPECTIVES
Living with Depression
B
Dena Lea ecause of the nature of depression, it took me years to an intelligent individual, I often feel these qualities are masked
get into treatment. I found it hard to accept that I need- by a sort of melancholia that has a mind of its own. I know
ed help, let alone find out where to go to get that help. intellectually that my life has value, but when I am depressed,
Once I finally got started, it was very difficult to find the there’s a part of me that simply doesn’t know how to believe it.
energy to continue. With depression, there are times when I’d
be too exhausted to do anything, let alone go out and confront At this point, you may be wondering “why am I still reading
the world. But the good news is, with the help of a few key this?” I don’t blame you, it’s a depressing topic — and a very
people, I am beginning to recover from the illness that has serious one. Perhaps you have had similar experiences, or may-
haunted so much of my life. Now that I have accepted my be you know someone who has described these feelings to
depression as a treatable illness, I know there is something I you. In either case, it is important to realize that depression is
can do about it — and I don’t have to do it alone. not an inherent weakness or personality flaw, and that it can
become a serious illness. People with depression cannot just
Imagine what it would feel like to wake up in the morning “snap out of it.”
wondering “what’s the point of getting out of bed?” Imagine
that this is a daily occurrence, and no matter how much you Most of us experience a period of depression at some point in
” have to do, or how bright and aware you know you should be,
you just can’t shake the feeling. This is what
our lives, but over time, the feelings fade and life resumes its
normal course. For a person with clinical depression, these
depression does to you: it robs you of your in- episodes may be frequent or continue for a long time. In my
Have you ever tried terest, your drive, your joy, and your ability to experience, the episodes were shorter, less severe and oc-
putting on a happy do anything to help yourself. curred less often when I was young. They became longer and
face when you more severe as I got older; eventually, my condition became
“chronic.”
weren’t actually Think about what it would be like to spend most of
your time alone because being around other peo-
feeling bright ple is just too difficult. Of course, you know Of course, understanding my illness was only the beginning
and cheery? there are people who care about you, but of my recovery. Now I have to deal with the outside world and
” when you’re depressed, you can feel
they are judging you. You’re tired of
being called names or told to “get over
uninformed attitudes about mental illness. I’ve met very few
people outside the mental health community who think about
depression in the same way as diabetes or heart disease, which
it,” and you’ve even become afraid to are also treatable illnesses. This makes it difficult for those of
expose those you care about to the us who experience mental illness to share our stories and
gloom and doom that seems to surround discover that we are not alone.
you. You may even fear that they, too,
will tire of being around your dis- I was fortunate enough to find my way to a local mental health
mal mood and shun you like agency, through which I have discovered a whole community
so many have before. of open-minded and knowledgeable people. This is where I
now go to get encouragement and support, knowing that I
Have you ever tried putting won’t be judged for needing help. My wish for the future
on a happy face when you would be for more people to see illnesses like depression as
weren’t actually feeling treatable medical conditions, so those of us living with mental
bright and cheery? For a illness can feel more supported as we move towards wellness.
person with depression,
it’s extremely difficult to
pretend that everything is Highs and Lows Choir
“normal”; it’s obvious to
you that it’s a façade, and
A choir for consumers and
it isn’t working. You end their friends and family
up feeling worse about yourself for having pretended.
Now try to imagine having all these feelings and not under-
standing that they are symptoms of a treatable illness. You
8 don’t realize it’s not your fault and even believe you’ve “tried
everything” and failed. From the inside of depression, you
chastise yourself for not being a better, stronger person. New members are always welcome!
For more information, call (604) 738-2811
As a person who experiences clinical depression, I know these (extension 211 or 201).
feelings from the inside out. Despite the fact that I know I am
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
My Squeaky Wheel
Frank G.
I
’ve decided that I must why mental health resources even though, according to
never procreate. For if I should place an emphasis on prevalent societal thinking, Sterle, Jr.
do, I’m convinced I’ll very family environment as well since I do not earn a “regu-
likely pass down the suffer-
ing for which I believe I was
as awareness and treatment. lar” pay cheque for doing
“regular” work, I am not ac- poetry
destined when I was con- Mental illness is like any oth- tually working or really con-
ceived by my parents who er form of illness, yet “nor- tributing to society. NOT MINE
raised me in a dysfunctional mal” people who have not
environment (although at been directly or indirectly But as long as the mentally- candlelight vigil
least part of my mental ill- affected too often tend to per- ill person’s wheel fails to for the me I have lost
ness was likely acquired ge- ceive it not as a real illness, squeak, it will get no grease. for the me I’ve become
netically). And, thus, my but rather as something you The community must speak but don’t wish to be
misery will end with me. can snap out of if your mind out to achieve change. Pen-
is adequately disciplined — sion cheques, at best, will an alien force
Potential parents concerned for it involves the mind, and barely take into considera- inhabits my nervous
about their future offspring’s if your character is strong- tion inflation levels and hos- system
acquisition of mental illness, willed enough, you should be pital bed numbers will plucks my emotions
however, need not complete- able to will it away, right? inadequately deal with those slowly
ly deny themselves procrea- with serious mental illness as if I’m being
tion. Instead they can, and Even at a time when society who will instead be left to the defeathered
definitely should, educate has established Mental mean streets, jail, or suicide. one
themselves as extensively as Health Week, it is still im- Our suffering is only wors- neuron at a time
possible — before they have plicitly socially acceptable to ened by the fact that mental
children — about how to rear stereotype people with men- illness cannot be measured in an alien force
their offspring in a mentally tal illness as being more po- a physically tangible manner holds my gray
functional environment. Al- tentially violent than the like skin cancer or AIDS, so matter
though people planning to be average person, although the that some of us are left to as if it wanted to
parents cannot control the opposite is true. Furthermore, languish in a private, hell- break it apart —
genetic traits which may be the opinions of people with like, internal torture cham- just a head
passed on to their children, mental illness are not taken ber of the mind. of cauliflower
new parents definitely can as seriously as those of the
control the emotional sur- “normal” population. Take, Although I do think about sometimes
roundings of their children’s for instance, the media’s on- taking my own life, I do not i think it has succeeded
family life and upbringing. and-off misuse of the word actually contemplate (there when i’m not
“schizophrenic,” a term for a is indeed a difference) such looking
And be not mistaken: it is too serious mental illness, to de- a drastic, selfish measure be- because inquiring minds
easy to ever-so-slightly treat scribe, for example, incon- cause of both fear of divine want to know
one’s infant in a psychologi- sistency in a politician’s punishment and the intoler- why i am crying
cally unhealthy manner election policy. This usually able fact that I, by my suicide, “I wish I knew.”
without even realizing the reveals how much consider- would leave behind my
fact and thus to leave the ation the media has for the loved-ones to grieve. these tears are not mine
child susceptible to dev- victims (including family
eloping, for example, a dys- members) of this illness. But always remember, people this grief is for me
functional thought process, with mental illness do not for something which
which can remain with him Furthermore, many people want to kill themselves; rath- has died
or her for life. For example, if with mental illness, although er, they simply want their will be reborn
my parents knew what in- officially considered “disa- mental anguish to cease. and will die again
credible suffering their al- bled,” are still perceived by Which is why often the only
lowance of my witness to their some in the “normal” com- consolation that many suffer- this grief is for me
incessant worrying would do munity as not really warrant- ing people have in life is their
to me as a little boy and as an ing social assistance; after all, belief that each day they en- but it is not mine 9
adult, they would very likely they could be digging ditch- dure and survive will not
have altered their behaviour es, right? But speaking for have to be repeated — every
in my proximity. myself, I always put in 110% day’s end is one (albeit small) — S.
effort when I’m doing my vol- step closer to that permanent, Consumer (Burnaby, BC)
These are compelling reasons unteer job (or any kind of job) blissful sleep and peace.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
Kelly’s Story — A Journey Beyond Grief
Donna
Murphy M y greatest joy has been in raising my only son, Kelly. At
the age of 16, Kelly sank into a depression, which end-
ed with his suicide on April 3, 1997. In this article, I have an
need so that they would not have to go through what we had
endured. To this end, I have kept my promise to my brother
and Kelly.
opportunity to tell my story, and trace the path of Kelly and my
journey through life, my continued recovery, and how I have It is fine to say that the world would be a better place because
become focused on my life mission to make a difference to Kelly Murphy lived, but I did not even know where to begin.
other children and their families through advocacy. I started to visit the professionals who worked with him and
listened. They told me what they believed in and what I could
April 3, 1997. That was the day that my path in life changed do to make a difference. One thing was very clear through it
forever. It was a sunny spring day, and I was running across all. The place that Kelly hated the most was the adult psychi-
Reprinted from the parking lot of my school when I was called back to take a atric unit; I was told that if I could influence a change in this
Lifenotes: A call from the RCMP. As a teacher of behaviour and conduct- area, it would be a great tribute to Kelly. This was the impetus
Suicide disordered children, I felt that behind the work that I did towards
photo artwork by Andrée Faucher, consumer
Prevention and it must surely involve one of my the realization of the Adolescent Psy-
Community former students. I was told that chiatric Unit at Surrey Memorial
Health there was an ongoing investi- Hospital (to open in 2001).
Newsletter gation and that I must stay at
( June 2000 the school. Another told me to teach, to help to
issue). enlighten people to childhood men-
As I waited for the officer to tal illness and to adolescent suicide,
arrive, I must admit that I was its prevalence in our society, and the
feeling unusually nervous. I great toll it takes on the lives of eve-
wondered if my son, Kelly, was ryday people. I knew that both these
in trouble, but then again I issues were very important to chil-
thought no, it’s one of my former People feeling depressed and hopeless enough to dren, and I knew that I could make a
students. Shortly after, the offic- consider suicide often see “no exit” out of their current difference in these areas. I also knew
er arrived at school and I escort- state. Below are some signs to watch out for. that this would become my life mis-
ed him into my principal’s office. sion: raising awareness of depression
We sat down and he looked at Warning Signs of Suicide and suicide in children and youth
me and said, “Donna, Kelly’s recent attempt or other form of self-harm and lobbying for education in the
talking or joking about suicide, what it would
dead.” Then he told me that my school system for suicide awareness
be like to die
handsome, intelligent, talented sudden risk-taking behaviour so that children would learn the facts
son had hanged himself that day deliberate self-harm, e.g., cutting one’s self about suicide. They would learn that
in his bedroom and that I should expressing hopelessness about the future they have other options, that there are
go home from school. To this day, withdrawal from friends, family or activities places to go for help when they are in
abuse of drugs or alcohol
it is so unbelievable that the hap- the depths of despair.
uncharacteristic self-neglect (hygiene)
py child I raised could fall into hears voices instructing them to do
such a depression as an adoles- something dangerous I knew that my great love and respect
cent that he had no recourse for a history of suicidal gestures or attempts for my son would lead me to help oth-
his pain but to opt out from this giving away treasured keepsakes ers and to make a difference. From
questioning own value and worth
life. I will never forget the face the start I have believed that I would
of that officer or how at that mo- To help someone who is suicidal, see www.metanoia.org/suicide/whattodo.htm work towards one small change, and
ment, the ground seemed to fall that when my job is done another will
out from under me, and I knew that things would never be the come along and take up the slack. Advocacy is a job that can be
same again. learned through experience, however difficult that experi-
ence may be. Had I not followed my heart in this belief, I
My boy — my only child, whom I loved more than anyone — would have devalued Kelly’s life.
gone, dead at the age of 18. I do not remember much else about
the next days as I said my last goodbyes to Kelly. However, I do What differences have I, an ordinary mom, made since Kelly’s
remember that my friends and family went into action as I death? Variety Club became involved through the 1998 Show
10 went through the process of burying my boy. My clearest mem- of Hearts when a vignette supporting adolescent mental health
ory of that time is when my youngest brother was overcome was developed, featuring Kelly and me. Through lobbying our
with grief, a grief so deep that even in my sorrow, my heart school district, a suicide awareness program — SPEAC —
went out to him. I took him in my arms and promised him that Suicide Prevention Education, Awareness, and Counseling was
Kelly’s death would not be in vain, that I would use my love to developed; every grade nine student in Surrey now receives
make a difference for other young people and their families in suicide awareness education. As well, my involvement in our
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
Manic Depression:
The Giver and Thief
Steve Noyes
I was asked to write some-
thing about my experience
of mood disorders. All right,
time is it?” he says and an-
swers his own question:
“Time to buy a watch.” His
people. He offers adventure,
achievement, transcendence,
and romance; he steals rea-
all over again. Then I realize
that I am he.
here it is: I hate my mood dis- laughter is not attractive, and son, security, real connection The watches glitter. They
order, manic depression. it lingers. He leaves, not both- with others, and tolerance. tick. What time is it? The time Steve has
ering to say goodbye, for we is forty, my life (statistically) published three
I picture this figure, Manic both know he’ll be back. Worst of all, having done his more than half over. He kicks books of poetry
Depression, standing on a damage he vanishes, leaving at some leaves, then turns to and fiction. He
snow-swept street corner, his I hate him because, in the me to blame, but not without mock me. lives in Victoria.
grin winsome and cruel, guise of giving me rare and his shadow imprinting my
opening his jacket. The inner precious gifts, he has time soul. It is as if he has the pow- Worse, other people seem to ____________
lining is decorated with his and time again stolen from er to transmigrate1, and when know him better than they Footnote
wares: locks of female hair, me. I have become aware of I have suffered from his grip, know me, or they think that I
1
the usual stimulants, foreign some of his tricks, the sneaky reeling from the effects — the am him, without grasping the the ability
attributed
language dictionaries, other way he will insert himself broken relationship, the lost complexity of the processes to souls to
beautifully bound books into my thoughts and desires, job — I find myself on a street involved, how many entan- move into
(usually of poetry), and many the clever way he has of com- corner, lonely, frightened, glements and retreats, the another
body
stolen wristwatches. “What ing between me and other needy, having to sell myself steepness of the slopes, the
community has brought a heightened awareness of child and me that they are impressed by how my family talks about
youth mental illness and suicide to every sector of society. My Kelly, as if his death had not been a suicide. We are not ashamed
message is clear: “If this has happened to me, it could happen of what he did, although all of us wish he had not made that
to you. If not to you through your children, then perhaps through decision for himself. We miss him, and rejoice in his sense of
a relative or the child of a friend.” humour, intelligence, and the funny things that he did while
he was here with us. It was my greatest privilege to have had
The day that Kelly died was the day that my heart broke forev- Kelly Murphy for my son — to have known him, to have loved
er. Up until that time, my road in life was so easy. The moment him, and to be able to raise him. This is where I get my strength
that the words were spoken — “Donna, Kelly’s dead” — the and focus.
road crumbled beneath my feet. I could not veer off in another
direction because there was no direction to go. So if I were to Through advocacy, I will continue to fight for changes for
continue to go on living, I would have to build a new road for families. I know that changes are coming and through lobby-
myself. To do this, I would have to rely upon the professionals, ing and fighting for what we know is right, we will bring
my family, friends, and my great love for Kelly. To go on, I depression and mental illness in children out into the open.
would rely on the insights that Kelly had given me and other This is Kelly’s contribution to society. This is why he lived on
gifts that I had been given through him. earth for his short while, and why I continue to fight. My
journey has just begun, and I don’t know where it will lead
The professionals I came to rely on were his adolescent psy- me, but I do know that it will be a journey that allows me to
chiatrist who offered me support in my quest, the people who continue to heal and helps others along the way.
worked at the Foundation Office at Surrey Memorial Hospital,
and Kelly’s counselor, Maria. Sometimes in life you are sent If you would like to get involved or support Donna’s formal
special gifts. So it was with Maria. Although she had worked advocacy efforts, you can reach her at (604) 596-9593.
with Kelly, she was truly sent to lead me on my journey through _______________
grief and into recovery. It was through her that I learned to Related Resources
pick up the pieces of my life, to go on living and continue to
For information about the Suicide Prevention Information and Resource
work towards acceptance. It was through my partner, Ron, Centre, to see Youth Suicide: A Framework for BC, and to see the newslet-
and through the great support of my family and friends that I ter Lifenotes, go to www.mheccu.ubc.ca
have been able to come to the spot in my life where I am now,
To see the draft suicide prevention strategy proposed by the US Surgeon
11
knowing that I am able to go on. I know that my life mission General, go to www.surgeongeneral.gov/library/mentalhealth/
will not end until I die and that Kelly’s life will make a differ-
ence to others. For more depression and suicide prevention information, consult the
Australian Early Intervention Initiative at ausienet.flinders.edu.au
And so my journey beyond grief continues. People have said to Night Falls Fast (Knopf, 1999) a book about suicide by Kay Redfield Jamison.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
chilling damp of field Jamison speaks in her He is watching; he is wait- someone called me “high-
the declivities. book A Fine Madness of be- ing. He will give me the op- functioning.” He knew I
ing granted access, through portunity to say some of this, would flinch and squirm.
He had this effect manic depression, of to blurt out what I really
on me because corners of her heart and think, in anger. It will mark Still, I have come to know him
his wares, after soul that were breath- me, set me apart and he will a little. I know what he hates,
all, were gor- taking, shocking her turn a childish circle, hands Manic Depression. He hates
geous and also with their beauty. I in his pockets, and walk off. involvement. He hates to be
seemed to match know what she’s talk- imperfect. He hates all the
my talents: a ing about. Once, inching my I once thought that by im- countless compromises and
skill with lan- way through an underpass in mersing myself in his sur- everyday tradeoffs of adult
guage, an en- total darkness near Tianan- roundings, the field of life. He hates to fit in, though
thusiasm for men Square in Beijing, sur- psychiatric disabilities, I this is what is expected.
studying foreign rounded and comforted by the could come to understand
languages, a ro- hundreds and hundreds of him, Manic Depression, and Above all he hates it when I
mantic, idealistic Chinese voices, making out work through the issues. It am satisfied and happy: his
fragments of their meaning has not worked out, just as fists knot in his pockets when
in their marvelous language, this article will neither fully he sees me laughing with oth-
I had a grasp, instantly, of the explain me, nor excuse me ers, playing with my daugh-
profound unity of human- from the consequences of my ter, working with a purpose,
kind. But one cannot live on decisions. relaxing.
nature, the usual attraction metaphor for long.
to the opposite sex. He per- The path I chose, of publicly “What’s the matter with
ceived these qualities and Too, the illness has given me educating others about mood you!” he cries on the street
traded me for them; I re- an empathic connection with disorders has led to a cul- corner. “Expand, transcend,
ceived an egotistic belief in other people’s frailty, the re- de-sac where the echoes of flee, run, soar, burn out, crash,
what is after all only a mod- alization that in meetings, in voices identifying me with huddle, suffer! The thrill! The
est literary gift, a deluded social exchanges, people talk my relentless nemesis and very thrill!” And he opens his
idea that I could penetrate around and around the one thus dismissing me are far too jacket to show me his trin-
and dissolve myself in other thing that they cannot and strong. At times I cannot dis- kets again and I see them
cultures without first under- will not say and how this re- tinguish those voices from my clearly: the locks of my true
standing my own, and a hab- fusal becomes a mask, a per- own self-judgments. It has loves grown grey and brittle,
it of infatuation with women sonality. But one cannot feed played out. He knew it would the books mildewed, the
whose real needs had noth- on this; it is not nourishing. play out, he knew it would print bleeding in black
ing to do with me. Still it irks me. My one gift bother me too much, involve wisps, the watches tarnished,
— to detect falsity. But it can- me to a punishing extent with stopped. He stamps his feet.
