M O O D S

I am a long-standing MDSG member and facilitator. Recently I drew upon skills I learned over the years in support groups to deal with two of the most horrific and life-shattering events I can imagine.

On September 11, I walked down 30 flights of stairs in Tower One of the World Trade Center. I was one of the very lucky ones. When the “earthquake” hit —or what I believed to be an earthquake at the time— my co-workers and I hesitated very briefly, just long enough to locate the stairs.

I walked down the steps hand-in-hand with a co-worker. At one point, we had to move to the left side of the staircase to allow the firemen to come up the steps. The atmosphere was pretty calm, considering. The only shouting I heard came later when smoke on the higher floors got too thick.

As I left the building, I did see two gaping holes in those commanding towers, but I just saw some glass on the ground, no injured people or debris. We were directed to the World Financial Center, and when I got near the Hudson River, I grabbed the hand of a colleague and walked north along the river.

The route was familiar to me, because it was the one I had taken last year during the Minds-in-Motion Walk-a-Thon for depression. But this was different; this time I was walking to a safe place, home on the Upper East Side. It took me four hours.

What followed were days of endless talking. I already knew the power of talking to those who had been through what I had; MDSG taught me that. After September 11, we, the survivors, endlessly told and retold our stories, but then feelings began to surface, too.

Many spoke of nightmares or fears—of riding over a bridge or even coming back into Manhattan. It was like being in a MDSG group and hearing someone talk about taking a shower at 4 p.m. and seeing everyone in the room nod, acknowledging that they, too, knew it can take a depressed person all day to get dressed.

From my years with MDSG, I knew I needed to reach out and talk to survivors of the tragedy who, unlike me, were not familiar with talking about their feelings, those who preferred to isolate themselves.

How many times as a facilitator, had I asked the silent ones in the support group, “Do you want to say anything?” Very often they said they just wanted to listen. This was true of many of my co-workers, too. Many seemed to be afraid to talk. And, while I understood this, I went ahead and urged survivors who lived near each other to get together and talk.

And, yes, I spoke to my horrified doctor and two therapists; they agreed that talking things over is beneficial, but they wanted to see me. I didn't want or need to talk to them. I needed those who’d been there and had escaped alive.

I had my breakdown four days later at 1:30 a.m. when I had a nightmare. I was lucky to have someone from our corporate counseling program to speak to over the phone at that hour. The very next day, however, my world again collapsed. 

My father was taken to the emergency room. A month earlier, the family had learned his condition was serious, but we didn’t think it was life threatening. After five days in the hospital, he passed away. He was hospitalized during Rosh Hashanah, the Jewish New Year, which I celebrated in a strange fashion. I spent the morning in synagogue and then went over to the hospital to let my father know that I had put in a good word for him.

I rode in a car on the holidays and spent money—two things I hadn't done in 10 years, and only then because I was depressed. Through all this, I continued talking to co-workers, friends and family. I knew from MDSG that talk was healing.

After my father died, I spoke to my therapists and psychiatrist who again expressed disbelief. I stressed that the only way for me to get through this was to talk and let the grief overcome me when it would. 

As I write this, it has been 17 days since the unspeakable event at the World Trade Center, and I look forward to hugging my co-workers—many of whom I have not seen since September 11. I have at times hugged MDSG members both to lend and to get support. I have cried along with them and offered tissues. 

At a support group, a member said she had been told by her mother “whatever doesn't kill you makes you stronger.” She said it seemed like just another throwaway cliché—like “just buck up” or “pick yourself up by your boot straps.” It seemed like a comment from someone who just didn't get it.

I now see this comment in a new light. If this is true, I say, then I must be Hercules. While I don't believe my Herculean powers will last forever, I am very thankful to have had them to help me. 

I know the effects of these two incidents on my life are far from over. I still hear about people I knew who are missing. The tears return when I hear another sad story.  As for grieving for my father, this is not over either; the grieving process for him and the victims of the trade center has become intertwined. Sometimes I cry for everybody all at once.

Through these experiences I realize again how important a good support system is. I am extremely lucky to have so many caring and loving co-workers and friends. In addition, my doctor and therapists stood by in case I needed them.

