I was reading about a suicide of a college student recently and when I read his friends description of his behavior it was clear that he had a major depression. I wondered if his friends did not recognize his depression or simply did not know what to do.

Some of the advice for helping a depressed friend goes something like:

• Listen
• Suggest professional help, facilitate an appointment and offer to go with the person.
• Have the person call a suicide hotline  or helpline

Although this is good advice, often with severely depressed persons these interventions are not enough.

If you believe someone is severely depressed what to do and they do not respond to the above ideas what do you do?

1. I suggest calling the police who will make a mental health arrest (if they feel it is warrented) and take the person for psychiatic evaluation. (although this may seem drastic and your friend may be initially be angry with you, this may save his life)
2. Consider an “intevention” using the model of AA. That is when  important people in the person’s life go together to see the friend and clearly and firmly express  their worries about the person who is depressed.  It is  critical to offer hope by clearly stating depression gets better with treatment (this is true) and sharing personal experiences and recovery if you are able. The person usually has a hard time believing depression will ever go away so it is critical to let them know otherwise. Have a plan (referral, visit to Emergency room) ready.

What is Depression?

People use the word depression loosely to mean a number of different moods. We use it when we are down about something going on in our lives, when we are grieving or just sad. I prefer to use the term “clinical depression” to distinguish these moods from the more serious type of depression that may need medication to relieve. Clinical depression is more than the “blues” or sadness. It is not something a person can “just get over” or talk themselves out of. Clinical depression is at least partially based on brain biochemical imbalance (we are still in early stages of understanding this) and often runs in families. Stress and psychological factors also play an important role, although we do not fully understand the causes and factors that result in clinical depression

Common symptoms of depression include:

• Sad or irritable mood
• Loss of interest / energy
• Poor or excessive sleep and appetite
• Difficulty with concentration and memory
• Physical complaints

Medication is often necessary in serious depression and MAY be helpful with less severe types.

It’s that time of the year where some of us (fewer I hope) make those New Year Resolutions that we often break leaving us feeling like failures.  Why is that??  I wonder if it is because we often try to make ourselves into something or someone we are not.

I love this quote from Steve Jobs of Apple.
“Your time is limited, so don’t waste it living someone else’s life. ”

In thinking about this I realized that as I have gotten older I am more and more sure of and ok with, who I really am.
But knowing who you really are takes thought and time.

That might be a good New Year non-resolution for 2010,  pay attention to knowing  myself better.  How can I do this you ask?

Here are some ideas I came up with, I am sure you could add many more.

1. Spend time alone
2. Spend time doing nothing
3. Allow thoughts to come, don’t judge them just acknowledge what are they about
4. Allow yourself to feel and acknowledge the feelings to yourself.  Remember feeling is not behaving.
5. Reconize what makes you happy and write it down.  It may come as a suprise and may be different then what you had believed would make you happy.
6. Recognize what makes you feel angry, frightened, stressed, bored, unhappy. Try and be specific.  Allow yourself permission to avoid these things when possible.
7. Spend more time with those you enjoy who bring you peace.
8. Cut down on your obligation visits.
9. If you have already unsuccesfully  tried  to improve relationships, then  give yourself permission to avoid those that make you feel bad or unworthy (even if they are relatives).
10. Ask yourself these questions frequently

• What do I really care about?
• What are my basic beliefs and values?
• What would I do if I recieved a diagnosis of a terminal illness, how would it  change my behavior?

Fight any feelings of self indulgence or guilt. Remember Self-Awareness is a basic building block of self-esteem,  Not selfishness.  Further healthy self -esteem allows us to be positive influence in our world.

Blue Footed Booby

When ever I go on a trip to a far off place I like to think about what I have learned. To me the important things to keep on learning are not so much facts ( I did learn a lot of these!) but what I call life lessons.

Sometimes these lessons are not so obvious. I need to put my mind to thinking about them.  One of the  lessons I seem to relearn with every new experience is that of patience,  tolerance and acceptance of differences. There are so many things about other’s behaviors that we don’t understand and often disapprove of. However, it seems to me that  when you understand more of the circumstances and situations of others (walk in their shoes)  the more their actions, if not approved of, are at least are more clearly understood.