It is not that he has given me not be said. prejudices I was powerless to Shall we leave him there?
nothing, though. Kay Red- change. He loved it when
Speaking of Depression:
The Language of Mood Disorders
N
Nan Dickie ot long ago, I read an article where depression was tried every weapon at one time or another to relieve the symp-
described as a “dragon” and a “challenging foe” toms of my illness: intelligent reasoning, denial, spirituality,
that we “try to defeat with pharmacological weap- will power, medication, and meditation, to name a few.
ons.” I reacted strongly to this choice of terms and
Nan is a freelance to picturing mental illness in such a confrontational way. As a Sadly, none of these techniques had any long-lasting, positive
writer living in person with a 40-year history of unipolar mood disorder, I’d effect on the sorry state of any particular episode. These at-
Vancouver. like to offer a different perspective on the use of language for tempts did not help me conquer depression, nor make the
this illness. enemy retreat. In fact, at times these activities directed against
12 a foe seemed to fuel the fire of depression. I would end up
At one time I, too, thought of depression as a savage beast that feeling like a failure — a loser in this impossible fight. My
I must try to obliterate, as a red-hot dragon that I must flee feeling of self-worth would be brutally diminished, if not
from, or as a deadly demon that I must annihilate with drugs. demolished.
I came to realize, however, that if I tried to “kill” my illness, I
would have to kill myself. Over the course of many years, I In recent times, I have tried to view my episodes differently.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
Rather than using provocative words such as dragon and foe, I
now use words that, to me, acutely describe the intensity of
the experience, admitting to its awful reality, without giving
Dealing with
depression the power of an enemy. I now use terms such as
“the Black Pit” and the “the Ominous Presence.” Admittedly,
these are not exactly emotionally-stripped terms. However,
Past Trauma and
with “Black Pit,” I have had some success in wrapping de-
pression into a shape that has dimensions that are less than
infinite. With “Ominous Presence,” I acknowledge depres-
Mental Illness
Bill
sion’s omnipresent darkness without bestowing it with hate.
In recent times when I have become depressed, I have tried to
I n her book Trauma and Re-
covery, the award-winning
Associate Clinical Professor
World War 1 and World War
2, Vietnam vets were not wel-
comed home as heroes. We
Davidson
remind myself that I have a biochemical brain irregularity, of Psychiatry at the Harvard owe them our gratitude.
some faulty wiring that causes intolerable pain. (Given the Medical School, Judith Lewis Bill is a former
nature of the disorder, however, I am not able to believe these Herman, writes: “The conflict Terms such as “shell shock” child and youth
facts while I’m in an episode.) I try to hold on to the fact that between the will to deny hor- and “combat fatigue” come care worker,
being depressed is not my fault though it is my brain’s flaw. I rible events and the will to to us from WW1 and WW2. who worked
try to remember that the enormous gap in my life during an proclaim them aloud is the While the terms labeled the primarily in
episode is due to the synapses in my brain. central dialectic of psycho- same phenomenon, there residential
logical trauma.” To say that I wasn’t a solid base of profes- treatment in a
I’ve been learning to view the seeming monster as something was startled and intrigued to sional or public understand- variety of roles
I must unfortunately live with, respond to, and, I believe, re- read those words would be ing, nor were there support from 1967 to
spect. I no longer pretend that this illness isn’t with me. I must an understatement. I got services available for return- 1995. Since
“own” my body chemistry. I can’t go back to the proverbial goose bumps. ing combatants of these ear- 1995, he
blackboard to redesign myself and start again. Depression is lier wars. has been
in me and of me. I am trying to love myself in spite of this permanently
Definitions disabled with
hardship and the despair it brings. It seems that it is contra- While it may not compare
dictory to both love myself and to seek to defeat an enemy The clinical category “Post- with the trauma experienced bipolar
within at the same time. Traumatic Stress Disorder” by war veterans, psychologi- disorder. Bill
(PTSD) came into being not cal trauma occurs elsewhere self-publishes
Until medications are able to deal with every twist and turn of as a result of any initiative by and it debilitates. Post-trau- “Healing
depression, I know I must accept the painful effects of this mental health professionals matic phenomena likewise Normal.”
unwelcome, permanent resident in my body. I must accept the but because of advocacy by abound and it very often is (www.
periodic invasion of the symptoms that the illness brings me. veterans of the Vietnam War. not recognized. It is often cs.ualberta.ca/
It was the voices of returning unrecognized in mentally ill ~davidson/
I try to shed at least a modest amount of healing light on the combat veterans announcing persons, and its manifesta- billious)
irrepressible blackness. I attempt to counterbalance depres- their invisible psychological tions (or results) are all too
sion’s brute strength with my “weapons” of self-acceptance, injuries, loudly and persist- often swept into the particu-
patience, and trust in my close friends and family. ently, that compelled the lar psychiatric label of an in-
professional community to dividual, rather than being
No words will ever rid me of this illness. But after years of overcome its initial skepti- addressed for what they are.
searching for language to help me live with recurring depres- cism and to investigate their
sive illness, I have chosen to describe it with compassionate, proclamations more exhaus- ... The uncovering of the re-
yet poignant, language. tively. And unlike vets of ality of psychological trauma
A Map for the Journey: By Nan Dickie
Many compelling questions face those who live with recurring depression, including “How can I make sense
of the world?” and “How can I find meaning and live a productive, fulfilling life when so much of it is inter-
rupted by my episodic illness?” For all those difficult questions — individuals with depression, their families
and supporters, educators and counsellors, indeed all of us — A Map for the Journey: Living Meaningfully with
Recurring Depression has been written to help provide some answers.
This book doesn’t tell how to cure depressive illness. Neither does this book pretend that the illness is easy to manage. But with a
mix of stories, articles, and essays, it leads readers through a variety of scenarios and approaches, drawing them towards some
13
useful solutions and guidelines that will help better manage devastating depressive episodes. It offers gentle, practical suggestions.
A Map for the Journey will be published by AmericaHouse Incorporated, and will be available early next year in bookstores and on
the internet through amazon.com or ericahouse.com.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
in its many forms is not com- reputation. I was noted for my I am struggling and am be- in some cases it may take
plete. Our awareness of the ability to tolerate high levels ing carried back into the longer. I was invited to begin
extent of psychological trau- of stress. I lived by my well- ward. I am thrown into a small at the beginning of the trau-
ma in our midst today re- honed crisis intervention featureless locked room in matic incident in the hospi-
mains wanting. We are skills and my creativity. A the “Special Care Unit.” I wail tal and to describe fully what
perpetually poised at the cut- broad spectrum of people and flail on the door with my happened to me, on a mo-
ting edge of history. trusted me and respected me. fists. The three security ment-by-moment basis. The
A sense of humour was my guards are storming into the psychologist would at vari-
Excerpted from While psychological trauma calling card. Then I burned room now. They are holding ous points ask for greater de-
“Healing does not necessarily mean out on the job and was pro- me down and are struggling tail and would frequently ask
Normal”, life-long pain, we have pelled in just a few weeks to undo my belt and zipper, for emotions to be verbalized.
Issue No. 1. learned that recognition of into the eye of a world-class trying to get my jeans off. I It was that simple. Details
the trauma itself is essential manic break. My former life see two female nurses watch- that had been lost in my in-
in the path of liberation from ended at that point. ing. I am in terror. “I can do it ner turmoil became clear. My
post-traumatic phenomena. myself !” I am screaming. emotional states were hon-
My own recent history bears As I booked off work in a state They are letting me strip by oured. Intentions at each step
witness to these facts. of the most profound exhaus- myself. I am putting on hos- of the experience were clar-
tion that I can recall experi- pital pajamas. I am demand- ified and accepted fully.
encing, I did not anticipate ing to phone a lawyer.
Invisible Trauma
that within days I would be The traumatic incident de-
... A cascading sequence of face down on the asphalt out- One security guard snarls, briefing itself took about 45
inter-connecting events sus- side of the psychiatric ward “You don’t have that right! minutes. Having been repeat-
tained and nourished post- of our community hospital. This isn’t jail!” edly told to “let it go” or to
traumatic symptoms and “get on with your life” prior
these incessantly con- I self-admitted into the psy- From that moment, my life to this, the sense of relief and
taminated all aspects chiatric ward last night. I path was cast into a set of ex- release was palpable. The af-
of my life and the don’t feel comfortable here. I periences so horrible that I firmation, by a trauma spe-
could not have even imagined cialist, that I had indeed been
them in my prior life. There traumatized was like salve on
were four more hospitaliza- a festering sore. Even bipo-
tions in the two years follow- lars can experience trauma.
lives of all who are close to ing my involuntary committal, No kidding.
me. A key ingredient in this decide to check out, to go to a totaling over three months.
was that post-traumatic friend’s organic, country Since then I have not obsessed
symptoms were attributed to home in California. I want a My obsession with this event about that incident, though I
my dramatically emergent safe place. I am being in- and the security guard who can still get a mild heat on
mental illness. A profound formed, over the desk at the deliberately injured me, who for a few minutes if I think
sense of abandonment set in. nurse’s station, with patients, intimidated me during a sub- about it on purpose. I have
guests and cleaning staff sequent admission, was seen become more able to relieve
Being seen as mentally ill is present, that I am being by all, inside the hospital and some other traumas and epi-
not a lot of fun. The reactions committed. (A private and outside, as a manifestation sodes of abandonment on my
of those around me, though confidential communication of the bipolar disorder — own. Goes to show that symp-
well-intentioned, have some- would have been less provoc- likewise my persistent sense toms are not solely bipolar:
times been excruciatingly ative!) Now I am shocked, at of abandonment. bipolar, not bonkers... It is not
painful. The minimization peak rawness, and revved my intention to attack our lo-
and denial of the traumatic beyond control. I run. Finally, in the summer of cal psychiatric ward, a criti-
nature of some events has 1998, I tracked down a psy- cal care facility that saves
been devastating. This seems I make it as far as the park- chologist specializing in lives daily ... but I challenge
to have occurred out of a lack ade. Three security guards are post-traumatic recovery. We those in the field to recognize
of knowledge and awareness holding me face down. Some- had four sessions. The first post-traumatic phenomena
— which is why I have sug- one’s knee is in my kidneys. two were spent getting in and the impact of their pos-
gested that my experience Now both arms are being touch with one another. The sibly unnecessary invasive
takes place at the boundary wrenched behind my back. I third one was the actual trau- interventions.
of knowledge. am yelling at one security matic incident debriefing, ______________
14 guard to take it easy on my and the fourth one was a Related Resource
left shoulder, “It was broken wrap-up session.
Becoming Traumatized
last summer!” He is jerking McGorry, P., et al. (1991). “Post-
In my former life I was a hard- it up higher, re-injuring it. I In my case, a single session traumatic stress disorder following
recent onset psychosis.” Journal of
working child and youth care am escalating into hysteria. produced remarkably posi- Nervous and Mental Disorders,
worker. I enjoyed a positive tive results. I understand that 179: 253-258.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
experiences and perspectives
My Daughter is My Guardian Angel
Donna Lea
F
our months after my second child, a daughter, was I remember calling a friend to babysit my children while I ran
born, I strolled along the boardwalk of Steveston pier to the library. Looking up seasonal affective disorder, I found Zwick
with my husband, children, and my children’s god- on the exact opposite page a description of postpartum de-
parents. It was an unusually bright and warm early pression. I immediately knew this was my problem. I visited a
spring afternoon and I was in a particularly joyous mood. specialist the next day and started medications.
I had spent the last week with a specialist who told me I had You may not see my turnaround as a big deal. But I had been
manic depression in combination with seasonal affective dis- fighting my head demons for 20 years with very little proper
order. I also suffered a rarer form of seasonal affective disor- medical attention. As a nurse, I had denied their existence
der in which, instead of sleeping excessively, I developed was anything more than a fault in my upbringing and person-
insomnia with the shorter days and darker skies. The special- ality. There were no lab tests, CAT scans, X-rays, or ultra-
ist prescribed numerous drugs for me to take for the first two sounds that could tell me what I had. So, if it could not be
weeks, after which she would work out some maintenance measured, in my mind it had to be my fault.
prescription that I would take for the rest of my life. She fur-
ther recommended I not consider having any more children, My daughter changed my attitude. To take care of her the very
as I would suffer a severe breakdown should I have a third. best I could, I had to confront my illness head Donna is a
on, take whatever treatment and medica- registered nurse
Breastfeeding would have to stop, as the drugs I was tions I needed, and begin to understand who lives in
prescribed would pass into my breast milk and and trust how the “new me” thought Delta.
could affect my daughter. Why I was so joyous and felt. My daughter is truly my
certainly had nothing to do with how I was guardian angel — she survived a
physically feeling, because the drugs were problematic pregnancy so that I could
knocking me for a loop and I felt distinctly finally be taken care of. Her birth and
crappy. And I wasn’t particularly overjoyed her life have brought me my own
to be diagnosed as mentally ill. I am a regis- health.
tered nurse — mental illness isn’t an asset.
“Hi, my name is Donna, I’m manic today and I I wonder what is in store for my son and
will be taking care of you. ROLL OVER! And daughter as they grow up. I worry about
don’t worry if the injection isn’t in the right place the mental illness in my family that stretches
— my medication tends to make my eyesight blurry back at least two generations and encompasses
… Sir, where do you think you’re going?” more than half of all my living relatives. Howev-
er, I know now that with my decades of experience, along
No, I felt joyous because for the first time in more than 20 with my wisdom as a nurse, I trust my instincts and judgment
years, I finally learned why I have always felt different. Since when it comes to my children, their behaviour, and their idio-
the early ‘80s, I have been in and out of hospitals for break- syncrasies. And when I am uncertain, I do not hesitate to ask a
downs, seeing various psychiatrists and doctors. I suffered professional for answers.
emotional damage due to misdiagnosis, improper treatment,
personal denial, and guilt over broken relationships. For years, I feel joyous in ways some mothers will never know. I feel
I considered myself damaged goods and unworthy of love and extra good when I get through a stressful day at work or at Reprinted with
attention. home without feeling like I need to run away from life for a permission of
while. I pride myself when, instead of being completely furi- The Province
In March of 1993, I suffered a severe breakdown. It took until ous about some incident, I can get ticked, talk about it, and newspaper:
the end of that summer to gain enough confidence to return to laugh it off. I feel lucky to be able to share my illness with my April 4, 1999
a fraction of my normally energetic self. I married in Novem- present colleagues who neither judge nor condemn me. This (B4).
ber and by August of the next year I gave birth to my son and, has not been the case in most other nursing jobs I’ve had where
14 months later, my daughter. a code of silence still operates in the mental health arena. ...
I noticed no postpartum depression with my son, but my daugh- I feel happy when my husband notices things I now do with
ter’s early infancy was troubled. I had bled during my preg- ease, that two or three years ago I would not have mastered. I
nancy and, after fighting to keep her in my womb for 38 weeks, feel lucky that the medications give me almost no side effects
I finally gave birth. It was October, clouds were rolling in and and that my ability to create, concentrate, and poke fun at 15
the days were getting darker. Seasonal affective disorder was myself is sharper than ever. I am lucky to have my husband
plaguing me, but I tried to ride a high of new-baby happiness. and son. My daughter, though, will always be the one who
By February, I was riding high all right, but more due to ex- saved me from myself. No, I don’t spoil her more than my son.
haustion, tension, and weeks of little to no sleep. I was seri- I just remember that day at Steveston and what her life has
ously losing perspective. given me.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
ALTERNATIVES AND APPROACHES
In this section, we examine some of the alternatives and approaches that have helped people with mood disorders return to a normal life.
After looking at an overview of some of the most prominent approaches, we’ll take a closer look at the closely related approaches of cognitive
behavioural therapy (sometimes simply known as “cognitive therapy”) and psychoeducation, and then highlight the efforts being made by
people with mood disorders to educate themselves, through the internet, and within the self-help movement. Then we’ll focus in on emerging
approaches, in particular on early intervention and prevention of mood disorders in youth and adults.
Treatment of Depression
Raymond W. (This article is continued py (CBT) and interpersonal about antidepressants. Five recognition that depressed
Lam, MD, from page 5 although it can psychotherapy (IPT), electro- simple messages from the cli- people have negative thoughts
FRCPC be read on its own). convulsive therapy (ECT), nician to address some of and pessimistic thinking pat-
and light therapy. these mistaken beliefs have terns that contribute to their
M ajor depression is one
of the most treatable
conditions in medicine and
Antidepressants
been shown to greatly im-
prove compliance to antide-
pressant medications (see
depression. They may dwell
on the negative aspects and
discount the positive aspects
there are many effective Antidepressant medications Table 1 below). of a situation, and will “cata-
treatments available. Unfor- have been used for over 50 strophize” when trying to
tunately, many clinically de- years and there are over 20 problem-solve. These “cogni-
Psychotherapies
pressed people never get antidepressants currently tive distortions” result in
treated. There is still stigma available. The newer medi- Psychotherapies are also ef- learned maladaptive behav-
attached to having a mental cations (the Selective Sero- fective for treating clinical iours. In CBT, the depressed
disorder that prevents many tonin Reuptake Inhibitors, depression. There are many person learns to identify and
people from seeking help. starting with Prozac in 1988) different types of psychother- test these negative cognitions
Sometimes they do not rec- specifically affect different apy, but the best validated and learns practical strate-
ognize that their symptoms neurotransmitters in the treatments are “short-term” gies to break the negative
are treatable, and sometimes brain. Not only are they as psychotherapies consisting cycle. CBT involves keeping
their depression is unrecog- effective as the older medi- of 12 to 16 sessions, once or track of mood states and do-
nized by health profession- cations, they are safer and twice a week. Several stud- ing homework assignments
als. An Ontario study found have far fewer side effects. ies have shown that these to practice what is learned
that 90% of clinically de- Unfortunately, there is no psychotherapies are as effec- during the sessions. When
pressed people had seen a particular symptom or blood tive as medications for some Roger underwent CBT and
family physician within the test that allows us to deter- types of depression. Combi- learned to reverse his nega-
previous few months, but only mine which antidepressant is nation antidepressant and tive thinking pattern, his
50% received treatment for best for an individual patient. psychotherapy treatment mood improved and he be-
their depression. The other The choice of an antidepres- may be most beneficial for came more socially active.
