According to Dr. Marchand, the risk of recurrence — “relapse after full remission” — for a person who’s had one episode of depression is 50 percent. For a person with two episodes, the risk is about 70 percent. For someone with three episodes or more, the risk rises to around 90 percent.

That’s why having a prevention plan is critical, he said. “Depression is often a chronic illness, but with a good prevention plan in place, it is often possible to prevent recurrences entirely or limit the severity and duration if depression does return.”

A prevention plan must include maintenance treatment, which is “treatment that is continued after symptoms are in remission to prevent recurrence.” This includes medication, psychotherapy or both, Marchand said. (If you’re currently receiving or have received treatment, make sure you have a prevention plan.)

It’s also important to understand what might trigger a possible relapse, and how you can prevent or minimize the influence of those triggers. Below, you’ll find three common triggers for depression, along with information on navigating a relapse.

Trigger: Not Following Treatment

“The biggest issue regarding relapse has to do with children and adults not following through on their treatment plan,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression. This includes anything from skipping therapy sessions to missing doses of your medication to ending therapy too soon, she said.

If you don’t want to take your medication because of side effects (or other reasons), talk to your prescribing physician about these issues. They may reduce your dose, prescribe a different medication or recommend another strategy to minimize side effects and respond to your concerns. Similarly, if you’re dissatisfied with your therapy sessions (or you’re having a hard time getting to your appointments because of logistics), speak up.

Depression, like other chronic illnesses, requires “commitment and management. [Y]ou have to learn to live with it every day but not allow it to define you,” Serani said. How? Focus on celebrating your strengths. “While your life may involve psychotherapy, medication and the need for a protective structure that keeps your illness at bay, also realize that you have passions, desires, gifts and talents that require just as much attention.”

Also, “make sure you take extra special care of your mind, body and soul,” Serani said. “This means being attentive to your sleep cycle, moving your body with exercise [and] eating wisely and well.”

Trigger: Ruminating

“Negative self-referential ruminations play…a key role in recurrence,” Marchand said. For example, individuals with depression tend to dwell on their (supposed) flaws and failures. They also may view neutral events with a negative lens.

That’s why it’s important to develop a strategy for managing these thinking patterns, he said. “Cognitive therapy or mindfulness-based interventions are particularly useful in this regard.”

Trigger: Not Knowing Your Personal Vulnerabilities

“Triggers may be very specific to each individual’s situation, since all of our emotional responses are unique to some extent,” Marchand said. To identify your triggers, “learn how to recognize the who, what, whys and whens of your emotional and physical life,” Serani said.

Look at your calendar for potentially difficult periods. For instance, this might be an anniversary of a divorce or death or anxiety about a mammogram, Serani said. Highlighting these days “allows you to anticipate and plan for threats to depression recovery.”

Also important is to “take an inventory of all the hats you wear in your life.” Serani suggested considering these questions: “What circumstances at work affect your mood and behavior? At home, do certain actions of those around you tend to upset you? Are you feeling supported or overwhelmed? What happens when you don’t get enough ‘me’ time?”

Check in with your physical state, Serani said. “If you find yourself excessively fatigued, irritable, having trouble eating or sleeping, you might be in the midst of a trigger event.”

Finally, you can identify triggers by “think[ing] about previous depressive episodes and determin[ing] if there were specific triggers,” Marchand said.

Navigating a Relapse

Sometimes it’s not possible to prevent a relapse. But by knowing the early signs and getting treatment right away, you can prevent a full-blown episode or lessen its severity and length.

“Generally, early relapse will take hold with subtle signs, like mild irritability and sadness,” Serani said. Tracking your mood states every day helps you spot these early, not-so-obvious signs. “Through journaling, mindful reflection, and even apps on the computer, keeping a running tab on mood states can help offset relapse.” For example, if you’ve logged in 7 to 10 days of negative measurements, contact your practitioner to get evaluated for a relapse, she said.

Marchand also stressed the importance of contacting your doctor or therapist “at the first evidence of recurrence. Interventions may include restarting medication or psychotherapy… [I]f [you’re] in maintenance treatment [it’ll include]…adjusting [the] frequency of therapy or the medication dose.”

If you have a relapse, you might feel overwhelmed, frustrated and deeply disappointed. But “don’t measure your success living with depression on whether relapse happens or not. Instead, realize that if relapse occurs, true success comes from rising after the fall,” said Serani, who’s had depression herself. Her mantra is the Japanese proverb: “Fall down seven times, get up eight.”

And, again, whether you have a relapse or not, take good care of yourself, seek support and show yourself some compassion. Depression is a difficult illness. But, with treatment and healthy strategies, you can manage (and possibly eliminate) your symptoms and get better.

But successfully treating bipolar disorder can involve several medication trials, and it can take years to achieve remission. Even if remission is attained, recurrence is the rule — not the exception. It’s not uncommon for all first-line treatments to be exhausted.

People in this situation may be considered by mental health professionals to be treatment-resistant. Luckily, there are treatments that can be tried when first-line, and even second-line, treatments for bipolar disorder fail.

What is Treatment Resistance?

There is no consensus among clinicians and researchers on one definition of treatment resistance. Generally, patients in an acute state (manic, depressed or mixed) whose symptoms do not improve after at least two evidence-based medication trials are considered treatment-resistant in research studies. In the maintenance phase, patients are considered treatment-resistant if they continue cycling despite several adequate medication trials.

In some studies additional criteria must be met in order to truly be considered treatment-resistant. These include functional measures of remission.

Dr. Prakash Masand, psychiatrist and founder of Global Medical Education argues, however, that “Treatment-resistance is more common than most clinicians think since a sustained response to treatment rarely includes an assessment of functioning. When functioning and residual depression are taken into consideration, far more patients would be considered treatment-resistant.”

First-Line Treatments for Bipolar Disorder

First-line treatments for bipolar disorder have been shown to be the most reliable. They are approved by the Food and Drug Administration (FDA). First-line treatments vary, depending on the phase of bipolar disorder the patient is in.

First-line treatments for mania include:

• Valproate (Depakote)
• Carbamazepine (Tegretol, extended release)
• Lithium
• All atypical antipsychotics such as risperidone (Risperdal), quetiapine (Seroquel) and aripiprazole (Abilify)

In the depressed phase of bipolar disorder, only quetiapine and an olanzapine (Zyprexa)/fluoxetine (Prozac) combination are approved as first-line treatments, although lurasidone (Latuda) is awaiting FDA approval.

For mixed episodes of bipolar disorder, carbamazepine and most atypical antipsychotics are approved. For the maintenance phase of bipolar treatment, lamotrigine (Lamictal), lithium, aripiprazole and olanzapine are FDA-approved.

Second-Line Treatments for Bipolar Disorder

According to Dr. Masand, many treatments are still available for people considered treatment-resistant. “People should not give up hope just because several treatments have failed. We have many tools in the toolbox outside of first-line monotherapy treatment.”

Primary second-line treatments in bipolar disorder include adjunctive treatments such as the addition of an atypical antipsychotic to lithium or valproate or vice versa. Dr. Masand notes that “patients in a manic or mixed state may actually respond more quickly to lithium or an anticonvulsant combined with an atypical antipsychotic.”

