Saturday, June 2, 2007

Dr Thomas Stuttaford answers your questions on depression and therapy

The Times doctor explores readers' concernsNEXT ONLINE CONSULTATION: the doctor is away on June 6. His new topic for answer online on Wednesday, June 13, will be announced shortly. For how to e-mail your question for answer online and to read other recent topics click here. See also extracts from Black Dog.

I have been diagnosed with anxiety and depression. I have been on Dotheipin for years. It helps but I do still have bouts of severe anxiety and cannot work at these times. I feel I have not been properly diagnosed and only one medication has been tried. Should I ask to see a specialist to reassess my condition and future medication? Chris Pearson, Leeds

Dotheipin hydrochloride is one of the older tricyclic anti-depressants that happens to have a highly sedating as well as anti-depressant action. It has a long action and this, combined with its sedating effect, means that it can be prescribed in one large dose at night. Dotheipin therefore then combines the advantages of an anti-depressant and a sleeping pill.

Its side effects are similar to those of all the tricyclic anti-depressants. The most important of these are its possible effects on cardiac rhythm and the ability they have in some cases of nullifying or reducing the effect of some anti-epileptic drugs. The possible, but no means invariable, side effects that might be considered inconvenient rather than clinically hazardous are drowsiness, dryness of the mouth, blurring of vision and difficulty in passing urine. It increases the effect of some anti-insulin treatment so that anyone with a diabetic tendency who is taking hypoglycaemic drugs may find that they need less of these.

One of the rules in treating all forms of depression is that if the treatment is not achieving the desired effect it should be reviewed, and possibly other drugs tried instead. The individual response to different drugs varies enormously, some time in the future it may be possible by analysing a patient's genetic make up to know which drugs will suit them and their condition together with those that won't. Until that day dawns trial and error, coupled with a very careful diagnosis only made after a long review of the patient's history, is all we, the doctors, can offer.

2. Our 44-year-old son is suffering from clinical depression and is currently being treated with alanzapine, mirtazpine and citalorpram - as recommended by his psychiatist. These drugs help quite a lot normally but occasions arise when he describes himself as feeling very low. At such times the temptation to self-medicate with alcohol is high. He has recently relapsed twice into binges but when sober, which is most of the time, he is able to function and work normally.

He has suffered intemittently with depression for many years but only during the last two has turned, occasionally, to alcohol. This tendency has been reduced considerably by a stay at a Priory clinic and attendance at AA meetings. He now has two unsuccessful marriages behind him and we are extremely concerned about his future. He is a gifted professional and a member of Mensa. He is currently living with us but we feel this will not help in the longer run. Carole Davis

As usual we can't comment on an individual's treatment other than to point out the type of considerations that leads doctors to prescribe a particular drug or drugs. Only the doctor who knows a patient can know the reasons why he or she has chosen this particular mix. Two of the drugs given to the reader's son are the anti-depressants mirtazpine and citalorpram. The third, olanzapine, is a major tranquilliser of the group of drugs known as atypical anti-psychotics. These are given to control agitation and disturbed behaviour.

The worst treatment that any patient whose behaviour and mood is such that they need a major tranquilliser can have is to self treat with alcohol. For many years I have been advocating a couple of glasses of wine for most people, but one of the absolute exceptions to this advice are the patients in whom there is any question of any symptoms that might be considered to call for the use of a major tranquilliser. Alcohol can undo all the good work and can produce a serious relapse.

It is not unusual for patients who suffer from this type of temperament to have an above average intelligence. The need is to find a means of controlling their mood so that patients can make some satisfying, if not demanding use of their intellect. However patients who have this personality should not push themselves too hard, they need a job that will satisfy them, but will not push them to the point that they are stressed, it is often a difficult balance to strike.

The reader's comment about the best place to live for patients with this type of personality is both shrewd and accurate. People with troubles like the reader's son have a strong dislike of judgment, whether intellectual judgment or moral judgment. For this reason examinations, for example, may be a trial for them. So is living at home, however kindly the parents, as children always know just what parents, or siblings, are thinking, even when the thoughts are unexpressed. The patients need to live near to home so that support is always at hand, but not at home.