50% were untreated; of these, sant is often based on the side people who are not respond-
half declined treatment due effects that may occur. Re- ing to one or the other. Un- Interpersonal psychotherapy
to stigma and the other half gardless, about 75% of peo- fortunately, there is still (IPT) is based on the recog-
were “living with it.” Even ple improve when they take limited access to these vali- nition that depression is
for the people receiving treat- antidepressants for clinical dated psychotherapies in the associated with significant
ment, only a minority was re- depression. For instance, Al- community. relationship problems that
ceiving effective treatment ice, the lawyer we met earli- either predate and contrib-
for depression. er in this issue of Visions, was Cognitive behavioural ther- ute to the illness, or that are
initially concerned about apy (CBT) is based on the consequences of having a
The objectives of treatment taking medications, but after
for depressive disorder are: using an antidepressant for a Table 1: Five Messages to Improve
1) to reduce and remove the couple weeks, started feeling Antidepressant Compliance
physical and psychological better. After two months, she ➊ Take the medications daily
symptoms of depression, 2) was feeling almost back to
to restore role function, and her usual self and able to re- ➋ The medications are not addictive
3) to prevent relapse and re- turn to full-time work.
currence of depression. In the ➌ Antidepressants do not work immediately, and it may take
two to four weeks before you start feeling better
past 20 years, a number of People are often uncertain
16 proven effective treatments about taking medications for ➍ Do not stop taking your medications without checking with
have been studied. These in- their depression. They may your doctor, even when you feel better
clude new antidepressant discontinue the medications
medications, specific focused before they experience any ➎ Mild side effects are common, especially at the beginning
of treatment, and will usually improve once your body gets
psychotherapies such as benefits because they have used to the medication
cognitive behavioural thera- unfounded negative beliefs
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
clinical depression. IPT starts best treatment. Contrary to the nations during her depression logical clock in the brain,
with a detailed assessment of usual negative public per- and was at high risk of sui- which may have difficulty
current and past relation- ception of “shock therapy,” cide, recovered completely adjusting to the changing
ships and then focuses on the modern ECT is a very safe and after receiving a course of light levels in the winter, or
most pressing problem such effective treatment for clini- ECT. ECT can be effective even 2) that light affects neuro-
as unresolved grief, social cal depression. During ECT, when antidepressants have transmitters like serotonin.
role disputes, social role tran- an electrical stimulus is ad- not worked, but it is an ex-
sitions, or social isolation. ministered to produce a sei- pensive treatment because it In summary, major depression
Practical strategies are then zure in the brain lasting 60 needs to be done in hospital. is a very common illness in
learned to deal with the prob- to 90 seconds. A general an- We recently reviewed ECT the general population and
lem relationship. Sarah found esthetic and muscle relaxants use at UBC Hospital. Of the health professionals will cer-
that IPT helped her to focus are used so patients are 130 patients treated over a tainly encounter many pa-
on her marital issues and asleep, and there is no mus- two-year period, 88% were tients who are clinically
family roles. Once these were cle response during the sei- rated as improved after ECT, depressed. Sarah, Alice, Rog-
addressed, her depression zure. Patients are carefully compared to only 12% who er and Maria illustrate the
improved. monitored during the proce- had little or no improvement. many faces of clinical depres-
dure and usually require Even though patients were sion that makes it challeng-
Some depressed patients im- about eight treatments over rated only a week after the ing to recognize. The causes
prove with antidepressants, the course of three or four ECT was completed, only 6% of major depression are not
others improve with psycho- weeks. There are some side of patients had troublesome known but there are likely
therapy, and still others need effects associated with ECT, memory disturbance. multiple biological and psy-
a combination of treatments in particular a temporary chosocial contributing fac-
to show most benefit. Again, short-term memory distur- Light therapy is another bio- tors. There are many effective
we cannot yet predict who bance for around the time logical treatment for people biological and psychological
will do best with which when patients are getting with winter depression, a treatments for depression,
treatment, and in some cases ECT. Studies using detailed form of Seasonal Affective and one can be optimistic that
it is a matter of personal neuropsychological tests Disorder (SAD). Light thera- patients with clinical depres-
preference whether to take found that six months after a py consists of sitting in front sion can feel better and re-
medications or to undergo course of ECT, there were no of a bright, fluorescent light cover to resume their normal
psychotherapy. intellectual or memory dif- box for about 30 minutes a lives.
ferences between those de- day, usually in the early morn-
pressed people who received ing. About two-thirds of pa- ______________
Other Biological Related Resources
ECT and those who did not. tients with SAD respond
Treatments
within a week or two to this Canadian Network for Mood and
There are, however, people This procedure can be a life- simple treatment, although Anxiety Treatment (CANMAT) at:
with severe or difficult-to- saving treatment for patients they need to continue light www.canmat.org
treat illnesses who clearly who are severely suicidal or treatment throughout the Depression Information, Education,
require biological treat- who have severe symptoms winter. We don’t know exact- and Resource Centre (DIRECT)
ments. For some of these pa- like psychosis. For example, ly how light therapy works, Toll-free Public Line: 1-888-557-
5051 (ext. 8000); Physician Line:
tients, electroconvulsive Maria, the 72-year-old wom- but the two main theories are: 1-888-557-5050 (ext. 800) or go
therapy (ECT) is often the an who was having halluci- 1) that light affects the bio- to www.fhs.mcmaster.ca/direct
Cognitive Therapy for Depression
B
etsy Jacobson of Brewster, NY, had grappled with “He saved my life,” Mrs. Jacobson said emphatically of her Jane E.
the crippling effects of depression and a deflated ego cognitive therapist. “At age 52, I was suddenly able to grow an Brody
almost her entire life. Reared in a domineering fam- ego. The difference in the therapeutic approach was dramat-
ily with a controlling father, she was unable to fulfill ic, and the relief I felt was immediate. Instead of dwelling on
her ambitions and use her talents as an actress. “I was sched- the negative, which the other therapists did, and which only
uled to fail at everything I did,” she recalled in an interview. ground my ego further into the ground, the cognitive thera-
Years of psychotherapy, including analysis, did nothing to pist treated me like a decent, respectable human being with
ease her psychic pain — nothing, that is, until she began valid feelings. A healthy sense of myself was drummed into 17
seeing a cognitive therapist. Cognitive therapy helps to im- my head while I learned how to change my thoughts and
prove people’s moods and behaviour by changing their faulty feelings.”
thinking, how they interpret events, and talk to themselves. It
guides them into thinking more accurately and realistically “In midlife, I finally became a free woman, a person with self-
and teaches them coping strategies to deal with problems. respect,” she continued. “I could start a brand-new life and do
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
things Betsy wanted to do, not just what my family wanted me anxiety attacks might automatically think, “I’m going to mess
to do.” Although Mrs. Jacobson returns to the therapist occa- up,” when taking an exam, participating in a social event, or
sionally for booster sessions, she said, she has acquired thera- being interviewed for a job. After failing such a challenge, the
peutic tools she can apply on her own, in case she finds herself person may conclude, again automatically, “I’m a loser.”
slipping into old patterns of thought or behaviour.
In therapy, the person is helped to recognize errors in thought,
Cognitive therapy is, in most cases, a short-term treatment which include exaggerating the sense of threat, anticipating
that can have long-term results. Typically, less than three disaster as the likely outcome, overgeneralizing from one neg-
months of weekly sessions can achieve therapeutic benefits ative experience, and ignoring times when things went well.
that may take years to accomplish with traditional talk thera-
py. That alone suggests that cognitive therapy will enjoy an Once damaging automatic thoughts are recognized, the per-
ever-widening role in the treatment of emotional disorders. son is helped to examine how realistic they are, consider al-
ternative explanations, imagine other outcomes, and realize
Many, if not most, people have no coverage for outpatient psy- that the symptoms of anxiety are not the prelude to a heart
chotherapy, and medical insurers and managed-care provid- attack or some other medical disaster.
ers who offer such benefits usually strictly limit their duration.
A similar approach is taken with depression. Dr. Judith S.
Furthermore, studies have shown that the results of cognitive Beck, Dr. Aaron Beck’s daughter and the current director of
therapy are long-lasting, with relapse rates far lower than the Beck Institute, said depressed patients have continual un-
with other modes of treatment, including psychiatric drugs. pleasant thoughts and that each such thought deepens the
Reprinted from And while medication is sometimes used, at least briefly, to depression. Generally, however, these thoughts are not based
an article in the relieve acute emotional disturbances and improve receptivity on facts and result in feelings of sadness far beyond what the
New York Times: to therapy, most patients can be spared the side effects of situation warrants.
August 21, drugs, which may include loss of libido (sex drive) and ina-
1996. bility to function sexually, gastrointestinal upsets, sleep dis- “Depressed persons make such mistakes over and over,” the
turbances, and difficulty concentrating. Becks have written. “In fact, they may misinterpret friendly
overtures as rejections. They tend to see the negative, rather
Mrs. Jacobson’s experience with cognitive therapy is hardly than the positive side of things. And they do not check to
unique. While no one approach to psychotherapy is suitable determine whether they may have made a mistake in inter-
for everyone, many thousands of patients have benefited from preting events.”
the strategies unique to cognitive therapy.
Rather than delve into the origins of such negativism, cogni-
In the 30-odd years since the approach was developed by Dr. tive therapists teach patients to identify their negative thoughts,
Aaron T. Beck, a world-renowned psychiatrist at the Beck Cent- recognize their mistaken nature and devise a corrective plan
er for Cognitive Therapy in Philadelphia, it has become the that leads to more positive assessments and an ability to deal
most scientifically tested form of psychotherapy. Independent more realistically with day-to-day problems. Dr. Frances M.
studies have shown that cognitive therapy is as effective as Christian, a clinical social worker and cognitive therapist at
medication and traditional psychotherapy in helping patients the Medical College of Virginia, explained: “Thoughts and
who suffer from depression, anxiety disorders (including panic beliefs have a lot to do with how people feel and behave. Early
attacks) and bulimia, according to professional analyses and a in life, people develop core beliefs about themselves and other
recent survey by Consumers Union. Cognitive therapy is also people and about how the world operates.” For one reason or
proving useful for patients with chronic or recur- another, some people develop negative core beliefs that dis-
ring pain. Mrs. Jacobson, for example, said the tort their interpretations of events and their predictions about
therapy had helped her enormously in coping their lives.
with the symptoms of fibromyal-
gia, chronic muscle pain. Christian said: “Because cognitive therapy focuses primarily
on the present and is problem-specific, patients generally are
A cognitive therapist directs not in therapy for a long time, and they learn coping skills
a patient’s attention to “auto- they can use throughout their lives. Much of the learning
matic” thoughts, the things takes place outside of the office. It’s a self-help approach, and
people say to them- the therapist acts like a coach, helping the patient acquire
selves that coping skills.”
18 Finding Help
The techniques of cognitive therapy can be applied in indi-
vidual counseling and in group, family and couples therapy.
result in un- The professionals trained in cognitive therapy include psy-
pleasant feelings. For chiatrists, psychologists and social workers.
example, someone prone to
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
Exporting the Treatment of Depression:
The Changeways Experience
I
n 1991, psychologists Dr. models have been offered in Randy
Peter McLean and Dr. Bill 40 communities across the Paterson,
Koch at UBC Hospital no- province (including multiple PhD
ticed a gap in Vancouver’s locations in the Lower Main-
mental health services. Peo- land). The Department of
ple receiving inpatient care Canadian Heritage has fund-
for major depression would ed the translation of our
eventually be discharged similar programs as part of low-up. Most participants materials for clients into Chi-
from hospital, but there were their own services. Initially, also consent to have us track nese, and Changeways is
few resources to help them the goal for the outreach their admissions to hospital now being offered in Canton-
in the next phase of their re- component was to form links over the next five years. It is ese by several agencies in the
covery. The doctors received with up to three agencies in hoped that by monitoring re- Lower Mainland. News of the
a grant from the BC govern- different regions of the prov- admissions we can more read- program has spread beyond Randy is
ment to test-run a group- ince. ily identify the predictors the borders of BC: training Coordinator
based psychoeducational and effective treatments of workshops have been provid- of the
program for depression. This Several years have now recurrent depression. ed in Alberta, Ontario, Prince Changeways
program, which began in passed, and Changeways has Edward Island, Yukon, Aus- Program.
1992, was designed to teach developed considerably. Our Once participants have been tralia, and Hong Kong. We
clients much of what was on-site program now consists through the Core Program, have records of over 4000 cli-
known about effective man- of a variety of elements. Cli- they have a variety of options. ents attending Changeways-
agement strategies for de- ents are referred from agen- They can sign on for our 6- based groups so far. Not bad
pression and to assist them in cies throughout the Lower session training in relaxation for a service with only three
putting this knowledge into Mainland and are seen once techniques. They can attend clinical staff, two of them
practice in their own lives. they are out of hospital. Upon an 8-session assertiveness half-time!
acceptance into the service training group. They can
A subsequent evaluation of they attend the Core Program, bring their family and friends Recently Changeways has
the first year of the program a seven-session group pro- to a single-evening lecture on become affiliated with the
revealed that 9% of program viding training in a variety depression recovery. They can Mental Health Evaluation and
participants were re-hospi- of lifestyle-based treatment also attend our monthly fol- Community Consultation
talized within 6 months — strategies for depression. low-up support program, Unit (MHECCU), which has
compared to 30% of non- ‘Changeways Continues.’ enabled the hiring of an ad-
participants in a comparison These include goal-setting Meetings of ‘Changeways ditional half-time psycholo-
group. As well, scores on techniques, ways of over- Continues’ provide a forum gist and an expansion of the
standard measures of depres- coming depressive “inertia,” for the sharing of experience outreach training program.
sion and related difficulties the roles of diet, exercise, and progress and typically Changeways now has its own
declined, and consumer feed- and sleep, ways of building include an educational web site designed mainly for
back was extremely positive. social contact and support, component. Some topics cov- mental health service provid-
Based on the re-hospitaliza- cognitive strategies for ered in the past year include ers (www.changeways.com)
tion data alone, it appeared dealing with the negative an update on medications, and is developing additional
to be cheaper to fund the pro- thinking so prevalent in “coming out” about depres- resource materials for men-
gram than not to fund it. depression, and relapse pre- sion to others, the role of tal health services through-
vention techniques. At ev- perfectionism in depression, out BC.
The program model was ac- ery session, participants set and anger management strat-
knowledged to be a success, achievable goals for them- egies.
and Changeways was made selves to carry out before the Changeways is: nurse Sarojni
Rajakumar, office manager Eliz-
an ongoing program of Van- next meeting. As part of the The outreach education com- abeth Eakin, psychologist Dave
couver Hospital and Health program they receive an 86- ponent of the program has Erickson, and coordinator/
Sciences Centre with a dual page manual of depression gone far beyond the initial psychologist Randy Paterson.
mandate: 1) to continue to coping techniques. goal of three outside agen-
Changeways currently offers four
training workshops for mental
19
offer the program to those re- cies. Staff from over 200 BC health providers: Group Treat-
cently discharged from inpa- Clients complete an exten- mental health services have ment of Depression, Relaxation
Skills, Assertiveness Training,
tient care for mood disorders, sive battery of psychological attended Changeways train- and Sexual Orientation Issues in
and 2) to teach providers at tests before and after the Core ing workshops, and pro- Healthcare. For information on
other agencies how to offer Program and at six-month fol- grams based directly on our workshops, call (604) 822-7153.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
Hope Through Knowledge:
www.mentalhealth.com
D
Robert r. Phillip Long was visiting Japan six years ago when for each mental disorder and look up medication side effects.
Winram he suddenly realized that there is a great variation in
care delivery and knowledge among countries, as well At this site, there are stories of recovery that include tips on
as among outlying districts within countries. At that time, he ways to overcome illness. The web site also offers a free book
had developed a computerized psychiatric diagnostic program written by a group of individuals suffering from schizophre-
Robert is the for doctors, but he thought this application could be broad- nia; another one on mood disorders is nearing completion.
Executive ened and made available to everyone. As the project grew,
Director of there was an obvious need to organize and make available Dr. Long is encouraged by the number of people visiting the
the Mood generalized information relating to the various diagnoses.
Disorders Huge amounts of data needed to be reviewed so that his site
Association would have the capacity to focus on the best information and
of BC. the most useful points of view.
Information on medications is clearly an important part of this
resource, but the value of client-centered treatment is cer-
tainly stressed. There is much more to “treatment” than the
abating of symptoms. Much work needs to be done so that
those who live with these illnesses can maximize their quality
of life. To this end, Dr. Long developed a quality of life ques-
tionnaire that can be printed as a graph. This allows individ-
uals to chart their progress on a weekly basis. In this way they
can see how they are doing and also identify their strengths site: there are over 6000 new visits a day to the home page
and weaknesses in combatting symptoms. with 110,000 pages downloaded a day. Approximately 12 mil-
lion people have visited since 1995.
The most popular feature of the site is the section that enables
a visitor to learn more about diagnoses for each mental illness. There is so much suffering that need not be. The pattern of
After a diagnosis is indicated, it is possible to access relevant mental illness is well documented by science; we know it can
treatment guidelines. These are drawn from psychiatric asso- be managed. We must communicate the good news about re-
ciations, particularly the Canadian and American ones. In this covery. There is no longer a need to hide conditions behind
way a person receives a type of second opinion that might be walls of stigma. Mental illness can be dealt with, and people
informative or thought provoking. The web site also allows can enjoy the happy fulfilled lives that they deserve. This site
the user to selectively retrieve the best research in the world is one of the tools toward that end.
The Role of Support Groups in
Recovery from Mood Disorders
Barbara
Bawlf E ver since I was diagnosed
with depression thirteen
years ago, I have found that
trist that alerted me to the
existence of what was then
called the Manic-Depres-
symptoms of depression sev-
enteen years previous to my
diagnosis, so it was a relief to
participants. We went around
in a circle, and everybody
talked about how they were
there is more to treatment and sive/Depressive Support finally get a name for my con- doing. After the process was
recovery than just medica- Group. He had seen an adver- dition and to know that there complete, I could feel my
tion. Supports in the commu- tisement for a meeting on the was treatment available. mood lifting substantially.
Barbara works nity such as family, friends, Rogers Cable community an- Here were a group of people
at CMHA and recreational facilities nouncements. Although the My first visit to the support who actually understood
20 BC Division have all helped, but the most doctor and I were unable to group proved a great boost to what it was like to feel the
in the area of beneficial resource for me continue our relationship, I my mental health. There way I felt. I didn’t have to ex-
consumer was the Mood Disorders Sup- will always be grateful for were about twenty people plain that my mood was not a
issues and peer port Group in Victoria. this information. sitting around a table in a big result of bad weather, a bro-
support. house in Esquimalt, owned ken relationship or grief. The
Ironically, it was a psychia- I had first experienced the by the mother of one of the people in the room would not
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○
ask stupid questions as to the
reason for my sadness. Fur-
thermore, the severity of the
Early Detection of
problems I heard about
seemed so much more seri-
ous than my own; strangely
Adolescent Depression
this helped immensely. If
D
these people could get up and epression is a common disorder which tends to begin in adolescence and which can Czesia
about while under the bur- recur in adulthood. The literature suggests that one in five adolescents in the commu- Fuks
den of such terrible pain, nity have emotional disturbance. Both boys and girls share increasing levels of depres- Geddes
then certainly I could. sion in puberty, but the rate of increase is faster in girls. Depression is significant because of its
association with harmful behaviours and mortality in all age groups.