And while antidepressants should never be used alone to treat bipolar disorder, adding them to an existing mood stabilizer or antipsychotic is considered a second-line treatment and is sometimes helpful for bipolar depression. “Additionally, adjunctive armodafinil (Provigil) may also be useful in bipolar depression,” Dr. Masand. said

Additional Treatments for Bipolar Disorder

There are additional therapies that can be considered even if both first-line and second-line treatments fail. According to Dr. Masand, third-line treatments include clozapine (Clozaril), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), calcium channel blockers, high-dose thyroid augmentation, omega-3 fatty acids and other anticonvulsants.

“Novel treatments are also being researched,” Dr. Masand said. “Agents such as n-acetylcysteine, mexiletine (Mexitil), pramipexole (Mirapex), ketamine and others have shown promise for the treatment of the various phases of bipolar disorder. It’s also critical that all patients with bipolar disorder receive an adjunctive proven psychotherapy such as psychoeducation, family-focused therapy, interpersonal and social rhythm therapy or cognitive behavioral therapy (CBT), as relapse rates have been shown to be lower when therapy is added to medication treatment.”

Dr. Lindskog explains that depression “is characterized by both emotional and cognitive symptoms.” However, she adds, “the relationship between these two symptoms of depression is poorly understood.”

The team compared ordinary rats against a strain of rats that had been bred with a disposition toward depression. This strain of rats has recently been found to have decreased emotional memory, impaired brain plasticity, and a smaller hippocampus.

The idea was to investigate the glutamatergic system, which is a system of amino acids vital for information processing in the hippocampus, in order to “reveal the mechanisms underlying the emotional and cognitive aspects associated with the disease.”

Clinical studies have shown abnormalities in the glutamatergic system in depressed people, but it is not yet clear how this affects the brain and contributes to depression symptoms.

All of the rats were injected with D-serine, a substance secreted by support cells for brain neurons called astrocytes. The “depressed” rats showed an improvement in their previously impaired brain plasticity and on memory tests.

Apathy was tested by releasing the rats into a container of water and observing whether they immediately tried to climb out or stayed floating in the container. The “depressed” rats showed no improvement in their level of apathy following the injection with D-serine.

“We have shown that there are two symptoms that can be influenced independently of one another, which means they could be treated in tandem in patients with depression,” said Dr. Lindskog. She added, “It’s likely that astrocytes perform a very important function in the brain.”

The researchers also found that the hippocampus in the brains of depressed rats had a lower plasticity that left them unable to increase neuron activity when needed. But after being soaked in D-serine, the plasticity of the hippocampus in brain samples improved.

A reduction in the size of the hippocampus is one of the most common findings in depressed patients and in this depressed strain of rats. It has a “prominent role” in memory and a potential role in emotional symptoms, say the authors.

Reporting the findings in the journal Molecular Psychiatry, the authors state, “Both synaptic plasticity and memory impairments were restored by administration of D-serine.”

Dr. Lindskog says, “D-serine doesn’t pass the blood-brain barrier particularly well, so it’s not really a suitable candidate on which to base a drug. But the mechanism that we’ve identified, whereby it’s possible to increase plasticity and improve memory, is a feasible route that we might be able to reach in a way that doesn’t involve D-serine.”

She believes it is crucial to learn more about this process. “These findings open up new brain targets for the development of more potent and efficient antidepressant drugs,” Dr. Lindskog says.

In their journal paper, the team explains that current antidepressant drugs sometimes resolve emotional symptoms without benefiting depression-linked deficits in memory and learning. This discrepancy “suggests the involvement of different mechanisms in the origin of these two key aspects of depression,” they write.

Perhaps this study holds the key to these different mechanisms. As the researchers say, “Based on our results, we propose a mechanism in which dysfunctional astrocytic regulation of glutamate affects glutamatergic transmission, causing memory deficits that can be restored independently of the emotional aspects of depression.”

They can also account for the lower D-serine level in the hippocampus of depressed rats: it is due to changes in the shape and function of astrocyte neurons.

“In summary,” they write, “our data describe interactions within the glutamatergic system that should be considered when designing new therapies for depression.” Several different aspects of the system should be targeted “to effectively treat both the cognitive and emotional symptoms that are associated with depression,” they add.

More recently it has been confirmed that, as Dr. Lindskog suspected, astrocytes are of major importance in depression. Dr. Boldizsar Czeh of the Max-Planck-Institute of Psychiatry, Munich, Germany, and colleagues took a further look at astrocytes.

They report that astrocytes “are regarded as the most abundant cell type in the brain,” but it seems they also regulate synapses, that is, the area that allows communication between neurons. They appear to control neuron development in the hippocampus.

In the journal European Neuropsychopharmacology, the team sums up all the evidence that antidepressant drugs affect astrocytes. “We propose here a hypothesis that antidepressant treatment activates astrocytes, triggering the reactivation of cortical plasticity.”

They believe that these astrocyte-specific changes probably contribute to the effectiveness of currently available antidepressant drugs, but they add that “better understanding of these cellular and molecular processes could help us to identify novel targets for the development of antidepressant drugs.”

References

Dysfunctional Astrocytic Regulation of Glutamate Transmission in a Rat Model of Depression. Gomez-Galan, M. et al. Molecular Psychiatry February 28, 2012 doi: 10.1038/mp.2012.10

Czeh, B. and Di Benedetto, B. Antidepressants act directly on astrocytes: Evidences and functional consequences. European Neuropsychopharmacology Volume 23 Issue 3 pp. 171-85 March 2013.

I communicated with Dr. Hudak recently, to clarify some questions, get his take on some extrapolations of anxiety and even to inquire about an interesting diagnostic title he proposed in his presentation.

Conference breakout workshops, be they NAMI or just about any organization, can never do justice to a topic in the short time allotted, but it is always good to get a small group together to at least begin a dialogue.

In his session, Dr. Hudak defined anxiety, reviewed the disorders as classified by the old and up-and-coming Diagnostic and Statistical Manual (DSM), discussed when and how to treat anxiety, and addressed referral concerns. Most of the content described herein is directly from his slide presentation, combined with quotes from my interview with him.

Interestingly, anxiety is “the only psychiatric symptom that is also experienced by individuals with no psychopathology.” Think about what that means. It can be found in normal emotion, or in psychiatric illness. But it can show up as “secondary to a medical or psychiatric illness, or as a primary symptom of a medical illness.” There are two states– not just psychological but also physiological — and four components — somatic, emotional, cognitive, and behavioral.

It is hardly a secret that even mild anxiety can show up in our bodies. The onset of hives for me during teen years, personally, was definitely emotionally-based, no matter how physically those deep red welts marred my arms. And as the emotional and behavioral components of anxiety are “givens,” in a sense, I asked Dr. Hudak to elaborate a bit on some of the cognitive components that might surface.

“The main one is an inability to concentrate or an inability to focus or pay attention,” he replied. “People sometimes complain to me that they feel like they have ADHD because their concentration is so bad.”

Due to internal family conversations that I have witnessed and been a part of at NAMI groups, though, I was thinking along the lines of more severe cognitive impairment even if acutely, as in stress-induced psychotic symptoms, disorganized thinking in how one presents to others, disassociation, or any manipulative behavior.

Given a chance to respond further, Dr. Hudak explained that “diistorted thoughts absolutely occur secondary to anxiety.” He gave the example of a mother who may not let ever her kids leave the house due to fear that they might get into a car accident and die.