How do you know when is the right time to come off anti-depressants if you have more reactive depression to a certain situation of incredibly stressful job, which has now been resolved and you are feeling happier and don't want to rely on the tablets to balance your emotions?m Name and address withheld

This question raises the point that anti-depressants must never be left off suddenly. So long as the anti-depressant have been taken for at least six months and the patient has now cheered up, especially if they have not only cheered up but the anxiety that was a factor in inducing the depressed state has been removed, the anti-depressant may then be tailed off. This must always be done after taking the advice of the GP. Anti-depressant treatment should never be abandoned even if it doesn't seem to be helping without the full knowledge of the doctor. Patients have to realise that for some cases long term anti-depressants are necessary, and if the depression recurs they may have to go back onto them.

4. I have suffered from depression from a very young age and feeling depressed at experiencing what I saw as my mother’s moodiness in the kitchen first thing in the morning when I was a child. I believe (though not sure) that I inherited the experience of depression. These days I am aware that I use my body a lot in an attempt to overcome depression, and to an extent this does work. Using the body includes moving, meditations and dancing. The depression however does return, and it seems that the habit is a strong one. So could you please suggest any further treatments or approaches that I could use, either using my body or other emotional techniques. I am NOT a user of prescribed drugs at all. A. D., Brighton

Physical activity is helpful in overcoming, or helping to alleviate, symptoms of many different types of clinical depression. It produces endorphins that to some extent are nature's own anti-depressants as well as pain relievers. Exercise also has an effect on other biochemical markers but as the reader says this effect is relatively short term.

The reader is very emphatic that she is not a user of prescribed drugs but some patients who suffer from depression need to have the cause analysed, and then any biochemical imbalance corrected with medication. This is often designed to have the effect of supplementing a deficiency that has occurred in someone's own natural chemistry. Some types of depression do best with a combination of medication and cognitive therapy (often referred to as CBT). In other types of depression any form of psychotherapy, other than CBT, can make the situation worse.

As well as brisk and unaccompanied physical exercise such as a long walk, any interest that distracts someone's attention from their problems such as painting or gardening is helpful, but alcohol and shopping, that also do this have their dangers and should be avoided.

I have had MS for 25 years and although I have remained fairly stable I find that I am prone to periods of depression. I am not keen on taking medication of any sorts as I have been on Prozac in the past. Can you offer any advice? Name and address withheld

When I was a junior hospital doing a neurological job one of the great debates was whether MS was liable to lead to depression or hypomania (over-elation), and in any event what was the cause of these mood changes. This was before the days of the functional or standard MRI scans and it wasn't fully appreciated that the changes found in multiple sclerosis, that are revealed by an MRI scan, often affected the higher centres in the central nervous system first.

It is now accepted that MS may cause either depression or over-elation, or sometimes both at different times in the same patient.

When these symptoms do occur treatment with an anti depressant may be helpful. Once the MS has gone into remission the anti-depressant medication can, with the doctor's approval, be tailed off slowly.

Fortunately the treatment of MS is improving rapidly so that the best way of dealing with this patient's problems is to make certain that he or she always has the latest and best treatment for the underlying condition.

I suffered with depression in my early teens and I was admitted to an eating disorders clinic for anorexia. I am now 23 and since leaving university and moving home I am now experiencing the depression again. I have lost interest in everything and find myself sickened by my lack of motivation and general low self-confidence. I have put on over a stone in weight through binge eating and I am sure this is contributing to my sadness. I started on a graduate scheme in September and this in when my problems grew. I feel a compulsive need to be liked and approved of by others and put on a happy-go-lucky show, but I desperately fear anyone becoming intimate with me or finding out about my pretence. Deep down I know I am doing the wrong job, but I'm unsure what I want to pursue and feel at a total loss with my inability to cope with a job when so many of my peers are handling it so well. I feel the desire to do something impulsive or crazy or to just escape but fear I may feel this blue wherever I go.