Poverty, the need to feed oneself and one’s family, and anger at injustice,  often leads to desperate actions. I saw this in Africa and again in Ecuador. No matter what you do or say most indigenous peoples  think US citizens are rich. And by their standards we are!  Some times this belief leads to your feeling like you are being taken advantage of or made a fool of.  ( I had a group of teen approach me with hands out asking for $5.00 tip, they seemed suprised when I shooed them away in no uncertain terms.  I also had an elderly women tried to cheat me out of $20.00, I confronted her and she sheepishly moved quickly away) After I did this I found I was not so angry at these people but was able to understand somewhat their feelings .

I did not let these incidents effect me for more then a minute or two.  I reminded myself for every one of these experiences there were ten instances where I was treated with respect and genuine caring. I am getting so much better at not letting negative experiences outweigh the good things in life and ruin my mood! I think this is also  a lesson of aging that is well worth it.

I Have some  pictures of my trip that you can view at http://amazongalapagos.shutterfly.com/

Ambivalence is said to be a common experience of the human condition. I have always believed this but have never felt it as clearly as I do about Kenya.  Talk about a love –hate relationship!

  So much to love: people who always smile and are extremely welcoming and friendly, children that are so engaging and loving, take care of each other, and are resourceful, strong and independent, gorgeous scenery, animals and natural resources.  These are the thing I remember most that will draw me back to Kenya.

On the other hand the things that have caused me so much pain, are: the hunger of so many, especially children, the juxtaposition of the very rich and very poor, pervasive corruption, garbage casually thrown on the road, lack of education, lack of jobs and the hopelessness for so many young adults.

Many Kenyans have difficulty being direct and honest; getting a straight answer can be a frustrating experience. Fibbing or out and out lying to get a few extra shillings can make foreigners very angry.  When this happened to me, I tried to remember that for so many of these people a few shillings can mean the difference between eating or not, and feeding their children. I have been told (and believe) that it is easier to make one dollar in the USA then one shilling in Kenya. One shilling is about a penny. So when I got so tired of people trying to sell me something or quoting prices with a “white tax” added, I remember how desperate they are for that little bit of money. Of course this is not true for all the people selling “”stuff, some are just dishonest, but the majority is desperate for those few shillings extra.

Neurotransmitters do exactly what their name implies; they transmit information between brain cells. If neurotransmitters are decreased, information and activity in the brain is believed to slow down. This is thought to be one of the causes of depression. If neurotransmitters are excessive, information overload may occur. This overload is thought to be what occurs in schizophrenia. However the phrase chemical imbalance is most often used to describe depression in a way that implies fact, and ignores any other factors underlying the depression. In any individual, it is impossible to say this for sure. Chemical imbalance is only one theory of depression, and is generally considered to be only one factor of many thought to effect mood. The term chemical imbalance is used to explain the use of medication for treatment. We do know that medication can be a lifesaver for some and for others may not be of much help.

The neurochemicals of most interest in mental illness are serotonin, dopamine, and norepinephrine.

Right now I am going through some major changes in my life, retirement, relationships traveling, finances, what else is there?  All change, no matter how planned or positive brings some anxiety along with excitement. This article came to me just in time to give me a needed boost. Thanks to my terrific financial advisor Jay Cappon who wrote it.  Check him out at his great website

                                                  Change: How Best To Deal With It

By Jay Cappon

Change is inevitable, and unfortuunately, dealing with this reality of life is not easy for everyone.  A prime example of this are the changes that are now taking place in the economy and the stock market. But I wish to focus not on financial change, but on change in general, and the premise that when we adapt and embrace change, we are more likely to achieve our goals and live our dreams. 

 One of the great advantages of humans is our ability to adapt to and prepare for change.  History is full of countless examples of this, yet, too often we are resistant to change. This is likely due to the comfort that the status quo gives to us. Staying with what is comfortable and familiar keeps us connected to our past, especially if it gives us “good” memories. But we must not lose sight of any exciting opportunities for growth and new experiences that change brings. Being open-minded to new  ideas is an essential ingredient for living a more meaningful and fulfilling life.