“If they do leave, they may be required to check in every few minutes to ensure her they have not died, which most people would consider very extreme.” He goes on to say that “cognitive restructuring (in order to get her to realize that the chances of this happening are extremely unlikely and her reactions are extreme) is a part of the treatment, but only part. Simply doing that alone won’t work. Other behavioral methods are needed as well.”

As for stress induced psychotic-like symptoms, Dr. Hudak felt them “extremely rare” (but I know many family members through NAMI who might disagree!) Most important, as stressed in his workshop, “anxiety is expressed in a wide variety of ways by different individuals.”

The outgoing DSM has obsessive-compulsive disorder (OCD) as an anxiety disorder, but it will apparently be given its own weighted place elsewhere in the new one. Anxiety Disorder NOS (Not Otherwise Specified) will still be there, though, and Dr. Hudak curiously had it labeled “Hudak’s Syndrome.”

“This is a joke I tell to drive home a point. Every major psychiatric category has a NOS category which is generally used as a wastebasket term, for symptoms that don’t appear to be a diagnosable psychiatric condition…. I don’t feel it is a wastebasket term but is an actual separate illness that people can have, and to emphasize that it is different from generalized anxiety disorder.”

He goes on to say that he has certainly heard others comment, as well, that anxiety NOS is an actual illness and not just an NOS category.

His presentation gives an integrated approach for the treatment of all anxiety disorders, with consideration of medications and behavioral therapy, yet he definitely feels, as most, that “cognitive-behavioral therapies are the only ones shown to be effective for anxiety disorders.” These include specific physical techniques to help people cope with anxiety, as well as cognitive ones, such as self-record keeping and progress-tracking. “Thinking skills” also help individuals face situations that cause anxiety.

In his presentation, Dr. Hudak covered panic attacks in depth. I found it interesting to note that he included explaining the harmlessness of panic attacks as a specific, disarming therapeutic technique to be included in treatment.

A thorough look at the latest medications, and the symptoms they best treat, was given via his slide lecture. Some interesting points definitely stood out. He mentions FLAMS (Frontal Lobe Amotivational Syndrome) as a potential severe side effect of SSRI meds. Individuals being treated with these may “feel apathetic and emotionless…. very difficult to treat.”

“Exposure with Response Prevention” was one of Dr. Hudak’s slides and topics. This “teaches people that the physical symptoms of anxiety are normal and OK.” In treatment, a careful attempt to try to raise the heart rate will take place (by doing triggering behaviors and mechanisms).

Dual diagnosis — mental illness and co-occurring substance abuse — is a problem for many. Whether attending AA or NA, or on a treatment with an agonist like suboxone, it has been documented that acute anxiety is one of the most common co-occurring conditions with these patients.

Dr. Hudak feels that the the best way to determine the cause of the anxiety in these circumstances is to get patients sober. Nevertheless, anxiety can and will present in myriad forms, for myriad people, as is clearly pointed by his research and effective presentation.

An effective workbook is referenced in Dr. Hudak’s material — Mastery of Your Anxiety and Worry, by Zinbarg, Craske and Barlow, as well as some local resources for OCD, one of Dr. Hudak’s specialties.

Yet cognitive symptoms are quite common. “[They] are actually significantly prominent in depression,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression.

And these symptoms are incredibly debilitating. “In my opinion, when cognitive symptoms of depression hit, they are more of a pressing concern than physical symptoms.”

Cognitive symptoms can interfere with all areas of a person’s life, including work, school and their relationships. Problem-solving and higher thinking, according to Serani, are greatly diminished. “This can leave a person feeling helpless and without a plan of action to defeat depression.”

Poor concentration can cause problems with communication, and indecisiveness may strain relationships, according to William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

The cognitive symptoms of depression also may get confused with other conditions, complicating diagnosis. Here’s a specific list of symptoms along with similar disorders.

Cognitive Symptoms of Depression

“Cognitive symptoms can be subtle and often go unrecognized,” according to Dr. Marchand. Fortunately, psychotherapy can help individuals become more aware of these symptoms, such as distorted thinking, he said.

Marchand and Serani shared these cognitive symptoms of depression:

• Negative or distorted thinking
• Difficulty concentrating
• Distractibility
• Forgetfulness
• Reduced reaction time
• Memory loss
• Indecisiveness

Disorders That Mimic Depression

“The cognitive aspects of depression usually involve a person’s thinking being sluggish, negative or distorted in quality,” Serani said. However, there are many other disorders that share these similar symptoms, because they, too, inhibit cognitive function. Unfortunately, this means that the “risk for misdiagnosis is high,” she said.

For instance, Serani mentioned attention deficit hyperactivity disorder (the inattentive type), post-traumatic stress disorder and substance abuse.

Co-occurring disorders can add to the confusion. “In many cases there are comorbid conditions such as dementia (in elderly individuals), adult ADHD and generalized anxiety disorder, and it can be difficult to sort out which condition is causing the cognitive symptoms,” Marchand said.

It’s critical to receive a proper and comprehensive evaluation to make sure that you have depression or another condition. Again, psychotherapy and medication can improve cognitive symptoms along with other symptoms of depression. Also, there are many strategies you can try on your own to reduce symptoms and feel better (which are explored in another article).

But it’s actually not uncommon for the first treatment to be unsuccessful. In fact, about 40 to 50 percent of people don’t respond to the first antidepressant they’re prescribed, according to Jonathan E. Alpert, M.D., Ph.D, the associate director of the Massachusetts General Hospital Depression Clinical and Research Program and co-founder and co-director of the Depression and Anxiety Group Practice.

Still, the people who stick with treatment do get better. So there is hope – real, tangible hope. Below, you’ll learn why treatment might not work, along with what you can do and how you can advocate for yourself.

Why the First Treatment Doesn’t Work

There are many reasons why the initial treatment doesn’t take. Here’s a selection.

Incorrect diagnosis. The treatment might be ineffective because the person doesn’t have depression in the first place. For instance, medical illnesses such as hypothyroidism can look like depression. Hypothyroidism produces significant fatigue, lack of motivation and difficulty concentrating, Dr. Alpert said.

A person might have another psychiatric disorder such as bipolar disorder. “On average bipolar disorder takes 7 years to diagnose,” said Kelli Hyland, M.D., a psychiatrist in outpatient private practice in Salt Lake City, Utah. Or an individual might have a personality disorder, which doesn’t respond to medication, she said. (In fact, “medication is often contraindicated.”)

Even if the diagnosis is correct, medical conditions can blunt the effect of antidepressants, Alpert said.

Stressors. Sometimes, the person is “living in an untenable situation,” Alpert said. So it doesn’t matter how well the antidepressant is working because the individual is still surrounded by stress – either at home or at work – that needs to be addressed, he said.

Adherence. Some people might stop taking their medication because they’re concerned that it’s habit-forming, addictive or a crutch, Alpert said. Other individuals might stop because they actually feel better. But, as he said, “Once someone responds, they need to stay on medication for a minimum of 6 to 9 months to ensure they don’t have a rapid relapse.”

Another reason people stop taking their medication is side effects, such as nausea, diarrhea, sexual dysfunction or weight gain, he said. (“Many of these side effects can be addressed by switching to a lower dosage or a different antidepressant or sometimes by prescribing a second medication that helps alleviate the side effect.”)

Alcohol or drug use. “Alcohol and drugs interfere with antidepressant response,” Alpert said. Even having a beer or glass of wine at night can mess with your medication, Hyland said.