My attention span has become limited and I feel unable to truly become asorbed in anything I do. I cannot find pleasure in anything and have lost interest in taking care of myself, I live in my tracksuit and rarely wear make up. I have been prescribed anti-depressants three times this year but fear taking them, of becoming dependant and the side effects. I have been seeing a psychiatrist but have been unable to find any answers. I feel a loss of control and want to break free from this. Please help. Emma, Birmingham

There is a close but not invariable association between anorexia and depression. Emma's description of the signs and symptoms of depression such as are found in a conscientious and well-motivated endogenous depressive person are classic. She not only has low self-esteem, but is aware that she is not able to summon up the enthusiasm and the sense of hope that would allow her basic abilities to be used and shown. She has a sense of hopelessness and sadness that is common. As sometimes happens in depressed patients she has become a compulsive eater. Most depressed patients lose their appetite and lose weight but our reader is in the sizeable minority who over-eat and put weight on.

Most depressed patients appearance tends to become a bit sloppy, they subconsciously feel it is not worth the trouble of planning what to wear because no one is interested in them and life itself seems hopeless.

A very interesting comment and one that I have heard frequently from depressed people from all ranks of society is that they think their abilities are non-existent. They mistakenly reason that if only other people knew them better they would know that they are the shams that they consider themselves to be. I have known celebrated and excellent surgeons who genuinely believe that they have neither surgical ability nor knowledge, accountants who claim that their opinion is valueless, and brilliant lawyers who tell me that they have recently gone through life feeling sorry for their clients for having such a useless advocate.

It is always a mistake to change job before the effect of carefully planned psychiatric treatment has been given an opportunity to act. Initially a depressed patient's reaction to the suggestion of medication is that they know it won't do any good. The problem they argue lies within them or possibly with the job or their family life. It may take time to find the correct anti-depressant that will suit a patient's case for it is not only a matter of choosing the right drug group but the right drug within that group. Medication works better if it is accompanied by cognitive therapy.

Emma, and all those who are as depressed as she is, needs to have a long, frank talk with her own GP for together patient and practitioner must decide whether it is the treatment that needs changing or the psychiatrist.

I am a 43-year-old woman suffering from mild depression and on medication (cipralex 5mg). I am feeling much better now but I feel that nothing has been changed. I need to address my problem.

My husband (47 years old) and I have three very healthy children. Our marriage life is not perfect but we are OK. The big problem for me is lack of sexual relationship. We have been married for 13 years and our youngest is six. We haven't had any sex for six years not any physical contact at all. We moved our house from London to very remote countryside, which he wanted. He is completely retired and doing DIY at home. I do not mind that he is here twenty four hours a day as we are very independant although I am not working either.

We had experienced very stressful times, house, builders, school, new life. Now everything is settling down but our relationship has been changed. Maybe it changed a long time ago.

We are not good at sexual things. We have children because we wanted and we planned. We had sex a half dozen times over 13 years. I wasn't happy but I was very embarrassed to mention or suggest our lack of sexual contact.

But it's always there. I am getting very upset and wondering what is wrong with us. He certainly has no affair with anybody because he is always here. I want to have good sex. I mentioned to him but he thinks that every couple is different and shrugged off my comment and was very embarassed to talk about it. I love my husband and my family and I will put up with this misery but I want to have a cuddly skinship and if he is not interested in me or sex, then what can I do? I feel so low and depressed every time I think about it. It will never go away. Name and address withheld

The reader's problem is a common one. It is surprising how many of the letters to our column in Body and Soul's Saturday Times has questions of this sort.

People's sexual needs vary enormously. There are a multitude of reasons why some people need no active sexual life or very little, but can be completely emotionally satisfied by the company and presence of a loving wife or husband, but don't need to express this physically. Conversely others can only maintain a relationship if there is physical contact and sexual fulfilment. If there is an imbalance in the sexual needs of a pair the inevitable result is that there is resentment and a gnawing resentment often leads to some degree of depression. It is not at all unusual for over-riding domestic problems to destroy what is left of the lust that existed in the initial lustful stage of marriage or still is present in the nesting phase, also known as the phase of acceptance, that follows it.

You have drawn the important conclusion that what really counts in your life is your household, your children and your husband's company rather than his vanishing or vanished enthusiasm as a stud. It may be difficult after 13 years to change this latter aspect of his character. To try to do so could, if the cure was mishandled, could make the situation worse.