I continued for many years,
on and off, to visit the sup- During adolescence, there is a rise in the onset of tobacco, alcohol and drug use, eating disor-
port group, whether I felt I ders, and mortality due to suicides. Young people who experience depression are at an in-
needed it or not, thinking that creased risk for engaging in these harmful behaviours. Adolescence, therefore, is a key time for
the very act of going would early detection of and early intervention in depression. Early intervention may do much to
be preventative. There were promote well-being and to prevent future suffering of affected individuals and their families.
people I met there that today It can also be cost-efficient by comparison to later intervention.
are still friends, so it also act-
ed as a social network. Adolescents experience remarkable physical and psychological changes. Their social environ-
ment allows increased independence and decision-making over many domains, including Czesia is an
The support group played a health. As they arrive at this age, they are better able to think and talk about health and illness Interdisciplinary
major role in my recovery by in terms of emotional, intellectual, and social aspects. They are also able to view their behav- PhD student at
giving me a safe place to iour as having an impact on their health. Adolescents’ mental health is influenced by their the University of
speak about my experiences concepts and reasoning regarding their social world. Cognitive development is deeply embed- British Columbia
with depression. I think for ded in adolescents’ perception of self, their identity in relationship to others, to society, and to (UBC). She is
most people that attend such the world. These aspects are critical in their ability to recognize signs of depression in them- based at the
groups, an environment is selves. Institute of
created that provides empa- Health Promotion
thy and education as well. Self-recognition of early signs of depression in adolescence is essential for early detection of Research. Her
We would often have guest depression. Studies show that about one in four young people perceive themselves as having research focuses
speakers, and people ex- emotional disorders. Their capacity and understanding of depression will affect their timely on adolescent
changed information on judgment to access appropriate support. mental health.
medications, doctors, and
alternative treatments. Adolescents’ help-seeking behaviour for depression and their attitude to seeking help from
doctors and counselors are also critical to early support and treatment for young people expe-
It is difficult when dealing riencing depression. Help-seeking may begin after one has recognized a problem and thinks it
with the symptoms of a mood is important enough to get help for it. Help-seeking for depression remains an unexplored
disorder to merely take a territory. The ability to recognize and assess one’s need for help is a skill influenced by matu-
handful of pills each day and rity and experience. Delays or inabilities to access care may be partially explained by young
expect to feel 100% better. people having difficulties in recognizing their own disturbances, by the severity of the distur-
My experience was that once bances, by adolescents’ coping resources, their attitudes and beliefs about seeking help, and
the symptoms had been treat- the visibility and acceptability of available services. Adolescents’ understanding of and atti-
ed and I felt physically more tude to depression will determine whether they think their symptoms are important and seri-
healthy, then I needed to go ous enough to seek help. What adolescents think and do about depression influences the
out and seek support in order service delivery structure.
to get back into society. The
support group offered me the Delays or incapacities in obtaining help and treatment nearly always have negative effects on
way in, guiding my path to the individuals experiencing depression, their families, and society as a whole. Current ap-
recovery. proaches to service provision are also likely to fail adolescents who recognize depression and
do not seek help. Adequate access to care is further compromised when adolescents who
Today, there are dozens of present to services do not fulfill clinical criteria for depression. Treatment for depression needs
support groups around BC. To to be more flexible and responsive to the needs of the affected individual. It should also be
find one near you, call the negotiated with those who require, but instinctively reject, services currently offered. 21
Mood Disorders Association
at (604) 873-0103 or the _____________
Mental Health Information Selected Reference
Line at (604) 669-7600 or Fuks Geddes, C. (1997). Adolescent depression: Recognition and help-seeking in a population based sample.
toll-free at 1-800-661-2121. Unpublished master’s thesis, University of Melbourne, Melbourne, Victoria, Australia.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
Early Detection of Bipolar Disorder
Eric
Macnaughton T he BC Early Intervention
study showed major prob-
lems with respect to the ear-
ple received an incorrect in-
itial diagnosis. From point of
first contact with the system,
treatment that often followed
from this.
polar illness seek help. In the
BC study, people with bipo-
lar illness usually sought
Eric is Policy ly detection and diagnosis of people with bipolar disor- While much of the attention help during the “down”
and Research people with bipolar illness. ders, on average, waited over in the early intervention field phase of their illness. The fi-
Coordinator at Once in contact with the twelve more years before fi- is presently focused on schiz- nal “trigger” leading them to
CMHA BC mental health system, over nally receiving the correct ophrenia or “early psycho- reach out was often an ina-
Division. half of the overall study sam- diagnosis and the improved sis,” research from around the bility to cope with their day-
world shows that long delays to-day life or a suicide
in correct identification are attempt, despite earlier peri-
a common occurrence for ods of mania or “hypomania”
Cross Cultural people with bipolar disorder.
As with schizophrenia, it is
likely that longer delays are
(less severe mania). In these
instances, details of the high
phase of the illness were usu-
Suicide Prevention associated with poorer treat-
ment outcome. Prominent re-
searchers argue that
ally not volunteered, and
were often seen as unrelated
to the illness by the
T
Michael J. his research report examines the concept of “self- misdiagnosis and person
Chandler continuity” and its role as a protective factor against mistreatment of bipo-
and suicide. First, we review the notions of personal and lar illness as “depres-
Christopher cultural continuity and their relevance to understanding sui- sion” may lead to an
Lalonde cide among First Nations youth. The central idea developed overuse of antidepres-
here is that, because to somehow count oneself as continuous sant medications, and
in time is essential to one’s identity, anyone whose identity is that these medica-
undermined by radical personal and cultural change is put at tions, in turn, may make the him or herself.
special risk of suicide, for the reason that they lose those fu- illness harder to deal with. Study participants of-
ture commitments that are necessary to guarantee appropri- ten commented that
ate care and concern for their own well-being. A number of similar studies they had seen their high
have shown an initial mis- phases as “who they
It is for just such reasons that adolescents and young adults diagnosis rate of between 40 were,” and often valued the
who are living through moments of especially dramatic change and 60% of people with bi- productivity and confidence
constitute such a high-risk group. This generalized period of polar disorder. It has also that came with them. As one
increased risk during adolescence can be made even more been reported that people person said, his high phase
acute within communities that lack a sense of cultural conti- may see three or four profes- was seen as “successful,
Excerpted from nuity, that might otherwise support the efforts of young per- sionals, typically over a peri- work-driven activity.”
Transcultural sons to develop practices which strengthen their sense of “a od upwards of ten years
Psychiatry at continual self.” before being recognized as It appeared that mental
www.mcgill.ca/ having bipolar illness. There health professionals, for their
Psychiatry/ We present data to demonstrate that, while certain First Na- is evidence that approxi- part, did not inquire in much
transcultural/ tions groups do in fact suffer dramatically elevated suicide mately 30% of cases of “ma- detail about the past fluctua-
tprr.html rates, such rates vary widely across British Columbia’s nearly jor depressive disorder” tions of moods or activity lev-
Volume 35 #2 200 Aboriginal groups: some communities show rates 800 within primary or specialist els in people who seemed to
( June 1998) times the national average, while in others suicide is essen- care settings actually fall into have simple depression. One
tially unknown. Finally, we demonstrate that these variable the bipolar “spectrum” of participant in the BC study,
incidence rates are strongly associated with the degree to disorders. Other research when asked by the research-
which British Columbia’s 196 bands are engaged in commu- shows that bipolar disorder er whether her depressive
nity practices that are indicators of a collective effort to reha- (with psychotic features) “crashes” were preceded by
bilitate and ensure the cultural continuity of these groups. may be incorrectly diagnosed extended periods of high ac-
Communities that have taken active steps to preserve and re- as schizophrenia and bipolar tivity (she answered yes), re-
habilitate their own cultures are shown to be those in which disorder with rapid cycling plied that no professional had
youth suicide rates are dramatically lower. or “mixed” states may be in- ever asked this question. She
22 _______________ correctly diagnosed as bor- remains diagnosed as “de-
Related Resources
derline personality disorder. pressed,” despite her own be-
The Mind of a Child, award-winning National Film Board documentary lief that her true diagnosis is
about youth suicide among First Nations communities. What is accounting for all of bipolar illness, and has been
Rouse, D. (1998). “Suicides Among Young Aboriginal Women in BC.” this? Part of the reason relates unsuccessful in her attempts
Lifenotes: A Suicide and Community Health Newsletter, 3: 12. to the reasons people with bi- to seek a second opinion.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
alternatives and approaches
Family Matters:
Other research highlights pression, actually fit a newly
this same basic pattern for proposed “Bipolar III” cate-
people who seek help for “de- gory. These people have a his-
pression”: previous “high”
periods are not seen by them
tory of “hyperthymia,” that is
a characteristic personality Supporting Parents
as related to their current rea-
son for seeking help and the
trait of being hard working,
cheerful, and energetic. In with Mood Disorders
relevant details are, there-
fore, not offered. This “cross
the BC Early Intervention
study, these were the people and Their Children
sectional” approach to assess- who typically described the
ment by mental health pro-
fessionals fails to uncover the
high energy prior to the on-
set of their illness as being
I work in an Intensive Family Program as a Family Counsel-
lor. I work with mothers, fathers, children, and relatives
who are often coping with a lot of stress. Some of the parents
Lyne
Brindamour
true picture of the illness. “just who I am,” or referred
have mood disorders and are often busy looking after their
to themselves as “always be-
own needs like medical appointments, bad and good days,
Another factor accounting for ing a hard worker.” Bipolar
side effects of medication, and community expectations.
lack of early identification is III is the designation of this
that knowledge about the re- “hyperthymic” state.
Parents with mood disorders are not only looking after their
lationship between bipolar
individual needs, but with the particular needs of their chil-
and unipolar de- The promise of this new ap-
dren as well. All children I work with are busy with their own Lyne
pression has proach to diagnosis is that the
stages of development and special emotional needs. Every fam- Brindamour
not emerged “high” side of the bipolar
ily I come in contact with is quite unique and has its own is an Intensive
until re- spectrum illnesses can be
vision of how they want their family to be together and its own Family
cently. recognized and dealt much
hopes about the future. My role is to stand back and listen to Counsellor at
earlier than is presently the
all family members. Usually I am told quite openly about how Family Services
case. With respect to medi-
my presence in the home could be most useful for the family. of the North
cation, this means more use
In one particular family, I was told that talking for one hour Shore, in North
of mood stabilizers, rather
about practical issues, such as meal suggestions, children, Vancouver.
Newly presented evidence than antidepressants alone, so
friendship, hobbies, is as (or even more) helpful as having a
is showing that in addition that the manic or hypomanic
formal counselling session. Another parent indicated that the
to hypomania (or Bipolar II), pole of the illness is control-
most supportive service she ever had was a homemaker twice
there is a continuum of disor- led. As noted above, inappro-
a week, so she could sleep and
ders between classic mania priate use of antidepressants
adjust to the new role of being
and strict unipolar depression. may worsen the illness, and
a parent with an infant.
The research also suggests may in fact trigger a manic
that the prevalence of disor- episode. The other side of the
Some parents mention that their
ders within the bipolar part equation is that the stressors
relationship with their chil-
of the spectrum may be as (e.g., overwork, sleep depri-
dren is difficult and want to ex-
high as 5% (rather than the vation, substance use, etc.)
plore new ways of interacting
traditionally-cited figure of that are so often part and par-
with them. A resource that they
1%), and that these disorders cel of the lifestyles of those
have found helpful is the work-
often masquerade as unipo- with a cyclothymic or hyper-
book Someone In My Family Has
lar depression, and are there- thymic temperament can be
fore under-recognized in seen for what they are and
A Mental Illness. This is an ed-
ucational workbook created for
clinical practice. kept in check.
children between ages seven
and fourteen. It was designed
People with Bipolar II, on
for counselors, other community mental health professionals,
close examination, often have ________________
and for parents and caregivers who wish to educate their chil-
a history (either prior to de- Selected References
dren about mental illness. To order Someone in My Family
velopment of their illness or
between episodes) of a per-
Akiskal, H. & Bowden, C. (2000). Has A Mental Illness, contact Family Services of the North
“The Spectrum of Bipolarity.” Sym- Shore at (604) 988-5281. You can also e-mail them at
sonality trait known as posium at American Psychiatric As-
sociation’s 153rd Annual Meeting. family@familyservices.bc.ca
“cyclothymia,” which is
______________
characterized by cyclical Cassano, G., Dell’Osso, L., et al. Related Resources
variations in energy level, (1999). “The bipolar spectrum: A
shifts from positive to nega- clinical reality in search of diag- For an article describing a program supporting children of parents with 23
nostic criteria and an assessment depression, see www.mhsource.com/put/p990957.html
tive mood, and a tendency to methodology.” Journal of Affective
daydream. Further, it is ar- Disorders, 54 (3): 319-328. All Together Now: How families are affected by depression and manic
gued, that a group of people depression, a booklet based on a cross-Canada research project examin-
Macnaughton, E. (1999). The BC ing the issues of families living with mood disorders. Features a special
who have been previously di- Early Intervention Study. CMHA, focus on the issues of adult children of parents with mood disorders. For
agnosed with unipolar de- BC Division. ordering information, see Health Canada’s web site at www.hc-sc.gc.ca
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
MOOD DISORDERS AND HEALTH ISSUES
In this section, we examine some of the key factors that affect the development and course of mood disorders. There are a number of things
that affect the possibility that someone may develop a mood disorder, or influence the eventual outcome of that condition. In this regard, there
has been much attention to factors such as age (youth are more at risk of depression, while the elderly appear to be more vulnerable to
succumbing to suicide), gender (women are twice as likely to develop depression), and to family background (those with a family history are
more likely to develop a mood disorder). However, in this section we’ll take a closer look at a finding that is just beginning to emerge: that is,
the close relationship between mood disorders and physical health issues such as lifestyle, stress, and other medical conditions.
Double Trouble:
Depression and Co-existing Medical Illnesses
C
Sarah onsider the following scenario: if you go to your doctor more likely to die within six months as their non-depressed
Hamid complaining of headaches, he or she is not likely to counterparts. Depression also seems to be an independent risk
announce “headache-itis” as the diagnosis and send factor for coronary heart disease in the older population. For
you on your way. Headaches are a sign. Yes, they can be signs those with the highest scores for depression, the risk for heart
of head trauma, tumour, or migraine, but more commonly they disease increased by 40% and the risk of death by 60% com-
are clues to other illnesses or environmental influences that pared with those with the lowest depression-symptom scores.
frequently exhibit headaches as a symptom. After all, who
hasn’t had an allergy headache, tension headache, hunger One theory behind the relationship is that depressed people
headache, eyestrain headache, or even a headache caused by make poor lifestyle choices — particularly around diet and
sleeping in on Saturday morning? Depression and other mood exercise — and that those with an existing heart condition
disturbances are exactly this complicated. may not be motivated to take heart medication regularly. An-
other theory suggests that stress is the common denominator
Sustained changes in mood can be signs of many things. They because stress, and the effects its hormones wreak on the body,
might indicate one of the various forms of clinical depression. has known links to both depression and heart problems.
Sarah is They could be related to a number of other medical conditions
Communications that have depressed mood as a common symptom. Or both of For more on this topic, consult the resources below or read the
Coordinator at these could be (coincidentally) happening at the same time. article on page 31.
CMHA BC In fact, the latter is probably more common than people real-
Division and ize. Data from the Mental Health Supplement to the 1994 Related Articles
Visions’ Ontario Health Survey shows that of people who had a mental “Depression and Heart Disease”
Production disorder in the past year, a full 72% also had one or more (www.suite101.com/article.cfm/depression/41789)
Editor. She is also physical health problems (see Figure 1). “Co-Occurrence of Depression with Heart Disease”
a consumer. (www.nimh.nih.gov/publicat/heart.cfm)
Below is a list of illnesses that might be implicated when you “Depression Can Break Your Heart”
go to a health care practitioner concerned about depressive (www.nimh.nih.gov/publicat/heartbreak.cfm)
symptoms. We’re not trying to scare you. It’s important to know
this not just for general education, but so that you make sure
Fig. 1: Mental and Physical Health Problems
you tell your doctor about other physical and environmental
influences in your life, and so that your doctor tests you for
some of these other illnesses if you show signs of depression.
Mental illness only
Knowing the full context of your health is important for mak-
5%
ing an accurate diagnosis and suggesting appropriate courses
of treatment — that responsibility is yours as much as it is Neither
your doctor’s. 31%
Physical
Depression and Heart Disease health
Depression often goes unrecognized and untreated when it problem
only
coincides with chronic illnesses like heart disease. Though
50%
depressed feelings can be a common reaction to both the diag- BOTH
nosis of heart disease and the lifestyle changes it demands, physical
24 depression that lasts several weeks or months is not the and mental
expected reaction and may in fact be clinical depression. health
problems
13%
Studies abound investigating the link between heart disease
(Data from Supplement to the 1994 Ontario
and depression. Montreal researchers have found that de-
Mental Health Survey. VI: pages 45-46.)
pressed patients who have had heart attacks are four times
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
Related Organizations BC Division: (604) 872-4400 (www.bc.cancer.ca)
Heart and Stroke Foundation of Canada Cancer Information Line: 1-888-939-3333
(www.heartandstroke.ca)
BC Head Office: (604) 736-4404 (www.hsf.bc.ca)
Toll-free: 1-888-HSF-INFO
Depression and Diabetes
BC Heart Health (www.heart-health.org) A diagnosis of diabetes is a painful thing to swallow at any
time in your life. And when you’re depressed about a major
life change and challenge, you’re probably less likely to exer-
Depression and Stroke
cise enough, eat responsibly, or take your medicine regularly
Even when the blood clot is not in your heart (heart attack) but — all of which feeds into a vicious cycle that makes both your
in your brain (stroke), there are similar risks for depression. diabetic and depressive conditions worse. Some research sug-
Research shows that about one-third of stroke survivors expe- gests that depression may not just be a complication of diabe-
rience depression after their stroke. Post-stroke depression tes but also a potential trigger. I can’t even begin to unravel
appears common, with women and people with more educa- this complicated relationship in such a short space. To learn
tion at higher risk. One major problem in diagnosing depres- more, read the article on page 28.
sion in this population is that some of the symptoms used to
classify depression can also be the direct result of brain dam- Related Articles
age resulting from the stroke. Going through a depression “Depression and Diabetes”
after something as life-changing as a stroke is understanda- (www.suite101.com/article.cfm/depression/42236)
ble but, even so, it should not be ignored. Researchers have “Diabetes, Depression, and Stress”
noted that post-stroke depression can have a significant im- (www.ncpamd.com/dmdepression.htm)
pact on people’s ability to recover. In studies, the depressed Goodnick, P. J. et al. (1995). “Treatment of depression in
group tend to repeatedly exhibit significantly lower daily liv- patients with diabetes mellitus.” Journal of Clinical
ing and activities ratings. Helping the depression can help Psychiatry, 56(4): 128-136.
rehabilitation. Related Organizations
Canadian Diabetes Association (www.diabetes.ca)
Related Articles BC Division: (604) 732-1331
“Co-Occurrence of Depression with Stroke” Toll-free: 1-800-665-6526
(www.nimh.nih.gov/publicat/stroke.cfm) Diabetes Resource Centre Information Line:
Paolucci, S. et al. (1999). “Post-stroke depression and its (604) 732-4636 or 1-800-268-4656
role in rehabilitation of inpatients.” Archives of Physical
Medicine and Rehabilitation, 80: 985-90.
Related Organizations (see previous section)
Depression and HIV
By now, I’ve probably driven home the point that people man-
aging life with a chronic medical condition are more likely to
Depression and Cancer
go through major depression than people who don’t have a
Like heart disease and stroke, cancer is a chronic illness that physical health problem. HIV and AIDS are no different than
can be accompanied by a major depression. Adapting to such heart disease, stroke, cancer, or diabetes in this respect. How-
a major negative life event can no doubt be stressful and de- ever, people living with HIV and depression have added
pressing and may take several months of adjustment; howev- challenges: they have to live with the double stigma of HIV
er, if after that time, symptoms of depression persist or worsen, and mental illness; their depressive symptoms might actually
there may be something else afoot that warrants investigation. be an early sign of other AIDS-related conditions; their sup-
Increased risk for depression is especially the case if the can- port networks are not always the healthiest; and certain pop-
cer is impeding your ability to go to work or carry out daily ulations living with HIV might more easily turn to substance
activities, interfering with your social activities or relation- abuse as a coping mechanism for depression. Since new treat-
ships, causing you severe fatigue or pain, or is a progressed or ments are being developed all the time that are extending the
relapsed cancer. Diagnosis and treatment of co-existing de- lives of people infected with HIV, there is every reason to
pression can bring many benefits: improved quality of life believe treating a co-existing clinical depression is worth it
and motivation, improved cooperation with doctors and treat- in the long run and can improve both a person’s quality of life
ments, and reduced pain since both naturally occurring and and motivation.
synthetic antidepressants also have a pain-blocking effect.
Related Articles
Related Articles “Depression and HIV”
Aass, N. et al. (1997). “Prevalence of anxiety and (www.nimh.nih.gov/publicat/hivdepression.cfm)
depression in cancer patients.” European Journal of “Depression and HIV: Assessment and Treatment” 25
Cancer, 33(10): 1597-604. (hivinsite.ucsf.edu/topics/mental_health/
“Co-Occurrence of Depression with Cancer” 2098.44d1.html)
(www.nimh.nih.gov/publicat/cancer.cfm) numerous articles on depression and HIV
Related Organizations (www.thebody.com/mental/stress.html#depression)
Canadian Cancer Society (www.cancer.ca)
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
Related Organizations to that small subgroup of people already at a genetic risk for
Canadian AIDS Society (www.cdnaids.ca) depression, symptoms of depression can be produced and/or
BC Persons with AIDS Society: (604) 681-2122 heightened by the allergic state. I find this a particular inter-
(www.bcpwa.org) esting finding because I have an inherited allergy and a ge-
netic risk for depression. The allergy and depression flared up
at the same time in my life. Until researching this article, I
Depression and Thyroid Disease never understood why.