Other medications. Hyland noted that other medications, such as steroids and hormones, can interfere with antidepressants. (Being perimenopausal or menopausal also can affect efficacy, she said.)

Sleep problems. “I tell my patients that if you’re not sleeping, we can take medication ‘til the cows come home,” Hyland said. “Insomnia exacerbates mood, anxiety and coping.” Treating an underlying sleep disorder or trauma is important, she said.

Severity of illness. With moderate to severe depression, people often do best with medication and therapy, Hyland said. And sometimes two or three medications aren’t enough, she said.

The Next Steps

If your first ineffective treatment was medication, there are several ways physicians proceed. Alpert begins by examining the reasons the medication didn’t work. If he can eliminate the above as culprits, he might increase the dose of the medication. He also might switch the patient to another antidepressant within the same class (such as switching from one selective serotonin reuptake inhibitor, or SSRI, to another). He then might choose a medication from another class.

Another technique is to add a medication to augment the effects of the initial antidepressant, “especially if there is some evidence of a partial response,” Alpert said. In other words, if a person thinks they’re about 20 percent better and they’re tolerating the medication well, the doctor may prescribe a second antidepressant that works on a different mechanism of the brain, he said. An example is combining an SSRI, which targets serotonin, with Wellbutrin, which works on dopamine and norepinephrine.

Physicians also might prescribe an atypical antipsychotic, such as Abilify or Seroquel, to bolster the effects of the original antidepressant, Alpert said.

Psychotherapy, including cognitive-behavioral therapy and interpersonal therapy, is highly effective for treating depression. Therapists help clients learn about their illness, cope with stressors in their lives, identify and change dysfunctional thinking, and take action to get better.

If you’re only taking medication, seeing a therapist can be tremendously helpful. (If you’re solely working with a therapist, it’s also possible that you might need medication.)

The statistics regarding obesity in America are alarming. Currently, 35 percent of American adults are obese (CDC, 2012), and that number is projected to rise to over 50 percent in most states by 2030 (Henry, 2011). We’ve been fighting the so-called “war against obesity” since the 1980s, and yet despite all of our efforts, the problem has only gotten worse. Clearly, what we’ve been doing to try to solve this problem isn’t working and is possibly making it even worse. In my opinion, the reason for this is that the psychological piece hasn’t been addressed yet and until it is, we will have an increasing problem on our hands.

Years ago I was seeing a client who we’ll call Sarah. Sarah was very obese and desperate to lose weight. Her doctor had recently told her that if she didn’t lose a significant amount of weight she would lose her mobility as well as have a host of other medical consequences. Sarah tried numerous diets and exercise programs but nothing worked. She even enrolled in a weight loss clinic but had no success. She actually ended up gaining even more weight during this time. Not knowing what else to do, Sarah’s doctor told her that she needed to talk to a therapist.

When I met Sarah she was quite desperate to lose the weight and very depressed. Much to her surprise, I told her that I didn’t want us to work on her losing weight, but rather I wanted to work on her depression and teach her to accept and love herself unconditionally. This seemed the opposite of what she needed in order to lose weight, but Sarah decided to trust me anyway. You see, like a lot of people, Sarah thought that if she could just hate herself enough, that would motivate her to do whatever it took to lose the weight. As a therapist, I know that that is simply not going to work. We therapists follow something called the “Rogerian hypothesis,” which states that people tend to move in a positive direction only when given unconditional love and acceptance. Well, I’m happy to say that after we had alleviated Sarah’s depression and she had learned to love and accept herself, the weight came right off.

The current methods for helping people lose weight seem to be the opposite of love and acceptance. Much of the efforts seem to involve trying to shame and scare people into losing weight. This simply doesn’t work. The worst thing you can do is give someone more anxiety and depression regarding their weight, and I’m going to explain why that is later on. Also, the ways we go about teaching people to lose weight are much more complicated than they need to be. One should not have to read a book, go to a clinic, or take a class to learn how to lose weight. There is a very successful diet that has been around for thousands of years and all of the big celebrities do it. Can you guess what it is? It’s called “Moving more and eating less.” How you go about accomplishing this is up to you. I believe that losing weight is not complicated and that people intuitively know how best to do it when it comes to themselves. They simply need to stop feeling so anxious and depressed about it.

Obesity and Genetics

Before I talk more about how obesity is linked to depression and anxiety, I first want to briefly address the popular belief that obesity is purely a problem of bad genes. This is the popular belief and I can see why it is so popular. In a society where people are constantly trying to shame you about your weight, it can feel good to be able to say “Hey, you have no right to shame me about my weight! It’s not something I can control! It’s because of these bad genes I have!” But in order for this to be true, it means that our genes would have had to somehow change since the 1960s. Scientists agree that genetics is not responsible for the obesity epidemic, although they do agree it is a factor. Depending on which study you look at, genes only account for between 1 percent and 5 percent of a person’s body mass index (Li et al., 2010). I think that most people would agree that 5 percent of bad genes doesn’t excuse the 95 percent of it that scientists claim is due to bad habits.

When confronted with these facts, people often cite that most of the people in their family are also obese, so it must be genetics. However, the more likely possibility is that families tend to eat the same foods and have similar habits. Genetics also doesn’t explain why obese people also tend to have obese pets (Bounds, 2011). Obviously the dog doesn’t share the same genes as the owner, but they do share the same environment. Of course, we can’t mention genetics without looking at twin studies. Since identical twins have identical genes, researchers often compare twins to examine the effects of genetics and the environment on a person.

Obesity and Depression

Researchers aren’t quite sure if obesity causes depression or if depression causes obesity, but the two are definitely linked. In fact, the two conditions are so intertwined that some are calling obesity and depression a double epidemic. Studies have found that 66 percent of those seeking bariatric, (weight loss) surgery have had a history of at least one mental health disorder. And of course, it doesn’t help that the medications people take for depression and other mental health issues can cause dramatic weight gain.

Consider this: According to the CDC, half of Americans will suffer from some sort of mental illness, and most of them will not receive any treatment for it. 63 percent of Americans are also overweight or obese. There are almost as many Americans taking diet pills as there are taking antidepressants (8 percent and 10 percent). People with mental health issues are twice as likely as those without them to be obese, and that’s even before they start taking psychiatric medication (McElroy, 2009).

So why are people with mental health issues so much more likely than those without them to be obese? We know that depression and bipolar depression slows down your metabolism (Lutter & Elmquist, 2009). Depression also depletes our willpower, making us less likely to avoid eating unhealthy foods. Depression also causes us to crave high-fat foods and sugar. This is where emotional eating comes in. When we’re feeling down, fatty and sugary foods make us feel better, at least temporarily. Of course, you don’t need to have depression or a mental illness in order to engage in emotional eating. It’s something we learn at a very young age. Eating something unhealthy is much easier than fixing the problem or dealing with what’s causing us to feel unhappy. Teaching people how to deal with unpleasant moods other than by eating would certainly cut down on emotional eating and would certainly lead to significant weight loss.