Fortunately, I even had the support over the phone of a kind, corporate counselor with a very soothing voice, known only as Melinda, to whom I spoke at all hours of the night. Above all else, I have a loving husband and family who allowed me to talk until I was blue in the face and have stood by me always. For this I am truly grateful.

At the many MDSG support groups we talk about how important a good support system is, but I know many people are not nearly as lucky as I am. Some complain about being lonely and isolated. A good place to begin to build a support system is at MDSG where you have the chance to talk to people who have experienced the same kind of suffering.

At MDSG, I have learned what compassion is all about. And I thank everyone there for teaching me how to better cope with such terrible life events.

I would like to dedicate this article to my father, because from him, I learned to keep on talking, and talking. Little did I know that someday a rush of words would help me heal a broken heart. 

More Thoughts About September 11th

by Li Lippman 

By now, all of us have experienced shock on some level from the events of September 11. Many of us witnessed the attack from the street or on television; some escaped from the scene; most of us know someone first-hand (or by a degree of separation) who worked at the World Trade Center.

Surely, we have noticed that since the tragedy, we have experienced troubling symptoms of trauma—loss of concentration, insomnia, loss of appetite, crying, a feeling that our work is insignificant, and a sudden interest in Middle Eastern affairs among other things.  People have moved forward in many ways, volunteering in the relief effort, running to city hall and getting married, getting back to flying, going out with friends and shopping in New York City.

Whoever you are, in the wake of the biggest terrorist attack on America, the process of grieving and growth are just beginning.

I think many of the coping skills needed to go on with our lives are similar to skills possessed by those who suffer from mood disorders. Setting up a support network, questioning the control we have over our lives and grappling with the idea of fate are concepts people with mood disorders have long dealt with. 

Could it be that those already in therapy, taking medication, and dealing with an illness like depression or manic depression are better equipped to process this disaster?  Who knows. 

I do know that since September 11th, I have seen people, who I thought might not have much resiliency, bounce back quickly. I have seen people who felt almost helpless find meaningful work in volunteering, donating blood, cooking for firefighters, giving applause on the West Side Highway to those involved in the recovery and just plain going on with their lives because they have a life and suddenly that was more precious than before. 

I wish you all strength as you persevere in this world so dramatically changed. Never have I felt so close to people I know and the strangers I see on the streets. I know that each of these people has lost someone in the World Trade Center, lost a workplace, a home, a piece of their heart as the buildings collapsed, lost a familiar skyline, lost sleep, lost patience, lost an innocence of some kind.

I am confident we have not lost joy in our lives because we, especially those who have had mood disorders, have been striving for joy our whole lives.

From the Chair

by Rich Satkin, Chairperson of MDSG 

In the aftermath of the attack on the World Trade Center and the Pentagon, there has been widespread discussion about the effects of stress. There is no doubt that everyone in New York City, especially, was traumatized, and although experts believe this tragedy-related stress will diminish eventually, it may take time.

Those of us with mood disorders may be vulnerable especially because this trauma may have already triggered episodes or may in the future.

On the other hand, some of us may avoid relapse, because having lived through so much emotional adversity, we may be better equipped to deal with such tragedy. Living a life of healthy, psychological vigilance may protect us. We also may be more adept at taking care of ourselves by keeping, in times of despair, to a routine and getting enough sleep, healthy food and exercise.

However, those who have experienced or are susceptible to post-traumatic-stress disorder (PTSD) may remain troubled for some time. PTSD has been described as a “[biologically-based] failure to consolidate a memory in such a way . . . [that it can] be recalled without distress.”

According to the National Depressive and Manic-Depressive Association, approximately half of those affected by PTSD recover within three months. Many, however, experience symptoms for more than a year. 

What can we do? Identify and accept whatever we’re feeling. Avoid jumping to the conclusion that our reactions are inappropriate. Having no feelings about the tragedy can be a sign of avoidance—a hallmark of PTSD. 

While anger is a common and understandable reaction to terrorism, feeling consumed with anger is not helpful.

Talk about your feelings with loved ones and others in your support network. This may lessen preoccupation with trauma and stress. Talk about how you’re coping and any problems you’re having in MDSG’s support groups.