If you go to your doctor complaining of depressive symptoms,
you will probably be asked, like I was, to undergo at least a Complementary medicine proponents also argue that depres-
couple of blood tests, one of which will gauge the level of sion can be a symptom of a food allergy. Talk to your doctor
thyroid hormones in your blood. A “hyper” or overactive thy- and naturopath further if you feel your bouts of depression are
roid can result in symptoms resembling anxiety. A “hypo” or connected to something in your diet (members of the grain
underactive thyroid is associated more with physical and men- family, egg whites, and molds are often the first suspects).
tal lethargy and fatigue. Therefore, when presented with a
case of depression, physicians will usually test for underlying Related Articles
hypothyroidism since most of these patients have some degree “Allergies and other forms of sensitivity”
of associated depression. According to the Thyroid Founda- (www.wellness.demon.co.uk/allbro~1.htm)
tion of America, since most cases of underactive thyroids be- “Asthma: The Mind-Body Connection”
gin after age 50, symptoms are often mistakenly linked to (www.ahealthyme.com/topic/depasthma)
aging, menopause, or regular depression. So get your thyroid Cuffel et al. (1999) “Economic consequences of comor-
examined. If the blood test does show you have a hormone bid depression, anxiety, and allergic rhinitis.” Psychoso-
deficiency, thyroid hormone therapy will often clear up the matics, 40(6): 491-496.
depressive symptoms. If not, the depression may have been “Depression and Allergies” (www.greatsmokieslab.com/
co-occurring, in which case you can and should still be treat- assessments/finddisease/depression/allergies.html)
ed for it as a separate illness. Marshall, P. S. (1993) “Allergy and depression: A
neurochemical threshold model of the relation between
Related Articles the illnesses.” Psychological Bulletin, 113(1): 23-43.
“Depression and Thyroid Disease” (thyroid.about.com/ Related Organizations
health/thyroid/library/weekly/aa120897.htm) Asthma Society of Canada (www.asthma.ca)
Related Organizations Allergy Asthma Information Association
Thyroid Foundation of Canada (cgi.cadvision.com/~allergy/aaia.html)
(home.ican.net/~thyroid/Canada.html) BC chapter: (250) 861-6590
BC chapter: (604) 266-0700 Toll-free: 1-877-500-2242
Depression and Asthma/Allergies Depression and Sexual Dysfunction
Emotional distress like depression or anxiety can bring on an Sexual health has a lot in common with mental health. Each
asthma attack. “When I see patients who are having severe can affect the other. Each can also, as we have seen so far, be
attacks, I always ask them, ‘What’s gone wrong in your life?’ ” affected by co-existing medical or psychological conditions.
says H. James Wedner, chief of allergy and immunology at When we experience sexual dysfunction, that is, our sexual
Washington University School of Medicine in St. Louis. In functioning is not quite right, depression can sometimes be
fact, researchers have found that severe depression and anxi- the culprit. After all, if you’re in a depressed state, you proba-
ety more than doubled a nonsmoker’s risk of developing asth- bly aren’t interested in much of anything — sex included.
ma. Why does this link exist? Several theories exist, all of Conversely, sexuality is such an important part of our self-
which may be true: depression weakens the immune system, worth and identity, that if you’re having problems in the bed-
thereby making it easier to react to allergens or develop a room, the sense of inadequacy or failure could spur on a bout
respiratory condition; depression changes levels of hormones of depression. Yet another cause: medications for many ill-
and brain chemicals which might set the stage for develop- nesses (including, but not limited to, depression itself) can
ment of asthma; and depressive states can make heart rate and impair sexual performance, so talk to your doctor and phar-
blood oxygen levels erratic, which might also increase the macist about side effects. For information on the sexual side
chances of a pending asthma attack. effects of psychiatric medications, see the issue of Visions on
Sexuality and Relationships. The good news is that many of
Asthma is not the only allergic state with a link to mood. Aller- the newer antidepressants, for example, have minimal or no
gic rhinitis (think hay-fever symptoms like a runny, stuffy sexual side effects.
26 nose, sneezing, and itchy eyes) is also associated with higher
rates of depression. Studies suggest a high rate of atopic dis- There’s also a fourth possibility: that another medical or psy-
order (a hay-fever-like allergy that is probably inherited) in chological illness could explain both the disturbances in mood
people with depression. One theory is that allergic reactions and sexual functioning. Underlying physical conditions that
can accentuate neurochemical activity imbalances in the nerv- can cause sexual problems include diabetes, heart disease,
ous system in a way similar to depression. When this happens neurological disorders, pelvic surgery or trauma, chronic dis-
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
ease like kidney or liver failure, hormonal imbalances, alco- salt, caffeine, and alcohol,
holism and drug abuse, or heavy smoking. Psychological causes and resisting cravings for
can include stress or anxiety from work, concern about poor junk food. Women also find
sexual performance, marital discord, unresolved sexual ori- relief from relaxation rituals,
entation, a previous traumatic sexual experience, and, of exercise, and sometimes
course, depression. Once the cause is sorted out, the good counselling. More severe cas-
news is that sexual problems are highly treatable. Talk to your es often require medication
doctor and be patient — especially if depression is the cause. such as antidepressants or
As my doctor once told me, “sexual side-effects are often the hormone therapies, in addi-
first symptom of depression to appear and the last to go away.” tion to these lifestyle tips.
Related Articles Related Articles
Dunn, K. M. et al. (1999). “Association of sexual “Premenstrual
problems with social, psychological, and physical Dysphoric Disorder”
problems in men and women: A cross sectional popula- (www.wellmother.com/
tion survey.” Journal of Epidemiology and Community pms.htm)
Health, 53(3): 144-148. “Pre-Menstrual
Ellery, D. “Medications and Sexual Problems.” (1999). Syndrome (PMS) or Pre-
Visions: BC’s Mental Health Journal, 8: 24-25. Menstrual Dysphoric
Michael, A. & O’Keane, V. (2000). “Sexual dysfunction Disorder (PMDD)”
in depression.” Human Psychopharmacology: Clinical (www.bcrmh.com/
and Experimental, 15(5): 337-345. disorders/pms.htm)
“Silence About Sexual Problems Can Hurt Relationships” Related Organizations
(www.ama-assn.org/insight/spec_con/patient/ Canadian Women’s Health Network (www.cwhn.ca)
pat039.htm) British Columbia Reproductive Mental Health Program:
Related Organizations (604) 875-3060 or (604) 875-2025 (www.bcrmh.com)
SIECCAN - Sex Information and Education Council of a family
Canada (www.sieccan.org) doctor and
Depression and Digestive Function
Health Canada: Sexual and Reproductive Health psychiatric
(www.hc-sc.gc.ca/hppb/srh/) Several studies have noticed an association between depres- professional
Sexual Health Network - Sexuality and Disability or sion, anxiety, and digestive disorders such as Irritable Bowel working
Illness (www.sexualhealth.com) Syndrome, Chrohn’s Disease, and ulcerative colitis. On the together
Canadian Urological Association ‘Links’ (www.cua.org) one hand, digestive disorders are chronic illnesses that affect
major aspects of a person’s daily routine, including their
emotional coping mechanisms. On the other hand, the excess
Depression and PMS release of stress hormones and digestive acids — common
One of the first questions my doctor asked me when I told him during bouts of depression and anxiety — is known to aggra-
I was depressed was “When and how often?” He asked me to vate digestive disorders. Making poor dietary choices when
keep a ‘depression diary’ for a month to see if there were any you’re in psychological distress may also play a role in upset-
patterns to my depression. It turned out not to be hormonal in ting the delicate balance of your intestinal network. Treating
my case — good thing too, because it had never occurred to me underlying depression and anxiety, as well as taking periodic
to think of my period as a potential cause. Unfortunately, a lot diet and stress management courses can go a long way to
of women make the opposite mistake and assume “it’s just providing gastrointestinal relief.
PMS” when in fact that’s only part of the story.
Related Articles
It is estimated that between 30 to 70% of women experience “Depression and Digestive Function”
pre-menstrual symptoms in the week leading up to their peri- (www.greatsmokieslab.com/assessments/finddisease/
od. About one in twenty of these women have symptoms se- depression/digestive_function.html)
vere enough that day-to-day functioning and relationships Heretik, A. et al. “Affective symptomatology in patients
are seriously affected; they are usually diagnosed with pre- with non-specific inflammatory intestinal disease.”
menstrual dysphoric disorder (PMDD) or what most people Ceska a Slovenska Psychiatrie, 90(2): 91-96.
refer to as PMS (pre-menstrual syndrome). PMDD/PMS is Hochstrasser, B. & Angst, J. (1996). “The Zurich study:
characterized by irritability, moodiness, crying spells, and Epidemiology of gastrointestinal complaints and
physical complaints like bloating, headaches, lethargy, and comorbidity with anxiety and depression.” European
changes in appetite. Even women who know they are going Archives of Psychiatry and Clinical Neuroscience, 27
through an ongoing clinical depression are not immune to the 246(5): 261-272.
effects of PMDD/PMS. Often, these women’s symptoms are Trikas, P. et al. (1999). “Core mental state in irritable
alleviated for much of the month and suddenly break through bowel syndrome.” Psychosomatic Medicine, 61(6): 781-88.
in the premenstrual phase of their cycle. For mild cases of Zubenko, G. S. et al. (1997). “Medical comorbidity in
PMDD/PMS, changes in diet can be helpful such as reducing elderly psychiatric inpatients.” Biological Psychiatry,
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
41(6): 724-736. (www.nimh.nih.gov/events/prbones.htm)
Related Organizations Michelson, D. et al. (1996). “Bone mineral density in
Chrohn’s and Colitis Foundation of Canada (www.ccfc.ca) women with depression.” New England Journal of
BC Chapter: (604) 685-1844; Toll-free: 1-888-685-1844 Medicine, 335(16): 1176-1181.
Schweiger, U. et al. (2000). “Low lumbar bone mineral
density in patients with major depression: Evidence of
Depression and Bone Loss
increased bone loss at follow-up.” American Journal of
According to a 1996 study by the National Institute of Mental Psychiatry, 157(1): 118-120.
Health, depression may increase a woman’s risk for broken Schweiger, U. et al. (1994). “Low lumbar bone mineral
bones. Mineral density (a key factor in bone strength) in the density in patients with major depression.” American
hip bones of women with a history of major depression was Journal of Psychiatry, 151(11): 1691-1693.
found to be 10 to 15% lower than normal for their age — so Reginster, J. Y. (1999) “Depressive vulnerability is not
low in fact that the researchers estimated the increased risk of an independent risk fact for osteoporosis in postmeno-
hip fracture was as much as 40% over 10 years. As one scien- pausal women.” Maturitas, 33(2): 133-137.
tist put it, “The affected women in this study, average age 41, Related Organizations
had bone loss equivalent to that of 70-year-old women. More Osteoporosis Society of Canada (www.osteoporosis.ca)
than a third faced a markedly increased risk of fracture.” OSTOP (Osteoporosis Society of BC): (604) 731-4997
Toll-free: 1-800-363-1933
One probable cause is excess secretion of the stress hormone
cortisol, which is known to cause bone loss and is a common
feature of some forms of depression. Supporting evidence _______________
General Resources
comes from studies which showed that women with past or
current depression do have higher amounts of cortisol in their Ontario Ministry of Health (1994). “Mental Disorders and Physical
urine and that higher amounts of cortisol in the urine are Health.” Ontario Health Survey: Mental Health Supplement. VI: 45-48.
associated with more fractures. So what about men? When “Depression Co-Occurring with General Medical Disorders”
both sexes were tested, bone loss was found to be greater for (www.nimh.nih.gov/publicat/co_oc.cfm)
men than for women. Among the implications of all these
“Depression Rates in People with Co-Existing Medical Illness”
research findings is that depression could be a significant (www.mentalhealthscreening.org/brochure/index.htm)
risk factor for developing osteoporosis at a relatively young age.
(Postmenopausal women do not appear to be at the same risk). “Depression in People with Chronic Illness”
(www.uncg.edu/edu/ericcass/depress/docs/chronic.htm)
Related Articles “The Unrecognized Link: Depression Co-Occurring with Medical Condi-
“Depression Linked to Bone Loss” tions” (www.nimh.gov/publicat/unrec.cfm)
Depression and Diabetes
Jasmeet
Bhullar B ecause of its prevalence,
depression has been re-
ferred to as the “common
the rate of recurrence. For
people with both conditions,
once depression has been rec-
is, having diabetes may in-
crease the likelihood of be-
coming depressed (or more
people with diabetes had an
increased likelihood of hav-
ing depression prior to devel-
cold” of psychiatric illness- ognized and treated, signifi- depressed); on the other hand, oping diabetes suggested a
es. While common in the cant improvements result in people who are depressed possible mechanism for how
general population, depres- the management of each ill- have a higher likelihood of depression can lead to dia-
sion is approximately three ness. In this article, we look developing diabetes (or wors- betes: pre-existing depres-
times more prevalent in further at the complex rela- ening this condition). In ei- sion may lead to inactivity
people with Type 2 diabetes tionship between these two ther case, the relationship and overeating, which may
(later onset diabetes), and health conditions. Quotes by involves many other biologi- result in obesity. Obesity,
possibly just as high for peo- Chris Laird, a person who lives cal and psychological factors, combined with a family
ple with Type 1 diabetes with depression and diabetes, as we’ll explain below. history of Type 2 diabetes,
(known as “insulin depend- will illustrate key points. then increases the risk of a
ent” diabetes or formerly person developing this kind
How Pre-existing
known as “juvenile diabe- of diabetes.
28 The Association Depression Can
tes”). It has been estimated
Between Depression Influence the
that the average person with Pre-existing depression can
and Diabetes Development and
diabetes has one episode of also worsen the course of di-
Course of Diabetes
depression per year. For peo- The relationship between abetes for a person who al-
ple with more serious de- depression and diabetes can While not proving a causal ready has it. In this scenario,
pression, diabetes increases occur in both directions: that link, one study showing that a lack of motivation — due to
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
depression — may lead to with diabetes can lead to forms of support for people brightens. Although treat-
poor self-care behaviours depression, or worsen a with depression. People with ment of depression cannot
such as obesity, smoking, al- pre-existing depression. diabetes are no exception, solely focus on diabetes man-
cohol abuse, and physical in- Dietary restrictions, and in fact may gain in- agement, improving diabetes Jasmeet is an
activity. These factors, in turn, blood-testing routines, creased benefit. Given their control will help people feel SFU student
may lead to poor diabetes hospitalization, and in- high vulnerability to relapse better emotionally, mentally, who recently
management and possible creased financial obliga- and given the emphasis of and physically. completed a
complications. tions of diabetes may psychotherapy on learning co-op placement
make people more prone skills for dealing with stress- Chris Laird explains his own at CMHA BC
As Chris Laird explains, to depression. ful situations, CBT can there- experience: “When I take my Division. She is
“When I’m depressed, I tend Managing diabetes can fore help prevent recurrences insulin adequately, my mood in the process of
to overeat, making it difficult be stressful. Stress can of depression. improves, I have more ener- completing a
to control my sugar levels…I cause hyperglycemia and gy, and I sleep better.” brochure on
eat more, feel worse, eat can also aggravate de- Antidepressants depression and
more, feel worse…” pression. Selective Serotonin Reuptake Lifestyle and self-help diabetes, a
Inhibitors (SSRIs) are the most measures joint-project
Figure 1 (below) illustrates commonly prescribed type of Exercising regularly, eating between CMHA
How Diabetes Can
the cyclical relationship be- antidepressant for people well-balanced meals, avoid- BC Division and
Influence the
tween the two conditions. with diabetes. SSRIs can help ing alcohol, and learning re- the BC/Yukon
Development and
decrease appetite, which may laxation techniques will not Division of the
Course of Depression
be beneficial for someone only help relieve your depres- Canadian
Treatments
Poor glucose control, an as- who has depression and is sion but will also help regain Diabetes
pect of diabetes, may be a Below we’ll discuss some of overeating, by helping to control of your diabetes. Feel- Association.
risk factor for depression. Re- the unique benefits (or risks) control blood glucose levels. ing or becoming isolated is a
search has shown that hyper- that various forms of treat- However, some antidepres- symptom of depression. As
glycemia (chronically high ment can offer to people with sants can have side effects difficult as it may be, people
blood sugar levels) can lead both diabetes and a mood dis- such as weight gain and vom- should talk to a family mem-
to biological changes in order. iting, which can negatively ber or friend about their feel-
mood, including feelings of affect glucose levels. It is im- ings. Joining a support group
fatigue and depression. Even Psychotherapy portant that frequent blood can help you meet others who
after depression is treated, As has been discussed else- testing is done to monitor any are going though similar ex-
hyperglycemia can bring on where in this journal, psycho- changes; that way, your phy- periences and can offer un-
new episodes of depression. logical treatments such as sician can make any neces- derstanding and support.
cognitive behavioural thera- sary changes to your insulin
There are a number of other py (CBT) and interpersonal dosage. Chris Laird agrees: “I do a lot
diabetes-related factors that therapy (IPT) — sometimes of volunteer work and try to
can impact depression: alone, and sometimes in com- For those taking additional learn new computer pro-
The emotional burden of bination with other forms of medications due to diabetes grams ... you have to keep
being newly diagnosed treatment — are effective complications, the possibili- yourself mentally and physi-
ty of drug interactions must cally active. This raises my
Fig. 1: The Cyclical Relationship Between be taken into account. It is self-esteem and helps with
Diabetes and Depression important that the psychia- my depression. When I feel
trist and/or other clinicians myself falling into a depres-
Depression are aware of all medical sive episode, I spend time
problems in order that the with people I feel comforta-
Lack of Worsened medication list can be re- ble with. It’s a rough world
Motivation Mood viewed, appropriate medica- out there…you need to be
tions can be prescribed, and around people you trust and
interactions can be moni- can talk to.”
Poor management Greater fatigue tored. ______________
of diabetes and lethargy Selected References:
Improving control of
High blood Visit www.intelihealth.com/IH/
blood sugar levels ihtIH/EMIHC000/333/333/
sugar levels
As previously mentioned, 286457.html
Depression affects diabetes self-care and unmanaged chronically and frequently 29
“Depression and Diabetes,” by
diabetes negatively affects depression. elevated sugar levels can lead John McManamy. Please see
to mood changes and depres- www.suite101.com/article.cfm/
sion. Once glucose levels are depression/42236
Adapted from: Polonsky, W. H. (1997). “Getting Up When You’re
within a normal range, peo- Refer to the list of depression and
Down.” Diabetes Self-Management, 14(1).
ple find that their mood diabetes articles on page 25.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
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30
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Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
Heart Disease and Depression:
Like Fish and Bicycle?
W
hen you saw the words ‘fish’ and ‘bicycle’ in risk factors for heart disease. Dramatic lifestyle changes, in Wolfgang
the same line, you probably failed to see a con- turn, can decrease the risk of mortality or recurrent heart Linden
nection between the two — and so you should. problems, or even lead to mild reversal of heart disease itself.