Implementing change in our life often involves a certain degree of risk. How successful we become at accepting and implementing change often depends on how well we prepare for it. The following suggestions are ways in which we can open our minds to change:

• Collect facts about the change Having this information in written  form will help you assess the impact of this change on you and how this impact may have a positive outcome.
• Evaluate all the possible risks What may go wrong if you go ahead and implement this change? Can you be negatively affected by the change? What may be the worst-case scenario?
• How will you deal with the risks Once you have identified the risks, develop a solution – in the form of a written plan – for each one.
• Commit yourself to perseverance
  Write down your commitment to the change, making it in the form of a contract to yourself. Then, keep it in a location where you will see it regularly as a constant reminder.
  
• Make the implementation process a series of small steps If you view change as a series of small steps instead of one large one, you will avoid “biting off more than you can chew”. It will be easier for you to reach several small milestones, along with a positive attitude and confidence in yourself.
  
• Reevaluate your process Be flexible  and make any adjustments – changes -  as you need to ensure success.
• Reward yourself for each small accomplishment.  Celebrate smaller  milestones and monitor the progress you have made. �
  

It is very true that change can cause many people to feel anxious or uncertain about the future. Yet, those of us who adapt, prepare for, and monitor change can experience it  as one of life’s great motivators– and rewards.

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 Sorry I am a little late with this blog posting. I just got home from a trip to Long Island where I grew up. In a small beach town on the south shore of Suffolk county I spent 4 days reminiscing and experiencing many bittersweet memories.

This visit I saw some friends I had not seen in 50 years; it was amazing how the memories came rushing back in a group setting with everyone talking of their personal remembrances. We each had something to share about that time so long ago.

I got to thinking about reminiscing and wondering why it has such a strong draw.

 I know that reminiscing is something that the older we get the more we enjoy. Based on this, a magazine called Reminisce has gained a large following and made lots of money with a very simple format. We also use reminiscence with older folks as a talk treatment to help those who are sad and confused. Try it yourself with an elderly relative who is agitated or unhappy. Just ask them a simple question about their past.

 This adventure “home again” got me to thinking about the meaning and importance of reminiscing and nostalgia and trying to figure out why they are so irresistible at times.

 Here are some of my questions and thoughts.

 Ø     Is it the sweet memories and pleasure of remembering that attracts us?

 I don’t think so; many of the memories are not sweet and actually sad or painful, but these also can have a strong pull.

Ø     Is it the wish to be young and innocent again?

Being young was often not the best time of our lives, and sometimes I wonder if we were ever truly innocent. As youngsters we picked up on and experienced anxieties and worries from our environment. Even though we may not have recognized or understood these feelings we often had a vague  discomfort that we used all kinds of psychological maneuvers to avoid.

I believe that these trips down memory lane are more for self-understanding, acceptance and sometimes even personal change.

Every time I make one of these visits I realize something else that has affected me all my life, and made me who I am. This can be something I view as positive or not.

  I am a person with a desire (? need) to understand and that need drives me to search the past. It can lead to forgiveness of others, self-healing and self-acceptance that is priceless.

I also notice that the bitter in bittersweet gets less with each visit, I think I will go “home” again next year.

 Send me your stories or ideas about reminiscence in the comments so we all can enjoy and learn.

As a psychiaric nurse practitioner I have been prescribing medication for years. I can tell you  that MOST NPs  have a different perspective from MOST physicians.  I don’t see every psychological problem as a diagnosis or a disease to be treated or cured. I see many problems as social, enviornmental and learned. I firmly believe they shouldn’t be given a label or diagnosis ( did you know insurance companies require a diagnosis in order to make payment) and can’t be fixed with pills .

 Having said that, I also know that clinical depression, and other legitimate mental illnesses often MUST be treated with medication. The problem is often figuring out which is which. It seems that many people who really need medications don’t get them, and so many who don’t need them are taking them ( and thus the medicine “doesn’t help”.)