I am 47 and thought the panic attacks I experienced in my twenties were a thing of the past. They have now returned. I eat well, sleep well, and love my home life and work, so am at a loss as to why there are times when, out of the blue, I feel terrified, sick and weak. I have come to dread even going out to visit friends, and the one hour travel into work on the train entails me trying to cope by listening to music etc. Once at work I am fine. The last time I went abroad I passed out through sheer terror, and felt miserably homesick. I have a horror of feeling ill, so the slightest indication that I am unwell makes panic that there is something seriously wrong. This is not fair on my husband who wants a foreign holiday. I am currently on the list for an angiogram, and have very low blood pressure, so added to all this is the worry about illness and mortality. I should be happy with my life, but am very depressed and anxious most of the time, a fact I try to hide from my family as they have their own health issues. Could the panic attacks be the approach of the menopause? Is there anything I could do to alleviate the problems myself? If therapy is the answer, what kind is preferable? My GP is very dismissive, I cannot talk to her about this. I don't know who to turn to. Name and address withheld

Panic attacks are very commonly associated with both the menopause and depression. Likewise depression is often related to the menopause and all the challenges and opportunities that this next stage in your life has to offer. Low blood pressure is most unlikely to be associated with coronary arterial disease unless there has already been a silent coronary. Furthermore heart attacks are extremely unusual in menstruating women unless they are also heavy smokers, continue to take the high dose pill or have a severely raised blood pressure.

Three forms of treatment have to be considered in this type of case. Is HRT indicated? HRT should still be prescribed for a short time, say not more than a year or two, if the symptoms are disabling either professionally, domestically or socially. It does seem that this patient's life is being ruined domestically by possible menopausal symptoms. It may also be necessary to add either, or possibly both, medication or cognitive therapy. A GP who is very busy, or perhaps not interested in either the menopause or basic psychiatry, is usually happy and always prepared to arrange a second opinion.

Is there any evidence that a post-viral syndrome can cause a long-term emotional or mental imbalance? About three years ago, when I was 35, my GP diagnosed me with a common post-viral syndrome. For this there is no cure and little genuine treatment. I was able to keep working, but could physically manage nothing else. I couldn't walk long distances, drive a car or climb a large flight of stairs. I looked awful and my hair started falling out. Needless to say I was depressed throughout, I had few or no emotions at all. After about year, the symptoms began to lift, and I was enjoying the novelty of vast amounts of physical and mental energy. My body repaired itself and I felt exhilarated. I fell immediately head-over-heels in love with not one but two new acquaintances, which was a bit excess to requirements for a woman who'd been married for 10 years.

Subsequently, I've spent the last two years riding an emotional rollercoaster. I feel little love for my husband and we've recently separated, and I'm still in the thralls of obsessive lust for the two lovely men who are still on the periphery of my social life. I can't help but suspect the recovery from my illness, my emotional overload and ultimately the end of my marriage are all related. SL, London

Post viral syndrome when the presence of a viral, or any other infection, has been proved is a relatively frequent cause of depression. Love-like exercise alters the biochemical balance of the body and may cloud judgment. It may well be that this reader's infection and subsequent depression has started the train of events that will alter her life forever. It would be as well for her to have cognitive therapy before coming to too firm a decision. Lustful love has a span of about 18 months to three years.

I have a 35-year-old daughter who I'm very sure has dorderline personality disorder, and has suffered from this since her late teens. She refuses so far to seek help and her partner is powerless, but I have a feeling that if she could be presented with a possible combination proved to have helped (and I have heard that Prozac plus anti-depressants can work wonders) she might be willing to talk to her doctor with some understanding of what is on offer and I believe that she might even try to take it from there. I would be so grateful for any hope you could give me. Name and address withheld

A borderline personality disorder is in many ways the most severe of all personality disorders. The symptoms sometimes grow less as people reach middle age, but even so there may be relapses either at the menopause, in old age or at other times of crisis. It is essential that this important diagnosis shouldn't be made without careful consideration, and often a second psychiatric opinion is needed.

Why is it so difficult to find out the cause of depression, surely with today's MRI scanners this must make it an easy task? Mike McKeary, Paisley

Even functional MRI scans essentially illustrate which part of the brain is activated by certain activities. They don't, and at the moment can't, give us any idea of the biochemical changes that are accompanying this action. Depression is the result of changes within the biochemistry of the brain rather than its structure.

No comments: