Wednesday 20 February 2008

Being happy

I reviwed a lady with F33.4 Recurrent depressive disorder, currently in remission.

She is unhappy. She in not clinically depressed. Real life is unpleasant so she feels saddened. A normal human emotion to a normal situation. I've no pill for this scenario, either.

It's difficult. Some clever philosopher who's name escapes me reckoned there are only 3 outcomes to choose for any problem :
- you address it, solving it
- you accept it, then live with it
- you don't accept it, then walk away from the situation
In a simplistic, reductionist way it's true, how else would you manage any situation?

With this in mind, I counsel her in all 3 areas. I make suggestions and look at solutions; she's not keen to make pragmatic change. She's not keen to look at accepting her situation; she wants to feel happy. She won't leave her abusive husband, her home of 20-odd years or her nearby difficult/thieving grandchildren to walk away from the stresses to live with her daughter, on the coast.

She wants to be in the same situation, with the same stresses, making no changes, but feel happy. She's well, she's not depressed, she's active. We agree there are no outward signs I'd see differently if she were happy (i.e. she's going to bingo, she's going shopping, she's knitting for family, she bakes for the local church), her mood's not changing her bahviour or limiting her one iota. It's just, the joy of life's not quite there any more and she's like it back, through a pill, please.

I can treat depression, most of the time. But gifting bliss is beyond me. I am not a stand up comic, a clown, or a Butlins red coat. Making people happy is not my job. So why do I sometimes feel it should be?


Ms-Ellisa said...

(hold the phone- it's not your job?? ;-) I always thought of psychiatrists that way, but thinking about it now, it seems quite ridiculous and childish, so I guess I must be growing up or sth...)

Is it one of those cases were "you can't save people from themselves" in a sort of way?

What will you do?

If this has been going on for some time now (I presume) why did she ask for doctor's advice now?

Nurse Sandra May said...

Its funny, I was thinking about this just the other day.

My mother is like is, in fact, I probably am as well. I ask for help, but nothing ever changes.

It is very difficult to make that change- its a big step. Its easy to accept you have a problem- but so much more difficult to solve it.

How would you feel if the only real option was to leave, totally trandforming your life?

I can see where she is coming from.

Jen said...

Very interesting post...thanks. I've thought about this for a while as I have recurrent depression, but for fairly obvious reasons that no one can do anything about (3 autistic kids, one with cancer, ill husband, mom died after a very long and painful illness, blah blah blah). After years of seeing psychiatrists and psychologists it's finally boiled down to "I have valid reasons to be sad", and I think that's been very frustrating for a lot of them as there's really not much that they can do.

One of the best pieces of advice that any of them ever gave me was to make the CHOICE to stay and deal with things. Always have money ready for an escape even if I never plan to use it, but by making the choice to stay, it gives me enough of a feeling of control over the various situations to try to figure out how to live with them.

We're used to easy fixes in our society, and sometimes I think that we expect too much of the professionals that we see in order to get help. There are situations that can be changed, but sometimes interior or exterior factors prevent that from happening. It must be extremely frustrating to be a professional and have so many expectations placed on you to make us "happy".

Jan said...

I have a diagnosis of recurrent depression. I regard myself as having recovered from it, even though shrinks would only concede that I'm "in remission". I've had no depressive symptoms for years, I've been largely happy for years (even through some very distressing life events), and I feel that this is down to two things: acceptance, and making a decision to be happy.

Cockroach Catcher said...

Good to question the whole push for the “happy pill”. In life one goes through difficult times and we Chinese are fairly philosophical about it – unhappiness is often viewed as something secondary to external circumstances such as loss and bereavement, political injustice (which has afflicted most of our families) and other life events that are beyond our control. Our classical poets wrote about such sadness and generally accepted what life befell them.

I remember some years ago a neurosurgeon said on BBC that he did one of these newer leucotomies on an abused wife so that she could put up with the abuse from her husband. Unfortunately I cannot find the quote. Sorry.

The Cockroach Catcher

XE said...

I sometimes think that it's no longer acceptable to be sad in our society. When bad things happen, sadness would be a natural reaction, but it doesn't seem allowed anymore. It's all very odd.

Random, and completely not related to your post: I've picked up this "Much Badness" thing from you! I've been reading through nutrition this morning, and I have that phrase scattered all through my notes! I keep coming across stuff like this: "...which can lead to altered blood lipids (inc LDL, VLDL, triglycerides) and potentially ketoacidosis. Much badness. Another potential problem is..." You must've gotten inside my head ;-)

Disillusioned said...

There's such a huge difference between sadness and depression...

I wish it were possible to give people a glimpse into depression. It's not, really. If you haven't experienced it, I don't know if you can ever understand what it is like.

The Shrink said...

"There's such a huge difference between sadness and depression..."

You know that, all too well, it seems. Most folk see "low mood" as "depressed mood" as "depression." Folk also see it as a continuum, with normal then sad then depressed then suicidal, which can be true but usually isn't (with depression and suicidality being separate entities). If you see it as just a continuum, with folk slipping from noraml to sad to depressed, why can't they slip back again? If it's arising through clinical depression and chemical neuroendocrine brain changes, it's trite to think folk can just shake themselves out of it. Heck, who'd choose to be clinically depressed.

There are similarities, sometimes there is acontinuum, but equally I think this difference between unhappiness and clinical depression is, widely, poorly appreciated.

Anonymous said...

what a complex issue.
On one hand I have a very close friend with clinical depression, I get so frustrated with her 'learned helplessness' the very things that perpetuate her situation she refuses to take action, its too difficult etc..
Then I try to see things from her point of view. perhaps I have the psychological 'buffering mechanisms' intact to deal with life's many stresses?
Yet, although I am not a religious person that old cliche 'god helps those who help themselves' sometimes i get so angry with her (not to her face) our lives have not been all that different, so why is her mood perpetually in the gutter? I would never presume to know how she feels but I do wonder why she feels what she does!
Mental illness seems so difficult for the ones outside to deal with..if it was a broken leg she could have it plastered up and forget about it, but depression seems to infiltrate every conversation.
This probably says more about my inadequacies than hers.

Disillusioned said...

medically brunette, the thing is that depression makes you unable to help yourself, or certainly that is my experience. I have had episodes of depression where I am completely unable to function. I can't think. I can't motivate myself to do anything. I can't make any decisions. It's only when I start to recover, when the depression lifts, that I can start to help myself - very small steps at first, then more major ones. And I often need a lot of support and encouragement to take those steps.

Depression is an illness. It's not a choice. It's not something you can pull yourself out of. There may be things you can do to help yourself, but for many of us the depths of depression prevent us from even doing that.

It's akin to being in a cave, with lots of dark tunnels leading off. One of the tunnesl leads to the light. Yet, in depression, you can't even make the first move - because you can't decide which tunnel to take, and because you know none of them will actually help you to get out of the cave.

Lucy said...

It's a difficult situation, to be sure. I have been clinically depressed, and I know and understand how different that is to feeling sad (disillusioned, you describe it very well). However, feeling sad all the time is also not much fun, so I really feel for this lady.

How straight talking are you allowed to be? Have you told her that you are unwilling to prescribe medication because she is not clinically depressed, and that the reason she is unhappy is her situation (which only she can change)? Are you 'allowed' to say things like this to patients?

Please forgive my curiosity!

ditzydoctor said...

thought-provoking. i have a friend somewhat like that, she seems normal otherwise, but at the slightest chance she has, she will moan away about how sad her life is and how she wants to change it, but will do absolutely NOTHING to change it because that's the way she wants it.

just how do you deal?

Milk and Two Sugars said...

Whether the problem is a patient's social situation or their obesity or whatever, they do sometimes come to us in the expectation that we can and will. It can make us feel like we're meant to have the answers. But we can't help those who won't help themselves.

Milk and Two Sugars said...

Edit: that we can and will fix it.

Anonymous said...

I am surprised you have no comedic skills Shrink. Perhaps you could develop some and become a Shrink with Special Interest?

I agree that this is becoming a dependency state/world where, since Prozac (in my memory), people have relied on the panacea of health care to solve all ills. On the other hand, it's usually left to healthcare to solve all manner of ills, including social and housing difficulties.
My dear father, may God rest him since he moved to Crete to live in retirement, amongst many gems proffered:
"If things don't change; then they stay the same"
All I could come up with was, "so can I borrow the car or not then Dad?"