So if depression causes weight gain and antidepressants cause weight gain, then what is the solution? Well, research has shown that talk therapy is just as effective at relieving depression as antidepressant medication (Doheny, 2010), and talk therapy doesn’t have the negative side effects that medication does. Another option is exercise. In a 2005 study on the effects of exercise vs. Zoloft (anti-depressant medication) on the treatment of depression, participants were randomly placed into two groups. On group received 150 mg of Zoloft while the other group engaged in 20 minutes of cardiovascular exercise three to four times a week. After eight weeks, they found that the exercise was just as effective at reducing depression as the Zoloft! Another thing to consider is that Zoloft has negative side effects such as weight gain, sleep problems, and sexual dysfunction. As you can imagine, the side effects of exercising are the opposite of that.

So many times we think we know where we’re headed; then we’re taking an unexpected turn.
~ Hopping Roller Coasters

Rachel Pappas’s memoir, Hopping Roller Coasters, details the unpredictable story of a mother and daughter who must cope with their mood disorders, until they can reach a place of mutual understanding that gives way to a stronger relationship with each other. Though I found the content to be emotionally painful at times, I think it’s an insightful read. Pappas provides us with an important takeaway message that revolves around genuine forgiveness and a path for healing.

Rachel’s story highlights her trials with bipolar disorder and how it affected her daughter, Marina. She transports the reader into their private moments, showcasing intimate arguments, where Rachel took out her frustrations on Marina in a raw and angry fashion. She didn’t mean the sentiments that came forth during the heat of an altercation, but biting words circulated between them. Rachel’s therapist ultimately put her on medication to regulate her mood swings.

We then read how Marina went through a period of hard knocks during early childhood and into adolescence; she had trouble focusing at school (she was diagnosed with auditory deficits), and she inherited her mother’s bipolar disorder as well. In desperate need of help, Marina endured a period of hospitalization and even moved away to live with her grandparents, hoping for a finer environment.

During Marina’s stay at her grandparents’, at 13 years old, she was hospitalized for getting hold of her grandfather’s painkillers. After a stretch of time, Rachel received a phone call from her mom, relaying the news that they couldn’t keep their granddaughter with them any longer. As difficult as it was to hear, she knew her daughter needed something more.

Marina also unfortunately struggled with cutting as a way to deal with her emotional turmoil. One of the more heartbreaking lines I read was when Marina explained why she did what she did. “It hurts on the inside, so I figured I might as well hurt on the outside,” she told her mother.

Fast forward a few years later: Marina was 16, and she and Rachel were at it again. Hurtful remarks and threats flooded their fights. “Where was my little girl? The one with the pixie cut who let me hold her hand crossing the street?” Rachel wrote. “My good-natured ‘pipster’ who accepted my excessive hugs and kisses into early puberty. I was losing her. No, I had lost her.”

What really struck a chord (even though I’m only in my 20s) was looking at this situation from the mother’s perspective. I could only imagine a parent’s sense of loss, among other things, when you’re watching your child transition away from childhood and into young adulthood. Now throw in that kind of strife, and it takes that particular awareness to a different level.

After another hospitalization at 18 years old, Marina went back on her medication and was finding her stride with a new job. She also began her first serious romantic relationship (which was definitely enjoyable to read about), and facets of her life were beginning to fall into place after a rocky decade.

In the final chapters, Rachel faced additional obstacles, but through it all, she found a new outlook regarding her relationship with Marina; she realized she didn’t want any friction in the connections that she valued.

By some twist of fate, Rachel’s personal challenges mended her history with her daughter and paved the road for forgiveness in both directions. They both knew that they unintentionally caused the other pain in the past, but they were able to move forward, become unstuck and salvage what really mattered. For that, I recommend this narrative.

Though the book could have used a good editor and been more intuitively organized, it’s still a fairly compelling read, and offers some pointed comparisons between the Spiritist approach and the modern mainstream U.S. approach — the latter of which views mental illness as a physical disease to be medicated away despite the sometimes crippling side effects of medication.

Bragdon begins by introducing us to Gerry, an “attractive young woman” who experienced what seemed to be a psychotic break during a time of extreme stress. About four years ago, Gerry began exploring alternative forms of healing, including consulting with Bragdon, a spiritually-oriented psychologist. Now, Gerry is doing well, engaged, and intending to enter graduate school. The author writes that Gerry’s recovery was facilitated by empathy, encouragement, caring health professionals and family members, and “teachers who helped educate her about lifestyle choices.”

This approach, Bragdon tells us, mirrors the Spiritist methodology that is currently in practice in Brazil, where more than 12,000 Spiritist community centers and 50 Spiritist psychiatric hospitals freely offer “a highly effective… program of integrative care, treating the needs of the public side-by-side with conventional medical practitioners.” It’s a community-oriented, relationally-focused, holistic and welcoming model that treats the patient as a human being who has just as much insight into her illness as any professional. But it also involves some practices that the average U.S. citizen might find unfamiliar.

“According to Spiritists,” writes Bragdon, “optimal wellbeing is ours when we are 1) doing the mission that we agreed to do before coming into this life and 2) treating ourselves and others with compassion consistently.” She goes on to explain that a Spiritist “considers that a pervasive and long-lasting mental imbalance that threatens life may come because a person is rebalancing themselves after a life experience that was not compassionate or may come from having lost his/her purpose in life.”

That part may not sound unusual, save for the part about making agreements before we were born. But the Spiritist approach offers multiple techniques that a non-religious, States-bound consumer might find “out there.” These include the laying-on of hands, inspired speech and prayer, blessed water, peer support for the patient and the family (called “fraternal assistance” in the book), interactions with mediums and psychics, and a post-hospital program of study and philosophical and spiritual conversation. It also welcomes family members and loved ones to be involved.

Although it’s unlikely that the U.S. healthcare model is going to follow the Spiritist one anytime soon, and although the author doesn’t provide objective proof of the success of the treatment, what I found fascinating about Bragdon’s book is how the Spiritist approach reflects some of the insights the mainstream psychological community has come to about mental health. The differences are obvious, but the underpinnings between these two very disparate models is surprising. Some descriptions of the Spiritist approach that may sound more familiar:

“The inspired speech directs the patients to focus on the value of compassion and love, helping them recollect loving relationships they may have had or may long for, assisting them toward greater self-acceptance, compassion, and tolerance,” one description goes.

“Perhaps Spiritism has been so successful in its treatments because it facilitates individuals clarifying their life purpose and aligning with that purpose,” Bragdon posits.

“The treatment aims at working with the patients’ motivation and with their state of readiness or eagerness to change.”

Another passage describes spirits that cause negative thoughts. Taken together, these concepts of forgiveness, self-acceptance, compassion, life purpose, negative thoughts, and motivation are all vital aspects of established psychotherapy modalities such as Cognitive Behavioral Therapy, Buddhist Psychology, Acceptance and Commitment Therapy, and Motivational Interviewing.

Bragdon’s book may be of limited value unless one is interested in different cultural approaches to psychological treatment. For those who are intrigued, however, it draws a compelling Venn diagram of the similarities between seemingly separate schools of thought. The author’s description of several U.S.-based holistic mental health clinics certainly gives the reader hope that there are people in the States working to change the dominant “medication-not-meditation” paradigm — even as we’re slow to accept alternative healing methods.

Resources for Extraordinary Healing: Schizophrenia, Bipolar and Other Serious Mental Illnesses
CreateSpace Independent Publishing Platform, February, 2012
Paperback, 264 pages
$24.95

Medication

With most psychiatric illnesses, medication is optional, and individuals can improve with other treatments, such as psychotherapy, said John Preston, Psy.D, a psychologist and co-author of Loving Someone with Bipolar Disorder and Taking Charge of Bipolar Disorder. However, “Bipolar disorder is probably the main psychiatric disorder where medication is absolutely essential. I’ve had people ask me if there’s any way to do this without medicine. [My answer is] absolutely not.”