Don’t dwell on negative thoughts. A tendency to view everything negatively is a powerful psychological predictor of PTSD. This is common enough in depression; in light of the tragedy, you may have to focus more intensely on positive thoughts. 

If PTSD symptoms arise, a combination of medication and psychotherapy is recommended. While cognitive behavioral therapy is considered most helpful in treating PTSD, psychodynamic therapy may be useful, too, in exposing the unconscious roots of the problem.

While our nation wages war against terrorism, it’s important to realize those responsible for this horrible violence worked for years to pull off their heinous plans. Some experts may say that those people, blinded by religious fundamentalism, aren’t technically diagnosable as mentally ill.

Contrast this with the widespread misconception that many people who are mentally ill are potentially violent. Remember: This is just that—a misconception. According to the Surgeon General, violence by individuals with mental illness who are in treatment is no more common than it is in the population at large.

It’s an important distinction to keep in mind as all of us at MDSG work to reduce stigma against people with mental illness. 

Have You Been Misdiagnosed?

by Jane Cartwright

The number of people suffering from manic depression who are misdiagnosed with depression is staggering, according to Gianni Faedda, M.D., who will speak to MDSG on the subject December 3. Are you one of them? Have you been told you suffer from depression alone, but you don’t seem to get better with antidepressants? Is your depression worse even though you’re on antidepressants? Does your depression recur? Come listen to a renowned researcher and practicing psychiatrist describe bipolar symptoms many physicians miss and why. 

More than half of those with bipolar illness are not getting proper treatment with mood stabilizers, because their doctors are not picking up subtle signs of elevated or shifting mood, according to Dr. Faedda.  Patients with manic-depressive illness (MDI) often seek help when they’re suffering from severe depression, he added, and without a thorough history of their illness or proper attention given to family history, many doctors misdiagnose major depression and prescribe antidepressants. 

But the clinical picture may be more complicated: the patient may be experiencing the depressed phase of manic depression. In these cases, taking antidepressants at all, or without a mood stabilizer, may make the illness far worse, said Dr. Faedda. And such a diagnostic mistake can be costly: the patient may lose his or her career, family relationships, friends and way of life. 

“The most common form of misdiagnosed MDI is probably the group of conditions that manifests predominantly with depressive symptoms,” said Dr. Faedda. “Those in which the up swing (or the manic phase of the cycle) is very subtle—perhaps even milder than what is described as hypomania (a milder form of mania). 

“These are forms that present basically as recurrent depressive conditions where there might be very short-lived, apparently ‘well,’ intervals between depressions,” said Dr. Faedda. “We have shown that these pseudo-unipolar forms can be highly recurrent, can sometimes have a seasonal course or a very early age of onset . . . Often these are initially treated with antidepressants, but turn out, in large numbers, to be what we call treatment-refractory depression (hard-to-treat depression).”

In fact, misdiagnosis may be more of a problem than we realize. Dr. Faedda cites a study in which 250 patients with major depression were evaluated. After the initial interview, 22 percent were re-diagnosed bipolar. But with further and more sophisticated evaluation, the number of bipolar patients jumped to 40 percent. “When a patient presents with depression, nobody poses the question, ‘Is this the depressive phase of manic depression?,’” said Dr. Faedda. “Almost everybody starts with a diagnosis of depression as if manic-depressive illness were a rare disease that only presents with mania. Nothing could be further from the truth.”

Sometimes bipolar depression “responds almost miraculously” to antidepressants, he noted, but this may be short lived. Or the depression improves but then switches to hypomania and increased cycling.

“Patients may sometimes enter what we call depressive, mixed states (symptoms of both depression and mania) ”, said Dr. Faedda. “These look like severe or agitated depression. There are a lot of excitatory symptoms such as anxiety, racing thoughts, restlessness and insomnia. These forms of illness--instead of improving with antidepressants--actually get worse.”

While the current estimate of the prevalence of bipolar disorder in the population is 1 percent—the same as schizophrenia—it may, in fact, be far more common; it may be as high as 5 to 10 percent, according to Dr. Faedda.

What can be done to avoid misdiagnosis?

“The first issue is education,” he said. “We need to provide the general public with the means to assess their behavior, to watch for changes in sleep patterns, changes in mental functioning, changes in physical activity and to urge them to report these to their doctor. 