Heart disease — which is clearly seen as a However, anybody who has tried to make such changes — to
physical disease — and depression may at first glance seem to quit smoking, to start and maintain a regular exercise pro-
be as closely linked as the ‘fish’ and the ‘bicycle.’ The purpose gram, and shift from unhealthy eating to relatively low-fat,
of this article, of course, is to convince you that depression low-sugar, and high-fibre diets — knows how much determi- Wolfgang is a
and heart disease are very closely interlinked in a number of nation is needed to make them last. Depression, not surpris- Professor of
different ways. Further, it will show that they should be con- ingly, robs people of the motivation and ability to make such Psychology at
sidered together whether you’re interested in reducing the changes. The worst thing depressed cardiac patients can do to the University
health risks associated with depression or in the optimal treat- themselves is to refuse participation in a cardiac rehabilita- of British
ment and rehabilitation of heart disease. tion program because they feel too depressed. Our own re- Columbia.
search at St. Paul’s Hospital has shown that even without formal
therapy for depression, depressed cardiac patients who ac-
The Nature of the Relationship
tively participate in an exercise program also show major re-
Research evidence shows very consistently that depression is ductions in depression.
a frequent consequence after the diagnosis of heart disease.
Untreated depression carries a sixfold risk for another heart
How do you Recognize Depression in People
attack or other cardiac problem. Given that about 30% of peo-
Who Also Have Heart Problems?
ple with heart disease show clinically significant depression
after diagnosis and initial treatment, and given that heart dis- Depression should not be seen as an “all-or-nothing” phe-
ease remains the number one killer in Canada, this group nomenon like pregnancy, where one either is or isn’t preg-
represents a large number of people that deserves our atten- nant. Instead, depression needs to be seen as a variation on a
tion. continuous scale of mood that can range from being not at all
depressed to being severely depressed. Of course, the occa-
Interestingly, the degree of depression that people experi- sional brief period of low mood is a frequent occurrence in
ence is not a function of how physically sick they are, but is well-adjusted individuals and should not be confused with
much more a function of the person’s pre-existing personality depression. It is therefore necessary to carefully monitor chang-
and his or her current life circumstances. Even somebody who es in mood that may have occurred over time and test oneself
has relatively mild forms of heart disease can be really de- — or seek professional help — to determine whether there
pressed, and this depression can worsen the disease. have been major losses of interest in eating, work, relation-
ships and hobbies, especially if they extend over long periods.
In addition, there is strong evidence that pre-existing depres- In the case of heart disease, there is the additional problem
sion can contribute to the development of heart disease. One that individuals who’ve had a myocardial infarction (heart
suggested mechanism linking depression to the development attack) are inherently weak and possess low energy levels. It’s
of heart disease is an irregular pattern of heart activity known easy to confuse this relatively normal, hopefully transient,
as “suppressed variability.” Understanding this mechanism physical effect of the heart attack itself with actual depression.
is the current topic of intensive investigation, and we are
likely to learn more about depression and heart disease as we
Does Treatment Work?
continue work in this area.
On this topic, there is reason to be optimistic. Numerous stud-
In this context, it also makes sense to introduce another term ies of pharmacological and psychological treatments for
that describes a combination of feelings of low energy and depression, alone and in combination, have shown that de-
fatigue, both physical and emotional. Referred to as “Vital pression is very much treatable, with success rates of around
Exhaustion,” Dutch researchers have shown that it is related 80%. New classes of drugs — in particular the Selective Sero-
to, but not the same as depression in the psychiatric sense. tonin Reuptake Inhibitors — have relatively few and mild
Vital exhaustion appears to be a frequent early warning sign side effects, are very effective, and can be taken over a long
(or precursor) of pending heart problems. time without fear of creating addiction. Psychological thera-
py, in particular cognitive behavioural therapy (CBT), has also 31
One also needs to consider that depression may not just have a been shown to be effective, typically as effective as the best
direct effect on heart disease, but that it could affect other drugs. The improvements due to drug treatment tend to be
behaviours that will either help or hinder treatment and re- very quick, whereas it takes longer with psychological thera-
habilitation. There is overwhelming evidence that lack of phys- py. However, there is evidence that psychological therapies
ical fitness, smoking, and poor eating habits are all significant have better long-term effects than drugs because they also
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
give a sense of empowerment back to depressed individuals. ple can take advantage of psychological services provided with-
Especially in the case of severe depression, a combination of in general hospitals. Some may be fortunate to have an extend-
medication and psychological therapy may be more potent ed health benefit plan that covers psychological services outside
than either one alone. of the hospital. However, there still remains an access problem
for individuals in more remote geographical areas and/or those
To date, the studies of drug treatment for depressed cardiac without good health benefits packages.
patients show an equally good response rate, compared to
other depressed patients. In terms of psychological therapies, One way of reducing the problem of access is through the use
research is still in its early stages but the initial work suggests of self-help manuals which are available in low-cost paper-
that CBT for depression in cardiac patients is again just as back formats, and there have been a number studies showing
effective as it is in depressed patients overall. One concern considerable benefit. An additional option is to use materials
that people like me have — note that I am a clinical psychol- now available through the internet.
ogist — is that individuals may have difficulty accessing this ________________
option. Antidepressants are easily available through family Relevant Resources
physicians and cardiologists, where costs are covered by the
Burns, David. The Feeling Good Handbook. NY: Plenum Books.
Medical Services Plan. CBT, on the other hand, is an option
most likely provided by clinical psychologists, which is not For a collection of up-to-date scientific papers, see: Journal of Psychoso-
routinely covered by insurance carriers. At no extra cost, peo- matic Research, Special Issue, April/May 2000, Volume 48.
Lest We Forget About Lifestyle:
Neurotransmitters Respond to More Than Medication
Sarah
Hamid W hen I was in the throes of a severe episode of depres-
sion in 1996/97, one of the first things I realized, and
what I tried to convey to people when I started getting better
Food
Food usually makes us feel good. Anyone who has been upset
was this simple fact: mood disorders affect everything. They and cuddled up with a box of cookies knows full well that
affected what I ate, how I dressed, how much and how well I mood influences what food choices we make. Every mood from
slept, what I wrote poetry about, what music I listened to, who I anger, jubilation, or even just boredom can trigger poor eating
hung out with, how I saw the world. In fact, the precise reason choices and/or overeating. People with eating disorders like
depression can sometimes feel like a nauseating merry-go-round compulsive overeating or bulimia often binge on food as sol-
or a ditch you can’t get climb out of is because all these things ace because the food pushes back the bad feelings and can
that are affected by mood disorders, in turn, affect mood. temporarily make pain go away. People with depression can
similarly experience a change in appetite, either eating more
So if I chose to wear black and ugly clothes because I was than usual or else not feeling hungry and skipping meals.
feeling down, it’s a safe bet to say I felt black, ugly, and down Drastic changes in weight (in either direction) usually alter
that day. Now that’s not to say that if I had worn a yellow one’s appearance and also further contribute to a deepening
sunshiney sweater that the veil of depression would have lift- of depression.
ed, but life with depression can be a series of self-fulfilling
prophecies, where someone feels blah and so does blah things, Certain foods we eat can also influence depression. For exam-
and doing blah things helps to fuel and maintain feelings of ple, consider the following:
blahness. In short, lifestyle choices like nutrition, sleep, and proteins (e.g., as found in meat, fish, eggs, nuts) contain
exercise become both symptom and cause of mood disorders. more of a compound called tyrosine which makes us more
What you should be doing is exactly what you don’t feel like alert, more mentally energetic, and generally more “up”
doing because of your illness. Unfair? Maybe, but at least carbohydrates (as found in pastas, potatoes, breads/cere-
there is power in knowing day-to-day strategies that can help. als) contain more of a chemical called tryptophan and so
32 when eaten alone make us feel less stressed, less anxious,
mood influences our food choices, our level of (and more focused, and relaxed
motivation for) physical activity, and our quality of sleep contrary to social hype, alcohol is not a stimulant but a
depressant and so is clearly counterproductive to alleviat-
the food we eat or don’t eat, the exercise we do or don’t do, ing symptoms of depression. Unfortunately, still too many
and the sleep we do or don’t get influences our mood people turn to the bottle for self-medication
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
there are clear connections between mood and foods rich and because your body tells you that it needs it.
in folates (green leafy vegetables). For instance, folate
deficiency can be associated with depressive symptoms.
Sleep
Low folate levels have also been associated with poor re-
sponse to treatment (and vice-versa) Studies estimate that about 80% of depressed individuals have
new studies report that eating fish (which contain sleep problems as a result of their illness. Many of these prob-
“omega-3 fatty acids”) at least once a week or taking ome- lems may be associated with depression or depression medi-
ga-3 fatty acids as a supplement are a deterrent to depres- cations (always ask your doctor what your antidepressant side
sion and manic depression effects are). The spectrum of possible sleep problems include:
drinking water is thought to replenish the cells in both difficulty falling asleep
the body and the brain. waking up in the middle of the night and having difficul-
ty getting back to sleep
waking up too early in the morning
Exercise
waking up too late in the morning and feeling like nap-
As the fitness boom hit North America in the ’80s and ’90s, ping throughout the day
science backed up the hype by not only demonstrating the unusually brief periods of REM sleep (“rapid eye move-
benefits exercise provides for physical health, but for mental ment” or dream sleep)
health as well. Numerous studies have shown that aerobic unusually long periods of light sleep (stage 1 sleep)
exercise three times a week can be just as unusually brief periods of deep, restor-
effective as drug therapy for relieving ative sleep (stage 3 and 4 sleep)
symptoms of depression in the short term. links to suicidal behaviour (e.g., see
In September 2000, Duke University re- Agargun M.Y., Kara H., Solmaz M.
searchers went further and showed that (1997). “Sleep disturbances and suicidal
continued exercise greatly reduced the behaviour in patients with major
chances of depression returning (8% re- depression.” Journal of Clinical Psychi-
lapse rate) — better than the drug-only atry, 58(6): 249-51.)
group (38%) and the exercise-plus-drug
group (31%). For more on this study, go to According to an article in Medscape, 85%
www.eurekalert.org/releases/dumc- of people with depression report insom-
eoe091400.html nia (can’t sleep) and 10 to 15% complain
of hypersomnia (sleep too much). People
Exercise helps treat depression in six ways: with seasonal affective disorder are also
it releases endorphins, the body’s own more likely to report the latter: sleeping
morphine-like, mood-elevating, pain- too much during winter. On the other
relieving chemicals hand, people going through episodes of
it increases levels of serotonin mania may sleep 2 to 4 hours per night for
it reduces levels of the stress-depres- weeks, even though they say they feel rest-
sion hormone, cortisol, in the blood ed. Changes in sleep patterns can also spell
it helps clear the head and provide trouble. Sudden bouts of insomnia can in-
perspective on life crease risks of relapse for major depres-
it provides a feeling of accomplish- sion, and even one night of sleep
ment and purpose, which enhances self-esteem deprivation for people with manic depression can spur on a
for some exercises, it can return a depressed person to manic episode in a person previously in the depressive phase
certain social networks. of their illness.
For mild depression, exercise alone can often do the trick in Once you find the right treatment for your depression, prob-
alleviating symptoms. For moderate to severe depression, ex- lems with sleep — like other symptoms — should start to
ercise alone is rarely enough; that said, exercise is a great clear up. In the meantime, help the process along by maintain-
addition to any treatment program of medication and/or psy- ing a regular sleep-wake pattern, not napping during the day,
chotherapy and can often help kick recovery closer to 100%. not eating a large meal or exercising too late into the evening,
Yes, depression is a poor motivator, but fear of relapse can be limiting caffeine consumption, and keeping a log of sleep
a great motivator. Even with my medication at a constant, if a habits so you can track your sleep disturbances with changes
week goes by that I don’t get a chance to do something aerobic in medication or lifestyle. Be sure to tell your doctor about any
several times, I begin to feel worse. Exercise makes me feel major changes to your sleep pattern.
good. For those of you who suffer from depression, just pick 33
something you like to do and do it: walking the dog, garden-
Stress
ing, playing beach volleyball — whatever! For the first month,
just do it as if you’re taking medicine (it takes about a month I could not end this discussion of lifestyle influences on
for mood-elevating effects to kick in). Thereafter, if you’ve depression without at least briefly touching on the issue of
picked a fun activity, you’ll keep doing it because you like it stress. Stress not only directly affects depressive symptoms (stress
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
Depression and Stress:
Recent Stressful Events are the Most Powerful Risk
Factor for an Episode of Major Depression
John
McManamy S tress: it’s there in the en-
vironment, from any mi-
nor annoyance to an event
with CRF were found to ex-
hibit symptoms of depression,
from weight loss to deceased
likely to precipitate a flight- sexual activity. CRF is found
or-fight response, to the kind in higher concentrations in
of violation that imprints the the cerebrospinal fluid of
mind with severe trauma. It’s depressed patients, who also
also there in our biology in have greater numbers of CRF
Reprinted from the form of hormones that neurons. CRF is also found in
“McMan’s
Depression and
play a key role in mediating
our response to the outside
STOP areas of the brain and ap-
pears to be hyper-secreted
Bipolar Weekly,” world. These hormones also during depression.
an electronic act as middlemen in a host of
newsletter co-occurring illnesses. process is now considered neglect, physical and sexual In a just-published Emory
found at www. beyond dispute, with thera- abuse, and other forms of University study, four groups
suite101.com/ Each day, we are learning pies increasingly geared to- maltreatment on both adult of women were subjected to
cfm/depression ever more on the relationship ward neutralizing its vast emotional well-being and the stressful experience of
between stress and depres- destructive powers. Accord- brain function is now firmly speaking and performing
sion, and although there is a ing to the Surgeon General established for depression.” math tests in front of an au-
lot we still do not know, the in his landmark Report on dience, then blood samples
presence of stress as a major Mental Health: “The compel- A study of rhesus monkeys were taken and heart rates
role-player in the disease ling impact of past parental separated from their mothers measured. The researchers
found higher levels of the found that the women with a
stress hormone cortisol, as history of childhood abuse
well as ACTH (adrenocorti- and current major depression
Lest we forget about lifesytle (cont’d) cotropic hormone), and low- exhibited a more than six-
er cerebrospinal fluid levels fold greater ACTH response
hormones interact with our nervous systems and neurotrans- of noradrenaline (a brain to stress than those in the
mitter activity) but also has an indirect impact on depression. chemical which affects control groups.
“Feeling stressed” affects — guess what? — our eating, exer- mood). Twenty per cent of the
cise, and sleeping habits. And the vicious cycle starts again… infants from the same study According to the authors of
also reacted negatively to the study: “Severe stress ear-
But if you make better food choices (like calming carbohy- brief separations from their ly in life is associated with
drates), release muscle tension and anxiety with exercise, and mothers. persistent sensitization of the
try to get at least 8 hours of sleep, you may just help yourself pituitary-adrenal and auto-
feel less stressed. As someone once said, “stress is not a thing ACTH is a hormone that is part nomic stress response, which,
but what you feel about the thing.” This is why to some people, of a biological chain of events in turn, is likely related to an
a move to a different city is an exciting adventure and to others beginning when the neu- increased risk for adulthood
is a panic attack waiting to happen. It’s all about perspective. ropeptide CRF (corticotro- psychopathological condi-
pin-releasing factor) is tions.” (In other words, higher
One of the best things about depression — yes, there is a best produced by the hypothala- levels of stress early in life
thing — is that when you begin to recover (and you will), you mus, which activates the pi- make people more sensitive
will have a new perspective on life that hopefully stays with tuitary gland to increase the to stress later on, and there-
you. Depression forces you to look at big things and survive. release of ACTH, which then fore put them at increased
When you leave that gray bubble, all the things that people induces the adrenal gland to likelihood for developing de-
around you obsess and stress over begin to seem so petty. You release more cortisol. Medi- pression or another mental
34 were trying to get through the week and your girlfriends are cal researchers refer to the disorder.)
bickering about which boy they like, or your parents are argu- centre of this activity as the
ing about whose turn it is to do the dishes. Recover, but don’t hypothalamic-pituitary- The findings also indicate
ever forget the lessons depression can teach you because those adrenocortical (HPA) axis. that just as stress is likely to
lessons in self-preservation, patience, and perspective are the be a factor in causing depres-
greatest lifestyle impacts there are. Laboratory animals injected sion, depression can also
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
mood disorders and health issues
bring on stress. on groups of Albanians and
Serbians, and represent the poetry
Situational occurrences such first of their kind by virtue of
as marriage breakup or be- being conducted in the midst
reavement also loom large. A of war (or very soon after), in
study of major depression in the region where the conflict
twins found that recent occurred. In both studies,
stressful events were the survivors were given psychi-
most powerful risk factor for atric evaluations.
an episode of major depres- I found my brain in the centre of a planet,
sion. According to the study, In the first study, two-thirds Lying on a beach.
those with the lowest genet- of the Albanians surveyed “Choose a brain” they said,
ic risk of depression had only reported being deprived of So I looked and found it.
a 0.5% probability of depres- food and water, being in a It’s still tripping out,
sion that month, but this shot combat situation, and being So I cleaned it,
up to 6.2% with exposure to close to death. More than half Told it of its compounds,
severe stress. Those with the had been forced to flee their Broke it open and
highest genetic risk faced a homes and nearly 40% had Went speeding straight through the universe,
1.1% probability that sky- experienced at least eight Star bases, planets, asteroids, dead space,
rocketed to 14.6% when specific traumatic events, and
stress was present. from the murder of a family all kinds of spooky creatures,
member to rape. Just trying to adjust.
The HPA axis is working
overtime during these stress- Not surprisingly, the re- — Ken Hansen
ful situations, and new stud- searchers found a high rate Consumer (Sechelt, BC)
ies are beginning to suggest of psychiatric disorder
two areas of the brain re- amongst the survivors. What
sponsible for kicking this surprised them was how high
axis into action. The hippoc- this figure was — 43%, twice from heart disease to diabe- putting off things until the last
ampus and the amygdala are their expectations. Adopting tes to stroke to bone loss to minute. Ultimately, you may
two key regulatory centres less conservative criteria cancer. (Editor’s Note: see ar- have to lower your expecta-
located in the cerebral areas raised the incidence to 83.5%. ticle on page 24 for more). tions — from what you de-
of the brain, governing mem- Scientists have yet to uncov- mand of yourself to how clean
ory storage and emotions, re- A study of the Serbian popu- er the pathway from a neuro- you want your house to be.
spectively. Both are major lation remaining in Kosovo transmitter shutdown in the
nuclei of the limbic system, also surprised researchers, brain to a tumour or insulin One final piece of good news
which underlies emotions. as the findings virtually dysregulation elsewhere in is scientists are developing
According to the Surgeon matched those of the Albani- the body, but stress is invari- and testing a “CRF antago-
General’s Report: “Sensory ans. Apparently, war in all its ably fingered as the likely nist,” believed to be a decade
information enters the later- terrible horror pays no regard messenger. from market. For those 20 to
al amygdala, from which to which group suffers the 30% of the population who
processed information is most. It’s simply enough that Fortunately, our brain cir- don’t respond well to antide-
passed to the central nucle- stress hormones flood into the cuits are not permanently pressants, a drug that attacks
us, the major output nucleus system like refugees stream- welded into place. Our stress might do the trick.
of the amygdala. The central ing across the border. The thought patterns can be
nucleus projects, in turn, to stress hormones, of course, changed and cognitive ther- In the meantime, though, it
multiple brain systems in- are too dumb to know that the apy is especially useful in re- pays to manage your stress as
volved in the physiologic and war in Kosovo is the cause of structuring how we perceive if your life depended upon
behavioural responses to fear. their migration into the blood and react to stressful situa- the outcome — which, as we
Projections to different re- stream. Any war will do, as tions. With a bit of practice, are finding more and more
gions of the hypothalamus will any situation approxi- “It’s the end of the world!” every day, it does.
activate the sympathetic nerv- mating war. In this regard, we can be altered to “Let’s find a
ous system and induce the all represent a population at solution.”
release of stress hormones.” risk. ______________
Our lifestyle choices play an Related Resource 35
Two Centers for Disease Those hormones, it seems, essential role in nipping For the Surgeon General’s Report
Control studies recently ex- have plenty of places to go — stress in the bud. A diet of on Mental Health as it relates to
amined stress on large popu- the heart, the pancreas, the mood-buster foods is simply depression and stress, see
www.surgeongeneral.gov/li-
lations. The studies looked at bones, and so on. Depression tempting fate, as is irregular brary/mentalhealth/chapter4/
the effects of armed conflict has been linked to illnesses sleep, lack of exercise, and sec3_1.html#etiology
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
DEPRESSION, CREATIVITY, AND WORK
In this section, we examine the relationship between mood disorders and the world of work, considering the impact that each has on the
other. For some, becoming unable to cope at work is the “defining moment” when the illness announces its presence. It is not surprising, then,
that the eventual return to work, with the appropriate supports, is often a vital component of a person’s recovery. Despite its importance,
obstacles abound which make it harder for people to get back, and stay, within the world of work. Helping people overcome these barriers is
increasingly being seen as a key task for our mental health support programs. We’re also beginning to understand that mental illness may not
always be a detriment with respect to work, and that people with mood disorders and other mental illnesses, in fact, may be over-represented
in fields of creative endeavour. As a society, we need to see people with mental illnesses as positive, productive members of the work force,
regardless of how “work’ is defined.