Patients typically need to take multiple medications. “On average, people with bipolar disorder take three medicines at the same time,” Preston said. A large study by the National Institute of Mental Health found that 89 percent of people with bipolar disorder who were doing well were taking several medications.

“Don’t be discouraged if it takes a while [to find the right medicine]. Almost everyone who’s successful has to go through the same process.” That’s because in order to find the best treatment for each individual, doctors prescribe various medications and combinations. The goal is to find the right combination with the fewest side effects.

Unfortunately, troublesome side effects are the rule, not the exception, Preston said. In fact, around 50 to 60 percent of patients stop taking their medication or don’t take it as prescribed. This is why having regular and honest communication with your prescribing physician is critical.

But many people feel uncomfortable. They don’t want to “complain,” or assume their physician will be upset with them, Preston said. “I find that clients often don’t think they’re allowed to disagree with their doctors, and often end up going off their meds rather than having candid discussions with their doctors,” said Sheri Van Dijk, MSW, a psychotherapist and author of five books, including The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder.

Remember that you and your doctor are a team. “You have every right in the world to talk about every problem you run into,” Preston said.

The other reason people stop their medication is denial or wishful thinking, he said. It can take months after stopping medication for an episode to occur. This only validates the person’s belief that they don’t have the illness.

But while episodes may not be fast, they tend to be furious. Episodes typically get more and more severe, Preston said.

“Long-term studies that have followed people with bipolar disorder who have stopped taking their medication and have current episodes show progressive damage to parts of their brain.”

Lifestyle Management

According to both experts, cultivating healthy habits is paramount. Sleep deprivation and substance abuse exacerbate bipolar disorder and derail treatment, Preston said. Even patients who receive effective treatment don’t end up getting better if they’re abusing drugs and alcohol, he said.

If you’re struggling with substance abuse, seek professional help. Make sleep a priority. Try to get seven to eight hours of slumber per night, and wake up at the same time each morning. Consult your doctor if you’re traveling between time zones, which boosts the risk for manic episodes.

Social Support

“Often the success or failure of treatment has to do with how the family is involved,” Preston said. Family can either play a positive part in treatment or unintentionally undermine it. For instance, a family member who finds out their recently diagnosed loved one is taking medication might say, “You don’t need to take medication; you can handle this on your own,” Preston said. Again, not taking medication for bipolar disorder “can spell disaster.”

On the other hand, families can advocate for their loved ones. For instance, a parent might accompany their child to therapy when they’re in the throes of an episode and can’t articulate their concerns or symptoms.

Support groups, whether in person or online, also can be helpful, Van Dijk said. They remind individuals they’re not alone.

Psychotherapy

“The backbone of treatment is medication. But psychotherapy is enormously important,” Preston said. “While medications help to stabilize mood, they don’t change our thinking patterns, and the way we think affects the way we feel,” Van Dijk said. For instance, learning to change the negative stories swirling in your head may help prevent depressive episodes, she said.

Take the example of a client who was upset because her family pretended to forget her birthday, so they could give her a surprise party. “Instead of focusing on the surprise and the thought that her family had put into the surprise party, she was focused on how ‘cruel’ it was for them to pretend they had forgotten her birthday,” Van Dijk said. She helped this client “take a less negative and more neutral perspective on these kinds of situations.”

Van Dijk also teaches her clients mindfulness or “living in the present moment and practicing acceptance.” This helps clients not only accept their diagnosis but also become more self-aware. “We become more aware of our thoughts, our emotions, and our physical sensations because we’re in the present moment more often, and because we’re working on allowing ourselves to have these experiences, even if they’re painful.”

This self-awareness may prevent symptoms from escalating. By being more mindful, patients can spot an emotion and figure out what to do about it — “if anything” – before letting it careen into a full-blown episode.

According to Preston, “Numerous studies show that family-focused psychotherapy plus medication is really successful.” The goal of family-focused psychotherapy is to help the patient and family fully grasp the gravity of the illness and the importance of ongoing treatment, he said. It also teaches families how to provide support.

Interpersonal and social rhythm therapy also involves the family or significant other. The goal of this therapy, Preston said, is for “families and couples to learn to communicate more effectively and reduce really intense emotional experiences. It also incorporates strategies for lifestyle management.”

A big problem with psychotherapy is that clinicians who specialize in these treatments can be tough to find. Preston recommended checking out the Depression and Bipolar Disorder Support Alliance for facts on finding a professional along with other valuable information.

Accepting that you have bipolar disorder can be difficult. But not following your treatment will create a life filled with “one catastrophe after another,” Preston said. Instead, as both experts stressed, be honest with yourself. And make a strong commitment to taking your medication as prescribed and practicing healthy habits, without abusing drugs or alcohol.

Further Reading

Preston recommended these additional resources:

• The Bipolar Disorder Survival Guide
• Bipolar 101
• Bipolar Medications: A Concise Guide to Medication Treatments for Bipolar Disorders in Adults and Adolescents
• Consumer’s Guide to Psychiatric Drugs
• The website Bipolar Happens

Managing Depression and Suicidality

It is common for clients with schizophrenia to feel grief and loss due to the myriad life changes that it triggers (Wittmann & Keshavan, 2007). In this sense, during treatment, it is essential for clinicians to help clients navigate through the grieving process. According to Tait, Birchwood, and Trower (as cited in Wittmann & Keshavan, 2007), depression has been found to lead to the abandonment of treatment by clients due to the isolating characteristics of the disorder. Abandonment of treatment poses serious drawbacks for clients.

Wittmann and Keshavan (2007) assert that the grieving process is a necessary component to coming to terms with a new diagnosis of schizophrenia. Due to the sense of loss experienced by individuals newly diagnosed with schizophrenia, it is essential for them to navigate and work through the grieving process (Wittmann & Keshavan, 2007). According to Lewis (as cited in Wittmann & Keshavan, 2007), by doing so, clients will learn to mourn the life and identity changes that have occurred, along with establishing the ability to integrate such change into their lives. It has been shown that counseling can be beneficial in such a situation.

Grief and mourning are a common component in clients diagnosed with schizophrenia (Wittmann & Keshavan, 2007). This is because the diagnosis of a serious, permanent mental disorder is a major life crisis for most. The disorder affects the mind in very serious ways (Wittmann & Keshavan, 2007). In some cases, clients might spiral into psychosis as a means of dissociating, or defending against facing, the losses their disorder has caused (Wittmann & Keshavan, 2007). Clinicians have a major hand in helping clients manage this crisis.

Numerous models exist to explain grief and mourning, and can also help professionals guide grieving individuals. Elizabeth Kubler-Ross (1969) proposed five stages of grief that individuals can experience while grieving. They include denial, anger, bargaining, depression, and acceptance. In contrast, Worden (2002) proposes four tasks, as opposed to stages of grief. These include accepting the reality that loss has occurred, feeling the pain and emotional responses to the loss that has occurred, readjusting to life after the loss, and finding ways to remember the lost individual. Although these models are meant to aid in grieving a person, individuals diagnosed with schizophrenia are, in fact, grieving the loss of the person they once were and will potentially no longer be. In this sense, these models offer a framework that can be used in counseling to help a client adjust to life after their loss of self.