For Medically Blonde and your very close friend who suffers depression. I understand it's difficult to perhaps see why she's so down all the time when you seem able to 'buffer' life's little stressors and she just won't get her act together. Wherein lies this difference? I might simply suggest; when you are stressed, you have your very close friend to support you for who you are. When she is stressed, who does she have?

Anonymous said...

Very nicely written, and you raise a good point. I don't think I have the patience or creativity for a career in psyche.

I guess I should wait for rotations before I decide that...

Anonymous said...

tainted_halo, I must respond!
My close friend with depression, she has me! the question is not who does she have but who do I have?! she isn't in a position to hear any of my stresses or ills or to help me, she has enough to deal with! (I am so sorry but that assumption has made me a little cross!) Probably part of the reason I get so frustrated with her is that I give her everything I can and just hope she can try to feel better. she's clinically depressed! of course I'm not going to burdne her with my problems!
(btw.. its medically brunette, not blonde :)

Disillusioned, I don't presume to know what depression feels like or how awful it is. I was simply venting my own feelings. Surely there are people that care about you and must feel similarly.. I just want. We all recognise that illness affects not just the person but their families and friends also. I do not see how mental illness is any different. She is ill, I am upset by this, upset by my inability to effect change and by her helplessness.

The Shrink said...

"How straight talking are you allowed to be?""

I'm totally straight talking.

"Have you told her that you are unwilling to prescribe medication because she is not clinically depressed, and that the reason she is unhappy is her situation (which only she can change)? "

Yes, I've had a very explicit conversation with her about this, a few times now. She accepts (and actually has done since I first pointed it out) that she's miserable through her situation not through illness within her, so she's accepting medication isn't being prescribed. But a big part of her still wants life to be rosier and hopes beyond hope that a tablet could deliver that.

"Are you 'allowed' to say things like this to patients?"

Censorship is bad ;-)
Yes, I we can of course say what so ever we wish to our patients. That's given me food for thought . . . I'll post on this tomorrow!

Disillusioned said...

medically brunette, I hear what you are saying about the frustration. I think I was reacting to your "learned helplessness" statement and my perception that you feel your friend is (albeit partially) responsible for her illness, or for her failure to cope with it. Sometimes i can cope with my depression - other times I can't. I suspect my own guilt about having depression was also triggered - for I am very aware of its effect on those around me, and if I could do anything to stop having it, I would. I'm sorry if my comments made you feel I was criticising you - I wasn't, merely trying to explain what depression is like from the inside out.

PhD scientist said...

Would a Shrink w. a Special Recreational Interest (like stand- up) an S.S.R.I. ....?

Re. the comments on who is / isn't depressed, there is also the question of what stage of life you are at. In my middle-aged middle-class profession I have come across rather few people diagnosed depressed prior to age 25-26 or so. For the years roughly 28-45 I have met loads. It is a common experience that my classes of medical students (age typically 18-21) find depression totally "foreign" to them as a concept. "Hmm, just give yourself time" I find myself thinking.

Anyway, it surely seems to be an question of interaction between your "internals" (personality, underlying tendency to depression) and your environment and circumstances, inc "point in your life trajectory".

Made by Mandy said...

A geek (not Greek) philospher once wrote

"If someone can remain happy whilst all around them is pain and distress then it is they who are truly mad".

I prescribe loraxepam 2 milligrams at 6 hourly rates, throughout the day.

Disillusioned said...

Interesting, PhD Scientist.

My first episode of depression was at age 17. It was explained to me then, and to my parents as far as I know, as my being under pressure (A levels). My first diagnosed depression was at age 26 - symptoms of both were virtually identical and I suspect there was a reluctance ont he part of my GP or parents to assign / accept the "depression" label (or possibly to tell me this was the problem).

And yes, in my case all those factors you mention (and more) seem to coincide....

PhD scientist said...

Following all the furore over the SSRI (re) meta-analysis the papers this week have been full of "who is/isn't depressed enough to be medicated" (I'm paraphrasing).

I was dreading reading some of this stuff but actually, if you real ALL of what they have printed about it, the coverage in the Guardian is quite interesting as it gives a range of views from different folk (academics on both sides of argument, patients, ex-patients, analysts and therapists, GPs, psychiatrists etc etc). Quite thought-provoking - though that is my "untutored" opinion as a science-PhD-not-MD.

"Competing interests": took SSRIs twice for fairly brief periods (< 6 months), and have done both analytical-ish and CBT therapy.