My Incredible Voyage into
Madness — and Back
Scott The following excerpt describes the author’s The crunch came in May, during the comple-
Simmie initial experiences with manic depression tion of the Victory in Europe celebrations…The
and his relationship with his employer, the finale of the celebrations was to be a major
Canadian Broadcasting Corporation, when parade in Moscow, followed by a summit be-
his illness came to a head while he was pro- tween Boris Yeltsin and Bill Clinton…
ducer for the CBC’s Moscow Bureau.
On the final night, after writing the final script
T
his is how it happened. In January, of the summit, I snapped. I blew up at our Rus-
Scott is a 1995 — after working roughly 50 sian editor — not entirely without cause — and
journalist with days straight — our crew went to the correspondent who had hired her. There was
the Toronto Star. Chechnya to cover the war. Cover- certainly no violence or threat of violence. And
ing any serious conflict can certainly not be I did yell. And that’s not like me.
described as fun. But proximity to danger
carries with it a certain adrenaline… The correspondent phoned senior managers back
in Canada. I was telephoned from Toronto a day later and told
We filed powerful stories back to Canada. I returned to Mos- I was barred from the CBC’s Moscow office pending an inves-
cow exhausted. Exhausted, dirty, but fine. Sometime after that tigation. …Two managers, on the phone from Toronto, shared
Excerpted with war zone experience, though, and a stressful trip home which only its conclusion: “Your position has been terminated,” I
permission from followed it, something began to change. I began, quite simply, was told. There was no mention of my mental health, no men-
Out of Mind: An to feel better than normal. Significantly better… tion of my job performance, not even any mention of “the
Investigation into incident” …
Mental Health, In terms of my ability to work, things were fine. I could still
published by the write scripts, book satellite feeds, plan coverage — all the I was in shock. I had worked very hard for the CBC over the
Atkinson Founda- things a producer is supposed to do. But I was also more talk- years; my career was a huge part of my life. This was a crisis…
tion. This was ative than usual, more animated. I started chatting about busi-
Scott Simmie’s ness ideas, some of them slightly grandiose, with colleagues. I
special report was starting to feel powerful… Scott Simmie’s new book, The Last Taboo: A Survival Guide
based on to Mental Health Care in Canada, will be released by
research he did I sent notes, of which I am not proud, to management. … A McClelland & Stewart in January 2001. It is written as a
while holding the manager, who detected something amiss from afar, suggested guide both for consumer/survivors and family members to
1998 Atkinson I leave Moscow and return to a position in Canada. The notion navigating our “systems” — including lots of really good
Fellowship in seemed inconceivable. I was feeling, by this point, exception- advice from people who’ve been there. It will be available
Public Policy. al. He agreed to retain me in the post, subject to quarterly in hardcover at $32.99. The book has been endorsed by
reviews of my performance. I was, in effect, on probation, and CMHA National and the Mood Disorders Association of
despite this scrape with management, feeling great. Canada.
36
’ next issue is on “Spirituality and Mental Health.” If you have a story idea
and/or would like to contribute an article, please contact Eric
Macnaughton at (604) 688-3234 or toll-free at 1-800-555-8222.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
Returning to Work
R
ecovery’s benchmark: My position at work was usu- when I was coming out of cious. She insisted on begin- Robert
“Are you working?” ally held for me so I did not depression; I did make more ning the meeting by serving Winram
“What do you do?” need to face the interview mistakes. In an office setting tea. When I saw the teacup, I
How I dreaded those ques- process. It takes a great deal where people knew of my ill- froze; I knew my hand trem-
tions — along with “Where of courage to prepare for a job ness, if a file went missing, our was so bad I wouldn’t be
have you been?” After a mood interview in the best of times. they would say “Robert must able to pick up the cup. I used
disorder episode, especially When recovering from de- have the file. Where did you both hands and rattled the cup
if it involved hospitalization, pression or manic depression, put it?” I tried to offset this back to the saucer a couple
I felt my isolation acutely. with confidence at a low ebb, by making an extra effort at of times. It’s hard to inspire
People could understand my a job interview can be a for- work. I would arrive early confidence if you can’t even
social withdrawal, but there mula for re-hospitalization. and leave late, and be very manage a teacup.
was no explanation for not There was one time when my flexible regarding break
working. Aside from the fi- potential employer wanted to times. When people asked It was difficult to restart work
nancial considerations, for visit me in hospital. I said no, how I felt, I learned to say after each hospitalization. I
reasons of self-esteem I would it wasn’t necessary and I de- “great,” rather than list off was afraid that I’d forgotten
be desperate to be working
again at the first opportunity.
layed his requests that I be-
gin work, until I was certain
all the ways my life was not
working. I tried to keep my
everything, but once I was on
my feet and
”
At work, I would be able to I could both look and be ef- requests for special accom- talking, I’d re-
tell myself I was back on fective. I had just one chance modation to a minimum. member, and It’s hard to inspire
track, that in fact I had made to make a first impression, so my confidence confidence if you
a complete “recovery.” I I avoided contact with him Back in the ‘60s and ‘70s, I did return. At can’t even manage
would be able to dismiss or other than by phone until I was particularly secretive work, some a teacup.
”
diminish the seriousness of was sure of myself. about my condition. One of the people were
my need for hospitalization. ways that strategy rebounded very kind and
Presently, we are fortunate on me was at Junior Chamber
The very moment that I was that there are societies that of Commerce, where everyone
out of hospital, I would push help prepare a person for “the went to give blood. I couldn’t
myself to be at work again. interview.” For example, in go because I was taking so
Often, I returned to work at Vancouver, PACT (at (604) many medications. I was ac-
the first possible moment, 877-0033) helps with this, as cused of being selfish and
only to face a relapse. Even- well as with the preparation undermining the group’s bid
tually, I learned to prepare of a resume. To develop skills, for perfect attendance.
myself slowly before setting there are job training organ-
out to work. For example, I izations such as THEO ((604) I was in sales and once need-
would clean my apartment, 873-1758). ed to make a boardroom pres- considerate towards me.
hang pictures, maximizing in entation to new owners who Years ago, when I was strug-
every way the pleasantness of One question that sometimes had flown in from Europe. As gling to complete a number
my living space. I would care- appears on job applications I started the presentation, I of forms, one of my competi-
fully put my clothing in or- is “have you been hospital- began to perspire heavily. I tors seemed to understand
der, not buy new things, just ized or do you suffer from a was wearing a blue dress and helped me with the pa-
polish shoes, attend to sew- nervous disorder?” Each in- shirt that soon began to show perwork right in the custom-
ing repairs, wash and iron dividual needs to decide how the wetness. Rivers of perspi- er’s office. Only a few weeks
everything that I owned. I’d to answer, but usually people ration flowed down my face. ago, I met her at a mental
clean my car. This process answer no. Then, when they I had no handkerchief. I got health planning meeting.
might take several weeks, but have the job and prove them- the sale — but at what cost? Now in a new career, she con-
at the end, I would be sur- selves to be invaluable and One mistake I frequently fided to me that she suffered
rounded with a sense of or- the environment seems to be made was that I wouldn’t give from manic depression. My
der that helped me combat supportive, often people will myself enough time to drive story is one just one of many.
the illness. Then I would un- confide in their supervisor. to the client. I’d arrive a few ______________
dertake small jobs for family However, this can be risky. minutes late and breathless.
and friends. I had to be care- Competitiveness in the mar-
Related Resource
37
ful here, because I had such a ketplace means some people There was a situation I once See: www.ilo.org/public/english/
need to regain my self- will use any means to over- faced, where I had just been employment/skills/targets/disa-
esteem, I would quickly take take their fellow employees. released from hospital and I bility/publ/index.htm#UnpRep
There are two international studies
on too many projects. needed to call on a woman dealing with mental health and
My memory was not good who was particularly gra- workplace issues.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
Supported Competitive Employment
David
Wells C MHA BC Division has been selected to host a province-
wide initiative to address the need for supported compet-
itive employment opportunities for the mental health commu-
consumers to pursue competitive employment as an option.
“Increasing capacity through the province” includes the iden-
nity. This will be a three-year initiative that will address the tification and support of several supported competitive em-
current state of supported competitive employment through ployment programs and initiatives throughout the province,
three primary means: education and information dissemina- demonstrating the effectiveness of different models of serv-
tion, addressing government policy and regulations, and build- ice, and establishing templates that can be used in creating
ing increased capacity throughout the province. programs in all sizes of communities. Currently we are com-
pleting the first draft of the project plan as well as conducting
David “Education and information dissemination” includes profes- an environmental scan of all employment-related programs
is Provincial sional standards training and certification in psychosocial re- and services that exist for mental health consumers in BC.
Director habilitation to professionals and service providers, mental
of Supported health awareness education to the community, the creation of The success of this initiative will be measured through the
Employment a dynamic inventory of mental health resources, and channels increased levels of service and effectiveness of those services
at CMHA BC to disseminate this research and information. throughout the province, as well as the numbers of mental
Division. health consumers who access those services. Success in this
“Addressing government policy and regulations” includes area will only be fully realized if we can address the barriers
establishing a definitive understanding of how the existing that exist because of government policy and regulation.
policies and regulations work together and working collabo- Ultimately, the success of this initiative will be measured by
ratively with multiple provincial and federal ministries to the numbers of consumers who realize their vocational and
design policies and regulations that encourage mental health employment goals.
Some Facts About Work and Mental Illness
People with mental illness are far less likely to find work than other disabled people.
In Canada in 1991, 48% of people with disabilities were working and 8% were actively seeking work, whereas 90% of non-disabled
people in the labour force group were working. In the US, 85% of people with serious mental illness are unemployed.
According to the 1981 Canada Health Survey, 26.4% of people with mental disorders were working, 11.8% were inactive due to mental disorder
and 13.8% were inactive due to other reasons. This contrasts with people with other health problems, of whom 41.4% were working.
Work for people with mental illness tends to be sporadic, poorly paid, and lacking employee benefits.
A LARGE “HIDDEN” SEGMENT OF THE WORKFORCE HAS MENTAL ILLNESS
A major Canadian insurer reported a fourfold rise in claims related to psychiatric disability over a four year period.
A western long-term disability plan sponsor with a white-collar workforce reported that close to 50% of long-term disability claims are
psychiatric in nature.
Mind, the Mental Health Charity in England, surveyed people with a mental illness who were working: 52% said they had concealed their
psychiatric histories for fear of losing their jobs.
Ontario research has estimated that 8% of respondents in the workforce with a mental health problem experience two or more months a year
of decreased productivity. Unlike people with a physical health problem who tend to take time off, those with mental health problems go to
work but require greater effort to function.
The Canadian Health Survey in 1981 found that 2.9% of people who list work as their “Main Activity” have a mental disorder. These workers
represent 5.2% of people who work and have at least one health problem.
STIGMA AND LACK OF AWARENESS ARE MAIN REASONS WHY CONSUMERS ARE LESS LIKELY TO FIND WORK
30% of employers are uncertain how to create supportive environments.
A 1995 poll of 300 CEO’s in Fortune 500 companies found that 16% thought that hiring people with disabilities had a negative impact at work.
A US survey found that employers viewed those with mental health disabilities with more discomfort than other types of employees. Employers
who had experience with workers with mental health disabilities were more likely to hire such workers.
A survey of employers in Britain found that the obstacles to employing disabled people were mainly a lack of understanding about the capability
of disabled people, lack of knowledge about financial and technical assistance, and undifferentiated approaches to access and accommodation.
A US report states that 43% of federal employers and 22% of private employers cited negative attitudes of supervisors and co-workers toward
people with disabilities as a continuing barrier to employment and advancement.
WORK HAS TREMENDOUS BENEFITS FOR PEOPLE WITH MENTAL ILLNESS AND FOR HEALTH CARE COSTS
People with mental illness do want to work and are very capable of employment that requires intelligence and creativity.
38 People with serious mental illness report that they use hospital and crisis services less when they are working than they did when they
were not working.
People with mental illness who work have reduced frequency, duration, and intensity of their symptoms.
A study of people with severe, persistent mental illness found that those who were working reported that work provided a distraction from the
symptoms of their illness and contributed to better mental health.
Sidebar courtesy of CMHA Ontario Division. For the source of any or all of these statistics, please contact Sarah at CMHA BC Division (1-800-555-8222 or shamid@cmha-bc.org)
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work: book reviews
Swing Low [A LIFE] by Miriam Toews
M iriam Toews is a high-
ly skilled, intuitive
young Canadian writer who
the psychiatric ward before
deciding to end his life. Dur-
ing that span of time, Mel has
side someone else’s mind,
even someone as close to us
as a parent.
to say she and her sister didn’t Review by
recognize their father when Sarah Hamid
they became pupils in his
happens to have a window a plan to regain an under- class. Who was this man?
into her late father’s soul. standing of what is happen- Even though Mel’s manic de- Mel’s suicide would come not
Swing Low is that window. ing to him; after all, he says, pression is not always ‘front too long after his retirement
Adopting the voice of her fa- “I’m a methodical man so this and centre,’ some of the most from this life of teaching.
ther as he recounts his life, business re: losing my mind poignant episodes in the book
Miriam invites us to learn is frustrating.” His plan, and are when he becomes acute- Though Mel certainly comes
more about what mental ill- Miriam’s as well, is to “grad- ly self-aware of his condition. to life in the pages of Swing
ness really is when we can ually sneak up on my brain As a much-loved teacher at Low, the prologue reminds us
see it in the context of a by remembering the past and Elmdale Elementary for over that it is also a journey his
touching and accomplished then by seamlessly tying it forty years, he wishes for con- daughter is undertaking to
human life. into the present.” And so Mel trol in his mental health like better understand his life and
writes. In writing, he re- he had in his classroom: “I the cause of his death. She
Swing Low is an incredibly counts the trips and triumphs like to imagine that the teach- concludes that despite spec-
moving piece of creative bi- of his Prairie life, dipping er has left the room inside my ulation, “there’s really only
ography disguising itself as every now and then back into brain and every last neuron one answer [to his suicide]
an autobiography. It chroni- the present. The story he tells is out of its seat and acting and that is depression. A clin-
cles the life of the author’s is wonderfully woven with up. I will walk in and ask ical, profoundly inadequate
Stoddart, 2000;
father, Melvin Toews, in his anecdote, vivid portraits of them to take their seats, and word for deep despair.” The
191 pp.; $27.95
own words as imagined by members of the Toews fami- miraculously they will.” Mel only better description of de-
his youngest daughter. We ly, witty dialogue, and lots of seems to miraculously shoe- pression — the kind of de-
learn in the first few pages of humour. horn his manic episodes into pression that can even lead a
the book that Mel was diag- the 9-3 school day. Teaching religious family man like
nosed at seventeen with You don’t read Swing Low is his life and purpose. He is Mel to suicide — is one Mel
manic depression (bipolar thinking about suicide or energetic, focused, passion- offers us himself near the end
disorder) and took his own about manic depression. You ate, and successful there. At of the book: “There are no
life at sixty-two. The reader read it just thinking about home, he lets the mania go windows within the dark
meets Mel in Bethesda Hos- Mel, about life, about its joys and his family only gets to see house of depression through
pital in his hometown of and its vulnerabilities, about his quiet depression. Miriam which to see others, only mir-
Steinbach, Manitoba where how little we can really know remembers one entire year he rors,” says Mel. And broken
he spends seventeen days in about what is happening in- didn’t speak at all. Needless mirrors can be dangerous.
Touched with Fire: Manic Depressive Illness and
the Artistic Temperament
by Kay Redfield Jamison
is depressed, suicidal, or fects of lithium and other Review by
F irst published in 1993,
Touched with Fire is
an authoritative — albeit
manic. “It is, rather, that a
greatly disproportionate
ron, shorter sections on Ten-
nyson, Melville, Coleridge,
Woolfe, Hemingway, Van
drugs on artistic output) and
at a societal level (genetics).
Chris Balma
fragmented — look at the re- number of them are; that the Gogh, and quotes — both lit-
lationship between manic- manic-depressive and artis- erary and personal — from This will appeal to anyone
depressive illness and artistic tic temperaments are, in dozens of other prominent interested in bipolar disorder,
inspiration. Piecing together many ways, overlapping ones; artists who lived with bipo- and art buffs, particularly the
clinical studies, biographic and that the two tempera- lar illness. Jamison correlates literary crowd (regardless of
notes, family histories, quotes ments are causally related to seasonal variations in artistic familiarity with mental ill-
and anecdotes, Kay Redfield one another.” Jamison is also productivity with the onset or ness). And a note to those with
Jamison advances a strong careful not to romanticize remission of the illness and more than a casual interest:
case for linking the two tem- the topic, emphasizing that also illuminates the long fam- many of the study sample siz-
The Free Press,
peraments. manic-depressive artists ex- ily history of mental illness in es presented by Jamison are
1993; 358 pp.
pend a terrible amount of many of the artists studied. necessarily small and some 39
Jamison, professor of psychi- energy dealing with the ill- methodology is, as she admits,
atry at The Johns Hopkins ness’s cycles, not simply rid- Finally, Touched with Fire far from ideal. There are also Chris is a
University School of Medi- ing them in inspired fury or deals with the issues sur- likely to be more current sta- writer and
cine, stresses that not every melancholic bliss. Included rounding treatment, both on tistics available since the last graduate student
writer, painter or composer is a detailed chapter on By- an individual basis (the ef- edition was put out in 1996. in Vancouver.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
Channeling into Creativity:
April Porter’s Search for Answers
T he delivery room nurse handed the squalling, squirming
baby to Aileen Porter. “You’re going to have trouble with
this one,” she said. ...
and the street drugs that made her feel better — at least numb
— were readily available. ... Throughout it all, April never
stopped looking for a diagnosis. She was, at various times, told
she had an eating disorder, OCD (obsessive-compulsive dis-
She remembers starting school when they lived at Willow order), or that she was spoiled and just wasn’t trying hard
Flats (“population 13”) near Chetwynd, BC. ... The home enough.
Excerpted from movies show the kids running and jumping and playing, al-
Heroes Next Door ways in motion. ... The movies also show April’s seventh birth- Her twenties and half of her thirties passed in a kind of blur.
by Gerald day party. Amidst the clowning and laughing and fun, she “I’d gone everywhere I could,” she says, “taken a series of
Haslam. suddenly felt awful — not sick, but scared, confused, and medications, but nothing really seemed to help.” Finally, at
angry. “It was just too much for me,” she recalls. She started 37, after more than 20 years of torment, she ended up at St.