A Safety Plan for the Newly Diagnosed

Clinicians should develop a safety plan for use in the event that a client presents with suicidal intent or depressive symptoms, as these are both common in newly diagnosed clients. One of the first issues to address is the onset of depressive symptoms or suicidal thoughts. A safety plan can involve listing symptoms characteristic of depression, including those characteristic to the client, as well as those that the client has not felt before, but could potentially feel in the future. This would help foster the client’s awareness of their own symptoms.

Along with such a list, clinicians can help clients determine the course of action to be taken if suicidal thoughts or feelings occur. Action plans can include emergency contact numbers, such as a suicide hotline and that of the primary therapist, the psychiatrist and other medical doctors, and family members or other individuals who serve as the client’s support system. One of these individuals could sit with the client and support them through the situation while attempting to contact appropriate clinicians. If the client has no close friends or relatives, suggest that they join an in-person or online support group.

Clients should be asked to keep a list of depressive or suicidal triggers. During sessions, the counselor and client could develop and implement ways for such triggers to be managed.

Clinicians should urge clients to remove from his or her home any items that could be used to self-harm. Making access difficult reduces the temptation to use them. This might be especially useful for clients who have already made attempts, and would also potentially increase the likelihood of them seeking some form of support or following an appropriate plan of action, rather than engaging in self-injurious behavior.

Clients can be encouraged to keep an up-to-date medication list with them at all times. This will help them if they need to seek out emergency services. During a crisis, it might be difficult for them to recall each of the medications they take, as their minds will be preoccupied.

Clinician should keep a current list of service providers to which clients can be referred. For example, if the client’s symptoms become more intense and overwhelming for them, and more in-depth treatment is required, the clinician should be able to make an appropriate referral or direct the client to an appropriate provider. This could further ensure the client’s safety, as he or she would receive the necessary services, especially if more in-depth treatment is required.

Conclusion

A diagnosis of schizophrenia presents serious implications for newly diagnosed individuals in particular. Those with schizophrenia have a vast series of challenges to face, including overcoming and grieving the loss of a sense of self, experiencing a loss of hope for the future, accepting the diagnosis, facing the fact that social, occupational, educational, familial, and romantic arenas might undergo marked change, and integrating new insights, coping strategies, and processes learned on their journey into their life.

Because the diagnosis of a serious mental illness can cause a major life crisis (Wittmann & Keshavan, 2007), clinician support is critical. This is especially true because depression and suicidal ideation are common in the newly diagnosed (Addington et al., 2004). Along with helping the client manage their diagnosis and helping to facilitate his or her grieving process, clinicians can help ensure client safety by establishing and agreeing upon a safety plan for use in the event that the client is experiencing depressive symptoms or suicidal ideations. Not only will this help clients to feel supported and cared for, but it will also potentially help save a life in the event of an emergency or crisis.

References

Addington, J., Williams, J., Young, J., & Addington, D. (2004). Suicidal behaviour in early psychosis. Acta Psychiatrica Scandinavica, 109(2), 116-120.

Kubler-Ross, E. (1969). On death and dying. New York: Scribner.

Wittmann, D. & Keshavan, M. (2007). Grief and mourning in schizophrenia. Psychiatry, 70(2), 154-166.

Worden, J.W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company.

Kakonge says that the book contains her “own babble through sixteen breakdowns over a five and a half year period.” The memoir is broken into small chapters, each offering a brief glimpse into the author’s life.

Through these diary-like musings, we witness the daily struggles of a young woman who experiences a variety of symptoms of mental illness. Kakonge discusses her numerous trips to psychiatric wards and the multitude of diagnoses bestowed upon her during these visits. In addition, she discusses the continuing struggle that she has had with whether or not to take psychotropic medication.

Memoirs may seem like they are a dime a dozen nowadays. What is worthwhile about this one is that the author does not allow her mental illness to prevent her from chasing her dream of becoming a journalist, even traveling from Canada to Africa in pursuit of a fulfilling career. All the while, the symptoms of mental illness continue to interfere. Yet Kakonge’s enduring will to succeed keeps the reader rooting for her success.

Kakonge also does an excellent job of drawing the reader into her reality during periods of psychosis. She does not sensationalize her situation; rather she describes her at times bizarre thoughts with a refreshing amount of frankness. For example, in the book’s opening she states:

“The security guard outside the door keeps looking at me strangely…Doesn’t he understand? This is a national emergency. I have to get out of this room because the women are coming to get me. Princess Diana, Oprah Winfrey, Princess Toro…are coming to get me to join their group.”

Kakonge does not attempt to psychoanalyze herself and figure out why she had such beliefs at that point in her life. Nor does she pass any type of judgment on herself. She simply lays her truth bare and allows the reader to come to his or her own conclusions.

In my own work as a counselor, I have facilitated writing groups for individuals with a variety of psychiatric diagnoses. Through this work I have seen the difficulties that can arise when one attempts to write about periods of mental distress. Oftentimes, writers are either hesitant to recall such memories, or unable to accurately remember the details of particularly stressful situations.

Knowing this makes Kakonge’s work even more impressive. I do not know whether she wrote this account strictly from memory or if she kept a journal during the time period she writes about. Either way, the detailed narrative of How to Talk to Crazy People offers an exceptional depiction of an individual’s struggle with mental illness.

The biggest fault I found in this work is its brevity: The book seems to just scratch the surface of Kakonge’s experience. It would be interesting to learn more about the author’s current thoughts as she recalls these tumultuous periods in her life, as well as to hear more about how she was able to overcome her mental health issues and find her voice as a writer.

Anybody who is looking to read an inspiring memoir about mental illness should check out How to Talk to Crazy People. This slim volume provides the reader with an honest portrayal of what it is like to live with psychiatric symptoms. Kakonge is refreshingly open. The reader comes away with not only a better understanding of mental illness, but also with a sense of encouragement from the author’s remarkable journey.

How to Talk to Crazy People
Life Rattle Press, 2012
Kindle edition, 88 pages
$20

Given my relationship with a woman experiencing the disorder, Jane Thompsonʼs Reboot: A Novel of Bipolar Disorder resonated quite strongly with me. Thompsonʼs book offers a fictional but true-to-life account, with her writing clearly based on her own struggle with the illness.

What struck me most is how Thompson reveals, in detail, the importance of what took me years to learn: that, due to the very nature of bipolar disorder, the person who is bipolar does not recognize this and may often forget or highly distort what happens in their manic state. In their euphoria they may imagine and remember, quite incorrectly, that everything was oh-so-wonderful, which is often quite far from the case. Particularly for an adult with bipolar disorder, recognizing the illness is a key step in the possibility of regaining stability and mental health. Without this recognition, an adult with bipolar disorder may quit taking medication, not prepare for the next manic episode, or put themselves and others at risk.

In the beginning, we find this lack of recognition in Marie, the protagonist suffering from the disorder and whose story parallels the authorʼs (and my girlfriendʼs). Marie misses appointments, remembers meetings cancelled when in fact, they had not been, and loses friends who seem standoffish to her. Before her treatment, she only dimly understands why her actions are irrational, rude, or possibly hypersexual. 

What makes Thompsonʼs book so fascinating and hopeful is the contrast between Mariaʼs lack of understanding before she realizes that she is bipolar and her later recognition of what was more likely going on when she finds a medication that works for her.