Many people may not know that “one of the most common features of manic-depressive illness is the patient’s tendency to self-medicate with alcohol or other substances,” he said. “There is often abuse of both sedatives and stimulants. You see this with about 50 percent of people suffering from manic-depressive illness. 

“A collaborative effort between the doctor, the patient and their families is important in order to reach an accurate diagnosis and to implement a successful course of treatment.” Dr. Faedda said. 

“Before a diagnosis is made, a careful family history must be taken. This is a hereditary condition. I ask all my patients if they or anyone in their family have had an unusual work history such as a frequent change of jobs, or frequent moves from place to place, or difficulty staying in a relationship or financial difficulties such as accumulated debt. I inquire about substance abuse, gambling, violent or criminal behavior.”

Dr. Faedda warned physicians not to prescribe antidepressants indiscriminately. “I don’t think anybody with a family history of manic-depressive illness or with symptoms suggestive of a recurrent illness should be treated with antidepressants alone,” he said, “not without careful consideration of clinical features suggestive of a mild, subtle or atypical form of manic-depressive illness. If one is not careful, a depression can be helped but at the cost of destabilizing the illness.”

He thinks the Diagnostic Statistical Manual IV, the instrument most physicians use to diagnose psychiatric disorders, is too limited in its definition of bipolar disorder. “It is essentially a research instrument for identifying patients with classical symptoms of the illness for research protocols,” he said, “not a way of identifying those who may benefit from mood-stabilizers. 

“. . . There are many (mood-disorder) conditions that fall on a continuum,” he said. “Certain forms only have depressive symptoms, other forms only have manic symptoms. There are forms that are highly recurrent, and there are forms that only have one or two episodes over a lifetime; there are forms that are rapid cycling, with very short-lived episodes; others tend to be almost chronic or chronic; there are forms with psychosis and others without.

“Before we go hairsplitting and defining subtypes, we have to define those conditions that are likely to respond to mood stabilizers. The real issue is guaranteeing that those who can benefit from mood stabilizers are given a proper chance to see if they’ll respond to them—as opposed to putting everyone on antidepressants and then going back and treating antidepressant-induced hypomanic or manic symptoms.

“The word bipolar, in fact, may be a misnomer, because there are forms of depression or so-called depression that are responsive to medications that help people with manic depression. I think it’s a tragedy that physicians are withholding mood stabilizers from patients only because they don’t meet manmade criteria now being considered almost like a dogma.”

Dr. Faedda, who is researching the course of manic depressive illness in children and adults, estimates 50 percent of bipolar disorder patients had symptoms as early as childhood. 

What symptoms should we look for in kids?

“Any pathology that affects mood or activity, including symptoms of attention-deficit disorder or behavior,” he said. A family history of any mood, anxiety or substance-abuse disorder is a red flag. “Children as young as four may think about suicide,“ he said, “and make attempts when they reach their teens. With as many as 20 percent of untreated, bipolar-disorder patients committing suicide, this is far from a benign condition.”

Ask the Doctor        with Dr. Ivan Goldberg

Q. I am a nurse. Another nurse told me she suffers from bipolar disorder, healed by God of manic episodes but not of depressive ones. Her behavior is odd, to say the least. She says her doctor told her bipolar disorder is caused by damage at birth to the 13th chromosome, which caused a chemical imbalance that external stressors can trigger into mood swings. This sounds a little strange to me. She feels she is not accountable for strange behavior during episodes of irrationality or grandiosity (Isn't this part of the manic phase?), because this is the disease talking and not her. I have never known her to do anything to harm a patient, but we both work with critical-care, pediatric patients. Do you think that I should alert our supervisor? For all I know, she may be putting me on.

A. Bipolar disorder runs in families and is transmitted genetically. But it isn’t known which chromosomes are involved. Damage to a chromosome at birth wouldn’t cause bipolar disorder, however. Unless I knew her behavior might harm patients, I wouldn’t talk to a supervisor.

Q. Are there tests available to determine if someone is bipolar? We’re unsure what we can request from our health-care provider or what can be done. What do you think of herbs? Are there any available?