Heroes Next Door hitting her head. But, she says, “I learned to push those feel- Paul’s Hospital. She was diagnosed: rapid-cycling bipolar II
profiles nominees ings down.” ... In Grade 9, living in Prince Rupert, she disorder. “My diagnosis was not a death sentence,” she says
of the first annual “discovered boys and booze.” She was outgoing, to say the now, “but a gift. Finally, the monster had a name.”...
Courage to Come least. “What saved me in high school,” she says, “was drama
Back Awards. You and music and my family supporting me in them.” Since June 1993, April Porter has been clean and sober. In
can order the 1995, channeling her creative side into works of art, she joined
book for $19.95 They moved back to the Vancouver area, where April started Gallery Gachet, the artists’ cooperative funded as an agency
by contacting the suffering from migraine headaches and deep depression. “I of the Vancouver Community Mental Health Services. She has
Coast Foundation would stay up all night,” she remembers. “I had a fear of displayed her work at the gallery, served as a volunteer, start-
Society. You can dying in my sleep.” She was scared a lot of the time. “I had,” ed working part-time in 1996, and is now employed there
phone them at she says, “no language with which to communicate. All I knew full-time as promotions director. (Editor’s Note: April has
(604) 872-3502; was that I was scared. But I’d had a good childhood in a loving recently accepted a position with CMHA Vancouver-Burnaby
write them at family; I asked myself: What right do I have to feel upset?” branch developing consumer-run business initiatives.) “It’s
293 East 11th my second family,” April says, “a place where I can express
Ave., Vancouver, Her mother, April remembers, “felt helpless and powerless.” myself artistically and put my administration skills to good
BC, V5T 2C4; or Aileen Porter wrote to a friend, saying, “There’s something use.” She had her first solo exhibition in 1998.
order the book wrong with April and she can’t get help.” “I doctor-shopped,”
online at www. April says now. One doctor bawled her out; another prescribed She works hard as an advocate for people with mental illness,
coastfoundation. anti-depressants. ... In her later high school years, very much serving on committees, helping others get access to services,
com into drama and music, she used both drugs and alcohol. giving advice. ... April considers that her continued recovery
depends in part on giving back to the community. Which she
At 18, April left home and enrolled in an English course at does, and then some. At Gallery Gachet, she organizes and
Douglas College. She made it through two semesters but fell publicizes not only the shows, but workshops and other events
apart — “just lost it” — during the third. ... She got into the featuring expert guests discussing a variety of topics from
world of rock-and-roll, working behind the scenes, organiz- stretch massage to anger management…
ing and promoting bands for concerts and nightclub appear-
ances, and working in theatre and special events. Those kinds April credits her “very supportive family and the world’s best
of jobs suited her two ways: it was episodic work she could do girlfriends” for the turnaround in her own life. And they, no
when she was up and take a break from when she was down, doubt, credit her.
Tattooing the World with Desire:
Depression, Disillusionment,
40 and the Psychology of Commerce
Bill Pope
I ’ve had bouts of depression
since I was a teen, but it
was the grinding responsi-
more out of touch with the
natural order.
The pressures involved in
making a living for someone
else — by marketing, pack-
comes commodity. You can’t
fight demographics. God (or
the devil) is in the details,
bilities of adult living that I worked for some years in aging, advertising — got and money drives the ma-
caused me to feel more and advertising, doing artwork. heavy. All the universe be- chine.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
My small family is extended es in self-esteem, drug and
now to the mental health com- alcohol courses offered by the
munity, by whom I feel proud city, and attending AA (Alco-
to be accepted. holics Anonymous) have all
aided my recovery. Being ac-
Being an alcoholic is a big- tive in volunteering helps me
ger stigma to me than having feel useful and makes me
depression. Learning to do want to work smarter. Bill is an artist
things sober is a struggle and and consumer
some of the pieces seem lost. I still get angry at the pomp- living in
My old friends who knew me ous media, but being away Vancouver. He
when I drank just thought from it helped me to develop a has provided
of me as morose, and some perspective. A sense of hu- numerous
can’t understand that many mour helps. There is life pieces of
depressives drink to elevate after tattooing the world with artwork for
their mood, vainly searching desire. I draw, paint, and write use in Visions
for a self-treatment for their for myself now, so I’m putting including the
sadness. my own brand on y’all, bar one on this
none. I hope to show some page and on
I still feel low from time to drawings somewhere, some- the cover.
time, but signs of life are time, but am not pressurizing
with me everywhere. Having things by setting deadlines
a strong faith helped me. So and predicting outcomes. My
has admitting others into my will is to be around long
life to help me be objective enough to be heard and seen.
and not treat myself so harsh- A few years ago, I wouldn’t
ly. Taking professional cours- have thought so.
Performance
Applying a price to every nat- was the jerk branding stuff
ural act is what modern soci- on to people. “Joe’s Butterfly
eties do, with our system of Repair” had to have their fly-
Pieces Raise
economics. Realizing this, I ers. I would drink to make
began to feel there was no myself numb enough to work.
will to give. Also there was,
and is, constant pressure on
me as a depressive to “do
something,” so that any nor-
When my numbness caused
me to lose my family, I de-
spaired at being so stupid as
Awareness of
mal act of commerce is a ques-
tion of self-worth as well as
self-esteem. “Will you have
to be trapped by loathsome
half-lies. The truth was I was
trying to deny my mental ill-
Mental Illness
I
fries with that?” becomes ness and deny that my drink- have been heartened to discover recently that creative Barbara
burdensome when, if I say no, ing had become a problem. works are being performed in BC which bring attention to Bawlf
I might be considered a neg- I almost died trying to cover mental health issues.
ative person. The psychology it up.
of commerce brought out a A dance piece called ICE: beyond cool was performed Septem-
mean streak in me. I was helped by going to the ber 20th to honour the life of a young student, Josh Platzer,
emergency ward and being who committed suicide one year ago. The performance was
I became inwardly angry and properly and respectfully held at Point Grey Secondary School and was by invitation to
abused by the way the mar- diagnosed by a doctor right the school community only. The next performance of the dance
keting machine sought to there. I spent some time in the drama took place in Ottawa, which kicked off a national tour
corral me and magnify my hospital and haven’t had a finishing in Prince George on November 6th. Five perform-
inadequacies. Symbols and drink in nine years. I’m also ances were held October 25-28th at Vancouver’s Internation-
signs abound to the depres- being treated for essential al Village near Yaletown.
sive. At work, every time I had hypertension. The depressive 41
to meet a deadline, the un- cynic in me would say: “Now ICE was developed from a series of workshops that were done
real ad art — detailed melo- what are the odds of that hap- over a period of three years with more than 250 teenagers.
drama with a hidden hook — pening?” but it happened, Vancouver DanceArts director Judith Marcuse and Headlines
hammered me down. I began and for the sake of those that Theatre director David Diamond produced and facilitated
to loathe myself because I love me, I’m happy that it did. the workshops, which developed into a piece featuring a 15-
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
member cast of actors and dancers. There is a talkback session at the end of each
performance where the issues surrounding suicide and depression are discussed
among performers and audience.
In Delta, an exciting project showcasing the writing of Tsawassen resident, Mau-
reen Haggerty is underway. Maureen is a person who first encountered mental health
difficulties in her teens, but was undiagnosed while in high school. She has written
about those experiences in the form of a play which, with the help of co-writer, John
Hedgecock is to be produced in Delta in February of 2001. A committee called Promo Productions is working to get the
production off the ground, and funding has been obtained from the South Fraser Health Region through a Health Innovations
Promotion grant that will assist in covering costs. The play will be performed in four high schools in the Delta area with a view
towards reaching not only teenage students, but increasing public awareness of mental illness as well.
Madness, Masks and Miracles
A
fter her last bout of “The title of my play,” says ries an attitude of “get over states. “Now that I have ‘come
clinical depression Swadron, “is about the mad- it, everyone has stress,” and out of the closet,’ I am in awe
last year, June ness or insanity we all have Susan’s mother who is totally at the number of people who
Swadron began to from time to time, the masks bewildered by it all. have come forward to share
collaborate with actors and that we are forced to wear, their own stories. When one
writers who live with a mood lest we be seen as crazy and Madness, Masks and Mira- in five people in North Amer-
disorder to write a play in- ostracized for it, and the cles is a story of hope, cour- ica suffers from clinical de-
corporating some of their miracles that finally allow us age and everyday miracles. pression at some time or other
experiences. Out of this to remove the masks once and It’s the kind of stuff that goes in their lives, can we really
collaboration has evolved for all.” beyond the stage, inspiring afford to have a WE vs. THEM
Madness, Masks and Mira- each of us to move through mentality? Of course not.”
cles, a play created to raise Swadron, creator of Mad- life with optimism, strength,
awareness and give hope to ness, Masks and Miracles is and dignity. As yet, there are “I thank God every day for the
individuals living with mood a psychotherapist, certified no male characters, but the miracles that have come to
disorders. Their families, life skills coach, and work- intention is to bring at least me,” Swadron says, “and that
friends, mental health profes- shop facilitator. She was first one male into the story. All of I am alive and well once again,
sionals, corporate employees, diagnosed with manic de- the current actors have been and can now give back some
government workers, stu- pression in 1971. touched by mood disorders: of what I have received.”
dents and the public at large either personally or through
will benefit from this project. On October 17th a success- a loved one. If you are an interested indi-
fully staged reading was pre- vidual or part of an agency or
poetry sented to guests who work in
the health and wellness pro-
When completed, many of
the play’s performances will
corporation that would like
to hire a performance of
fessions. be supported with profession- Madness, Masks and Mira-
ally facilitated workshops by cles, or would like to have a
In the play, Susan Levy is a experts in the field of men- package with the play and
With all the power of gravity, successful lawyer, suffering tal, emotional, physical, and workshop series combined,
Suction and travel, from clinical depression and spiritual health. please call June Swadron at
I force my way past panic attacks. When she can (604) 682-5559 or Lee
Limits of space and beyond no longer “keep it together,” Besides the horror of the Clarke at Hub Productions
Into the future of my life, her hopelessness takes over. physiological, emotional, and Ltd. at (604) 681-1892. The
Where things are new She attempts suicide and psychological characteristics next public reading will be
And a whole lot more true wakes up in the psychiatric of mental illness, one of the at the Porridge for the Soul
Than the average day ward of a large city hospital. most painful aspects is the breakfast:
That I knew. It is here she encounters Na- stigma associated with it. Tuesday, January 2nd,
dine, a person with manic “The amount of shame and 2001 at 7 am
— Ken Hansen
42 Consumer (Sechelt, BC)
depression, as well as Cyn- guilt that I have carried most to be held at the Canadi-
thia, who currently suffers of my life — as though I ac- an Memorial Centre for
from postpartum depression. tively and purposely did Peace (1825 16th Ave-
We also meet Dorothy, a wise something wrong — has nue, Vancouver (near the
and compassionate nurse, caused me as much pain as corner of 16th and
Susan’s law partner who car- the illness itself,” Swadron Burrard)).
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
depression, creativity, and work
A Path to Recovery Paved with Movies
When I showed Benny & Joon, along with a facilitated discus-
M ovie Monday started as a sparky idea from a guy recov-
ering from a severe depression and second suicide
attempt. I was becoming slightly hypomanic, part of my man-
sion, this was the first time I’d presented a popular film with a
mental illness-related theme. The discussion was very wide-
Bruce
Saunders
ic-depressive illness — the creative, optimistic side of a roll- ranging and involved people with personal experiences of
er coaster emotional ride I’d been on much of my life. Finally mental illness who had lots to say. This was their forum, and I
I was on a better mood stabilizer and the right kind of sup- learned a lot. After that, Movie Monday’s schedule has always
port. And I was hot on a new scheme. included a rich peppering of such films — which include
discussion opportunities and special guests — like One Flew
My wife was keen that our life get back to normal. “Look after Over The Cuckoo’s Nest, Shine, and Curtis’ Charm. In January,
yourself, your family, and your gardening business,” she said. we’ll be presenting our third Reel Madness Film Festival in
But I’d discovered a 100-seat lecture auditorium in the base- Victoria: five days of films and discussions about mental ill-
ment of Eric Martin Pavilion in Victoria with a video projec- ness and recovery.
tor, and the idea of showing films there for patients and
ex-patients had captured my imagination. When people gather I also realized early that just showing up week after week,
for popular film entertainment, there are a lot of other cool addressing the audience, consistently putting up eclectic, cre- Bruce lives in
things that can spring from that. Now, seven years later, 420 ative programming, talking about mental illness and health, Victoria, BC and
events later, my day job (landscape maintenance gardening) making at least part of our psychiatric hospital a friendly is the founder of
is thriving, as is our family, and Movie Monday is still a vital approachable place — has a pervasive effect. Even though we Movie Monday
interest and creative expression for me. have a small venue, the ripples of information, positive atti- and the Reel
tude, and hope travel out into our community. Madness Film
Just a month out of hospital, with no funding and no long term Festival.
plan, my friend Peter and I started things going. It was much And the ripples come back to me. What I’ve gained is a whole
to the credit of the hospital’s audio-visual staff that they even other identity. Where before I felt like I was hanging on to a
considered allowing me free use of the facility. I reasoned that thin pretense for living, now I have a unique opportunity to
it would be a health-related event, but even I thought it was a express myself artistically and intellectually. I’ve learned to
bit chancy. I realized right away that the key was consistency. express myself on paper effectively and speak publicly. I have
The entertainment had to be there regularly, so people would lots of reasons to interact with artists, filmmakers, and with
make it a habit and a community would build. movers and shakers in the mental health community, both
peers and professionals. I’ve been more stable and happy than
At first I publicized it through the hospital and my support ever before. Movie Monday has given me a platform to make
group. When just a few people showed up, I broadened my something good of all the losses and dreary experiences. Our
promotion to hostels and drop-in centres downtown. The first family is proud of dealing well with an illness that has haunt-
few months, I got butterflies in my stomach every time I thought ed my family of origin and could have claimed me and even
of having to be there next Monday with a show for the expect- my children. I feel I’ve turned that fate around. Last June, I
ant audience. For a person with mood swings, consistency can celebrated a 50th birthday I never thought I’d reach. I’ve still
be a scary prospect. But I was enthusiastic about movies and got an illness that I have to manage. It’s never lost on me though,
since it was my idea — there’s nothing like ownership — I was walking through the hospital to set up for another event, that
able to make it work and pursue those goals I had imagined it’s great to come back into this place each week, not as a
from the start. I treated it like my gardening business: with patient, but as a provider of a service, feeling like a winner.
relentless promotion, focus, attention to detail, and thrift.
For more info on Movie Monday or for a schedule of Reel
A big leap in commitment and exposure to the public was Madness events, go to www.islandnet.com/mm.
made when, hoping to raise funds for better equipment, I was
featured in an article in Victoria’s city paper. It was a turning Bruce Saunders (right) and
point when I weighed the risk of talking about my illness his wife Laurel (left) in
publicly. It’s been a very positive move for me and for my costume for Movie Monday’s
family. One of the best results of this experiment has been to “Sing Along Sound of Music”
shed all the baggage that comes with the usual se- which ran July 31/00.
crecy, and to make a constructive thing of our fam-
ily’s challenges with mental illness. Weekly now, I
see the healing effect of that 43
openness.
Quite early on I realized
films could stimulate discus-
sion about mental illness.
Visions: BC’s Mental Health Journal Mood Disorders No. 11, Fall 2000
resources
General Information about Mood Disorders Available for ordering or downloading at www.ontario.cmha.ca
For exhaustive links to web sites about depression, see depression.
miningco.com, www.depression.com, and www.psychcom.net/ See “Dealing with Depression,” the Summer 2000 issue of Expres-
depression.central.html#contents. For exhaustive web sites about sions, a Health Canada magazine for seniors. Find it at www.hc-
bipolar disorder, see bipolar.miningco.com and bipolar.about.com sc.gc.ca/hppb/seniors/pubs/expression/13-3/exptoce.htm
Res<urce List
Rapid-Cycling Bipolar Disorder: see www.mother.com/~andys/ Women and Depression
index.htm and www.ndmda.org/rapid.htm For links to a number of recent articles, see www.suite101.com/
welcome.cfm/women_and_depression
“Dealing with Treatment-Resistant Depression”: this article is aimed
primarily at clinicians. See www.medscape.com/Medscape/ Study in Grey: Women Writing About Depression, edited by Wynne
psychiatry/TreatmentUpdate/2000/tu04/public/toc-tu04.html Edwards and Shirley Serviss. Rowan Books (2000).
Depths of Despair: an excellent CBC radio documentary on mood “The Age of Anxiety”: a great Newsweek article on mood and anx-
disorders. See www.radio.cbc.ca (follow the links to “This Morning”). iety disorders and gendered brain differences. Available at
newsweek.washingtonpost.com/nw-srv/printed/special/wh99/
Learned Optimism by Dr. Martin Seligman. Pocket Books (1998). A ch4/wh17_1.htm
book on preventing depression and building optimism. For other
books on depression, see www.vcn.bc.ca/rmdcmha/depression.html For an article on postpartum mood and anxiety disorders, see
www.medscape.com/medscape/psychiatry/TreatmentUpdate/
Mood Disorders and Creativity 2000/tu02/tu02-04.html
“Michael’s Depression Page” (www.geocities.com/mjattwood_nz/
depression.html) lists numerous links to sites dealing with Medications and Side Effects
mood disorders and creativity, while “The Reading Room” For good web sites on medications and side effects, see:
(www.geocities.com/the_reading_room/index.html) and “Fire Internet Mental Health at www.mentalhealth.com/p30.html
and Reason” (www.geocities.com/SoHo/Village/5990/index.html) National Empowerment Society (USA) www.power2u.org
are web sites featuring collections of creative work by consumers. Steven Thow’s www.mhsource.com/wb/thow9903.html (and
go to topic #8: “What can I do about my drug’s side effects?”)
“Mood Swings and Everyday Creativity”: an article by Dr. Ruth Dr. E. Fuller Torrey’s Treatment Advocacy Centre and Ralph
Richards at www.mentalhealth.com/mag1p5h-md04.html Nader’s Public Citizen at www.citizen.org/eletter/
Children, Youth, and Mood Disorders Alternative Treatments
For information about childhood bipolar disorder, see For general information, read CMHA BC’s overview at www.
www.geocities.com/EnchantedForest/1068 (a web site for fami- cmha-bc.org/yellowbk/newtreat.html. For information about a
lies and those who care for children with bipolar disorder); see “supplement” known as SAM-e, go to www.suite101.com/
www.mentalhealth.com/mag1/1997/hp97-bp03.html (an article.cfm/depression/28543. Read an article about St. John’s
article published by The Harvard Mental Health Letter); and see Wort at www.suite101.com/article.cfm/depression/17231. For a
www.appi.org/pnews/oct4/adhd1.html (an article about the link list of links about a number of alternatives, see Steven Thow’s web
between bipolar disorder and attention deficit disorder). page at www.mhsource.com/wb/thow9903.html (and go to topic
#16: “Where can I find information about on herbs and alterna-
For numerous links related to mood disorders in children and youth, tive medicine and treatments?”). Also, see the web site of a research
see www.psycom.net/depression.central.html#contents (follow the consortium studying a promising new supplement for bipolar dis-
links to “Depression in Children and Adolescents”). order at www.truehope.com
For articles about medication and children with depression, see Electroconvulsive Therapy (ECT)
www.suite101.com/article.cfm/depression/32180 For general information, see www.ect.org, www.psychcom.net,
44 depression.central.ect.html, and for a good review article, see
For an electronic journal article devoted to prevention of depres- www.suite101.com/article.cfm/depression/23856 . For informa-
sion and anxiety, see http://journals.apa.org/prevention/ tion about a promising alternative to ECT known as rTMS (Repet-
itive Transcranial Magnetic Stimulation), see www.psycom.net/
Seniors and Depression depression.central.transcranial.html
See the Winter 2000 edition of Network on Senior’s Mental Health.
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