“Reboot” details another important facet of bipolar disorder. While it is defined as a psychiatric mood disorder with disruptive mood swings, characterized by one or more episodes of abnormally high energy levels, accompanied by racing thoughts and euphoria, with or without depressive episodes, no one truly knows what causes it and what can stop it. Treatment and medication are thus experimental. In the book, Marie takes several different medications with no apparent effect. After reporting this to her physicians, she is told that the medications will eventually work, or that she doesnʼt realize that they are indeed working.

Thompsonʼs novel also correctly illustrates the dangerous side-effects of these medications. Marie is advised to take Haloperidol, which could lead to tardive dyskinesia, i.e., involuntary repetitive body movements, and is told incorrectly that she is not old enough to develop the symptoms. My own reading of the dangers of such medications had me worry when my girlfriend Elle, at about the same age, temporarily developed a habitual puckering and pursing of her lips after taking the many medications, including Haloperidol, that she was prescribed. For both Marie, in the novel, and Elle, in my own life, therapy is trial and error. One hopes to find a treatment or medication that works.

Without giving away the bookʼs lovely ending: Marie finally finds a drug that works for her. As her moods stabilize, so does her life. She gets a significant raise at her job of several years, makes friends, and begins to enjoy going out. She starts to feel appreciated for who she is, and is happy.

I wiped tears from my eyes and broke out laughing several times as I read “Reboot.” For those of us who are close to someone suffering from bipolar disorder, this book means a lot.

Reboot: A Novel of Bipolar Disorder
CreateSpace Independent Publishing Platform, June, 2012
Paperback, 264 pages
$15 

Before writing this book, Williams spent time as a hang glider pilot, winning one world championship and several national awards. Then, he tells us, he experienced a mental crisis that could have been labeled psychosis, but avoided getting diagnosed or “helped” by psychiatry. Instead, he says, he worked through his experiences on his own. This caused him to become interested in helping others, and he became a psychologist and researcher focused on the detailed exploration of the experiences of people who have undergone psychosis and then full recovery.

One of the key ideas Williams sets forth is that psychosis, in the presence of the right conditions, can be expected to most commonly result in a positive outcome: an outcome that is better than the state that existed before the psychosis. This assertion flies in the face of most of what our culture thinks it “knows” about psychosis, but the author documents the argument well.

Still, the perspective should not be confused with some romantic notion that psychosis is always a good thing — Williams is clear that it is hazardous under the best of conditions, and likely to lead to major ongoing life difficulties when the focus is just on attempts to suppress the process, as usually happens in developed countries today. What is critical to note, he tells us, is that these poor outcomes are typically due to poor handling of the experience, and not the nature of the experience itself.

Another major point Williams makes is that the core issues in madness are not a struggle with an “illness” experienced only by some, but rather a struggle with the existential issues that we all face, such as being caught between a fear of being separate and a fear of being overwhelmed or engulfed by connection. He outlines how the ability to regulate one’s approach to such dilemmas is lost in psychosis, usually in response to a number of stressful experiences—but also how the loss of one’s prior approach has the potential to lead to the emergence of new and healthier ways of being organized. He discusses these ideas first theoretically, then by clear descriptions of how these issues played out for the individuals he has researched, as they went through psychosis and then recovery.

The author argues that psychotic experiences typically occur as part of a process of experimentation at a deep level of the mind, a risky process of profound disorganization and then reorganization. He illustrates how the current mental-healthcare system interferes with rather than safely facilitates this process, and how recovery seems to only be possible when people manage to break away from the system to at least some degree. He then sketches out the possibility of a very different system of care that would recognize the meaningfulness and positive potential in psychotic breakdown.

Unusual as his ideas may seem, Williams convincingly demonstrates a very extensive knowledge of psychosis. In fact, his book may be among the best types of “preventive” measures — preventing one from entering the black hole of biomedical psychiatry, that is.

Rethinking Madness: Towards a Paradigm Shift In Our Understanding and Treatment of Psychosis
Sky’s Edge Publishing, April, 2012
Paperback, 398 pages
$24.95 

While the book does tell the story of Zach Schidkunz, a young man convicted of murder, the real heart of it is the author’s journey as he attempts to come to grips with what has transpired. The reader is witness to how a parent can make sense of a world in which his beloved little boy can go from college, to suffering from serious depression, to prison.

We are introduced to Zach as a fairly typical, middle-class child. It’s not until college that he begins to show signs of depression, including self-injurious behavior. Eventually, Zach’s psychiatrist recommends a psychotropic medication — Zoloft. Things seem to be getting better until a shocking incident: Mr. & Mrs. Schmidkunz discover a female shooting victim in their home. Even more shocking, the evidence seems to point to Zach as the perpetrator.

Gail Schmidkunz is, understandably, utterly distraught by this idea, and attempts to piece together the possible causes for this incomprehensible situation. What could possibly drive his son, a young man who had no history of trouble with the law, to suddenly, fatally shoot a female friend? What role did Zach’s history of depression and psychiatric treatment play in the incident? Could Zach be held completely responsible for his actions, or were there mitigating factors on which accountability could fall?

All of these questions have been examined by the justice system as well as by Schmidkunz. The author provides us with a vivid picture of the confusion and torment that the ordeal led to. Not content to leave his son’s fate to the courts, Schmidkunz consults with lawyers and mental health professionals to try to make sense of this terrible situation.

After much investigation, the author arrives at a controversial conclusion. One of the medications that Zach had been prescribed, Zoloft, had reportedly caused bizarre side effects in a select number of people. One of these side effects is aggressive behavior. Perhaps, the father postulates, this medication could have been the underlying cause of his son’s actions. The difficult next step was to convince others that this was a possibility. Schmidkunz discusses his battles with doctors who disagreed with his theory as well as the legal team behind the pharmaceutical company that produces Zoloft.

The questions raised in I Am Not Silent are not necessarily easy to answer. How do we determine to what extent a person’s actions may have been caused by mental illness, or by a medication one was taking for that illness? And if medication does play a part in a criminal act, whom do we hold responsible: the person taking the medication, their doctor, the company who produced the pills? Is there some type of proactive monitoring that can take place in order to prevent stories like Zach’s from happening to others in the future? These are complicated legal and ethical issues to contend with.

Whether or not psychiatric medication played a part in Zach’s actions is certainly up for debate. Though Zach was ultimately found guilty, the reader will have to draw his or her own conclusions about the verdict based on the evidence Schmidkunz presents in his memoir. But whether you agree with the author’s assessment of the situation or not, I Am Not Silent is an intriguing read. Schmidkunz presents a heartfelt, honest portrayal of the difficulties such circumstances can present to a family. Through his and his son’s story, we gain an inside look at the ways the criminal justice system deals with defendants who have a history of psychiatric diagnoses.

There is nothing that can be done to bring back the young woman that the Schmidkunzes found in their home. What caused Zach’s actions may never be fully understood. However, stories such as his can hopefully help us gain a clearer understanding of the effects of psychotropic medication and how to best utilize them in order to help those suffering from psychiatric symptoms. You may or may not agree with Gail Schmidkunz’s conclusion about his son’s crime, but it is nonetheless worth hearing his story.

I Am Not Silent: Oor Zoloft and Depression Story
InspiringVoices (July 9, 2012)
Paperback, 208 pages
$14.99