A. There are no biological tests to determine if a depression is part of bipolar disorder. There are tests to see if a depression is the result of any number of metabolic disorders such as hypothyroidism. You should request a consultation with a psychiatrist (not a psychologist) who is an expert in the diagnosis and treatment of people with mood disorders. No herbs adequately treat bipolar disorder.

Q. I’ve been diagnosed with depression and post-traumatic-stress disorder and have been treated with Selective Seretonin Reuptake Inhibitors (SSRIs) like Paxil that seemed to stop working after a while. When Celexa stopped working, my doctor added Wellbutrin SR 150 mg once a day. I felt okay until I dipped again into depression. She increased the Wellbutrin to 300 mg, but I couldn’t tolerate this. I became confused and couldn’t complete my college papers. For the first time in a long time, I suffered from panic disorder. Oh, I also take 1 mg of lorazepam three times a day. How can I find out if I really suffer from bipolar disorder? My depressions are like a roller coaster, and sometimes I’m unable to function. I think a blanket diagnosis of depression, post-traumatic-stress disorder and panic disorder may not be all. My doctor is a wonderful internist, and I can’t afford a psychiatrist.

A. Unfortunately, the only way to find out if you have bipolar disorder is to consult a psychiatrist who is an expert in diagnosing this disorder. Most internists and all too many psychiatrists fail to diagnose bipolar disorder because they’re unable to spot the large group of people who suffer from the “soft” symptoms of the disorder. You can read about soft bipolar at:  www.psycom.net/depression.central.soft.bipolar.html

Q. (In a recent newsletter you wrote:) “Most people with bipolar disorder never develop psychosis.” When I took the MDSG facilitators' training classes with you in November 1995, I asked whether psychosis always accompanies a manic episode; your answer was, “Not always, but more often than not.” (I was particularly interested because of my own most recent manic episode, which included psychotic features, and I noted your answer in writing.) Regarding the frequency with which psychosis occurs in bipolar disorder, whether in manic or depressive episodes, what has changed your opinion?

A. Here is an expanded explanation. When I use the term “bipolar,” it includes people with bipolar I (depression and mania) and bipolar II (depression and hypomania, a milder mania). Many people with bipolar I have a psychotic aspect to their manic episodes, but people with bipolar II have only hypomanic episodes, no manic episodes, and psychosis is never part of a hypomanic episodes. There are many more people who suffer with bipolar II than bipolar I.

We Get By with a Little Help from Our Friends . . . 

MDSG provides award-winning services to New York’s entire mental health community---over 800 individual support groups a year, the distinguished lecture series, our telephone information service, this newsletter. And all at the lowest possible cost, through volunteers.  The $4 contribution for meetings doesn’t cover all our expenses. We need your help to pay the phone bill, print the newsletter, promote MDSG in the media, and meet other needs.

Annual membership is $35 for individuals, $50 for families. Your membership card is a free ticket to support groups and most lectures. Contributions are tax deductible. So be a friend of MDSG--support us as we support you!

Memberships and contributions to MDSG are tax-deductible to the extent allowed by law. MDSG is an IRS-recognized 501(c)(3) organization..

About  MDSG

MDSG/NY sponsors a series of  lectures on various aspects of mood disorders. Anyone can attend our lectures. More information is available on our lectures page at www.mdsg.org/lectures.html. Our next lectures are:

Writers on Depression
Monday,  January 7, 2001   Nell Casey, Martha Manning, and Andrew Solomon
Meet three renowned authors who have dedicated their writing talents to this topic. Andrew Solomon's recently published "Noonday Demon", as well as Nell Casey's "Unholy Ghost", have received critical acclaim for their honest and heartfelt depictions of the effect depression can have on an individual as well as their loved ones. Martha Manning, psychologist and author of numerous books on depression, was most recently prominently highlighted in Rosie O'Donnell's magazine which dedicated its August issue to the subject. For more information, see the lectures page. 

Omega-3 Fatty Acids
Monday, February 4, 2002  Andrew L. Stoll, M.D.
Omega-3 fatty acids are effective mood stabilizers and antidepressants, according to a double-blind, placebo-controlled study conducted by Dr. Stoll at Harvard. Come hear him discuss the results of the study and decide whether these supplements may help you.