 Any way, back to the “I told you so” part. As a concientious prescriber I have always feel it is critical to keep up on the latest in medication information. To do this for a number of years I went to what I thought was the “best”, Harvard .I attended quite a few of Harvard’s well known and respected psychopharmacology conferences. More then once I listened to the physicians who are now identified as not reporting their drug company income. After a few times I got tired of the same old message: more medications, higher doses, polypharmacy and  a drug for each symptom. I stopped going.

I have to say many of the physicians in the audience seemed to be swallowing these ideas whole. This is in part because of the traditional viewpoint taught in medical schools, the “disease and cure model”.  

Now comes the  hard part. We all need to take some responsibility for fostering this as this is ALSO the public expectation of medical care That is, we expect providers to be able to “fix it”, no matter what it is.  We often want, no insist on a pill. This is a big part of the reason for the overuse of antibiotics.

Dr. Biederman’s push for the diagnosis of Bi-Polar disorder in kids was particularly disturbing to me. Of course if we give them this diagnosis, it will naturally follow that we can give them a drug (or two) and FIX them. Few seem willing/able to look at social or environmental facts. Or if they do, they realize how difficult it is to change these things; pills are so much easier!  By the way pills are all most insurance companies will pay for (with higher and higher copays of course) and pills are what many of the public wants instead of dealing with all the other factors.

In order to make things better there are many pieces that need to be looked at. The first is regulation, but also I recommend the following:

• Patients need to stop expecting doctors to know everything and fix everything, and ask more questions. Even when they are afraid of the answers! If they don’t get their questions answered in a way they understand (not necessarily like),  they should  get a second opinion.
• Doctors and all health care providers start excepting there own limitations and the limitations of our medical knowledge
• We also need more self oversite by medical professionals. This is not a closed private club, its a public trust. Persons who break that trust should be given fair treatment but severe consequences.
• The broken health care system in this country needs to be seriously overhauled.

Ok lets get to work.

I am a new nurse on a psychiatric inpatient unit. I was told that I was allowing a patient to “split.”  The person who said this to me seemed annoyed. Can you tell me what it means? What did I do wrong? I didn’t want to ask her.

 You may have heard the expression “splitting” as a description of the way that persons with personality disorders  relate to others.  Splitting is a coping mechanism (also called a defense mechanism) that is used by both persons with and without Borderline Personality Disorder.  It is a mechanism that is considered immature and is an unhealthy way to deal with disappointment in relationships.

• How does Splitting Work?  

  Splitting is defined as the inability to reconcile the presence of both positive and negative aspects in another. Splitting allows the person who uses it  to see others as either all good or all bad. Of course no human being is either “all good or all bad” but a combination of strengths and weakness. Splitting and Relationships  Although being the “all good” person may initially feel flattering, be aware that it will not last! When the person who is seen as all good disappoints (which of course is inevitable when expectations are unrealistic) they quickly become “all bad”. It is often this change in perception that will make someone struggling with BPD enraged. Persons who use splitting have unrealistic and unobtainable expectations of others, chaotic relationships, and are inevitably disappointed.

• Splitting and Relationships.
  
  Although being the “all good” person may initially feel flattering, be aware that it will not last! When the person who is seen as all good disappoints (which of course is inevitable when expectations are unrealistic) they quickly become “all bad”. It is often this change in perception that will make someone struggling with BPD enraged. Persons who use splitting have unrealistic and unobtainable expectations of others, chaotic relationships, and are inevitably disappointed. In order to grow and heal, a person who uses splitting as a way of  coping must somehow come to terms with the limitations of other human beings (and of themselves).
  
• Dealing with Splitting.

  In order to grow and heal, a person who uses splitting as a way of  coping must somehow come to terms with the limitations of other human beings (and of themselves). On an inpatient unit the best way to deal with splitting is not to engage in conversations about other staff with patients. Refer them to the person themselves or if necessay the nurse leader.  It is critical that all  staff are clear and in agreement  about the treatment and approaches to be used with the patient . This is also the same way to deal with difficult people in work or social groups who try to get people to take sides on an issue. an open discussion with everyone involved is the best strategy to avoid splitting.