“It’s not who I am”

“If Clara Hughes can come out and say it, so can I,” says U of T graduate student Amanda Coletta with a smile as we finish our interview.

Later that same day, I meet with Aaron*, a third-year political science student at U of T.

“For the most part, it’s been sort of an open secret. My family is aware of it, and my very close friends are aware of it. I don’t talk about it too much, though,” he says.

Coletta was diagnosed with major depressive disorder at 21 years old. She refused her doctor’s recommendation of psychopharmacological treatment, opting instead for cognitive-behavioural therapy the following year. Aaron was diagnosed with bipolar II disorder when he was 18 years old. He took antidepressants — prescribed by his psychiatrist — for several years, after a single attempt at psychotherapy left him unmotivated to return for further sessions.

 

 

Distinguishing mood disorders

graph3-01Although their diagnostic criteria are officially distinct, depressive disorders and bipolar disorders are the two main categories of mood disorders recognized in common clinical psychology. While both disorders include major depressive episodes as part of their primary symptoms, bipolar disorder is also characterized by manic episodes.

According to Dr. Roger McIntyre, a professor of psychiatry and pharmacology at the University of Toronto and head of the Mood Disorders and Psychopharmacology Unit of the University Health Network, bipolar patients in a manic state “have lots of energy, they don’t sleep as much, they’re often very angry and irritable; in some cases, [they are] jubilant, jocular, and euphoric.”

“I started to notice I was having trouble getting up in the mornings; I was having trouble thinking positively about myself and about the world — there was sort of a dark spectre over everything,” says Aaron about the depressive state of his disorder. “[But] I [also] went through periods of delusions of grandeur — feelings of invincibility and total control…That’s how the mania side presented itself. But for the most part, it consisted of prolonged periods of chronic depression,” he adds.

In contrast, depressive disorders are characterized by chronic low mood. The two main depressive disorders are major depressive disorder (which is usually referred to using the umbrella term “depression”) and dysthymia. Major depressive disorder consists of persistent major depressive episodes, while the depressed mood characteristic of dysthymia tends to be less disabling, although dysthymic patients are likely to experience major depressive episodes.

The nature of major depressive episodes varies between patients; they can involve feelings of irritability, or, conversely, indifference to one’s surroundings. Those who suffer from depression often report feelings of “numbness” and a loss of enjoyment of normally pleasurable experiences. Many feel as though they are a burden on those around them, often without an explicit reason for feeling so. Other symptoms of depression may include excessive lethargy, too much or too little sleep, disordered eating, and/or suicidal ideation.

“I started to have a lot of irrational thoughts; I was very paranoid about things, and I started worrying about things that I never used to worry about, like people’s opinions of me. My own self-worth started to really go down,” says Sarah*, a third-year student who received help for her depression last year. “At first, when it started happening, I told myself, ‘This isn’t depression,’ because I didn’t want to think that I had it,” she continued.

“Depression is a very painful experience,” says Dr. Phyllis Spier, a general practitioner child psychiatrist in the Canadian Medical Laboratories Clinic in Thornhill, Ontario. “It’s not just a cold – it’s a state of mind, it’s an abnormality of brain metabolism, and it’s not to be ignored,” she adds.

The most recent statistics on the Canadian Network for Mood and Anxiety’s webpage suggest that “over one million Canadians suffer from some form of depressive illness.” They also suggest that the illness’ recurrence rates are quite high, at “50 per cent after one depressive episode, 70 per cent after two, and 90 per cent after three episodes.”

 

 

Approaches to treatment

PillsThere are two main branches of treatment for mood disorders: psychopharmacotherapy, which involves taking medication (i.e., antidepressants or antipsychotics), and psychotherapy.

Cognitive-behavioural therapy (CBT) is the most commonly referenced and employed psychotherapy for depression. It involves restructuring the ways in which patients approach and interpret various interpersonal and intrapersonal situations.

“My [cognitive-behavioural] therapist and I have this book, and it basically has a whole bunch of exercises inside, like thought records, so when you feel an episode coming on, you identify where you are, who you’re with, what day it is, and what your thoughts are so you can see if there’s a pattern — [for example], if being in certain situations or being with certain people or people saying certain things to you triggers an episode,” says Coletta of her cognitive-behavioural therapist’s approach.

Sarah also praised the usefulness of the cognitive-restructuring methods she learned through CBT. “It [involved] a lot of mental imaging, taking bad thoughts and coming up with either a mantra or an image that distances you from them. So if I thought of something that upset me, I would just picture a stop sign, or I would imagine throwing the bad thought into a box…it was all simple, manageable things, but just knowing that I had an arsenal of things in my own personal toolbox really helped; it made me feel less like there was nothing I could do when [the depressive episodes] started happening.”

Medications prescribed to patients with either disorder tend to overlap. The most commonly prescribed antidepressants are selective-serotonin reuptake inhibitors (SSRIs), which sustain the effects of the neurotransmitter serotonin — a chemical that contributes to feelings of well-being — in the brain for longer than usual. In addition to an antidepressant, bipolar patients must also take a mood stabilizer drug to account for the manic effects of the disorder. The necessity of psychopharmacological treatments varies between disorders.

According to McIntyre, psychopharmacological treatments are the “standard of care” for bipolar patients; the individual must be prescribed and successfully taking medication before initiating psychotherapy, if at all, in order for the latter to be effective.

Depressed patients can opt for either treatment —or both, if necessary. However, McIntyre says, “My strong recommendation to almost every patient is that they need both. I’m a strong proponent that the treatment for depression today is with medication, with, in some cases, psychotherapy, and I think lifestyle modification, which includes aspects of exercise, diet, and healthier living; we haven’t emphasized [the latter] as much… I think that people do require these multiple tools to give them the best chance of success.”

 

 

Adverse side effects

People with depression or bipolar disorder are often concerned about the side effects that accompany many medications — both Coletta and Sarah refused medication upon their doctors’ requests.

“My family doctor said, ‘You may have some side effects.’ She also said, in young people, antidepressants sometimes create suicidal feelings. But what I found was that the withdrawal effects of the particular drug she prescribed me were fairly serious,” said Coletta, adding that she did not feel comfortable accepting the drug under those circumstances.

For Sarah, the decision came as a result of concern for her additional — or “comorbid” — anxiety disorder. “One of the issues I was having with my anxiety was that I couldn’t eat, and Prozac often affects appetite a lot.”

According to McIntyre, the increasing amount of generic medications — medication that is molecularly similar but not identical to the brand-name drugs — on the market is a key problem in experienced adverse side effects.

“[Generic drugs are] cheaper in acquisition cost…The good news is that [they] can be covered for people who can’t afford it and who are eligible for ODB [the Ontario Drug Benefit Program], but the bad news is that generic medications are not the identical drug as the brand name medication. They’re similar, but not identical… When a generic medication is available, the company who makes that medication does not need to demonstrate that it works. All that Health Canada requires is that the company who’s selling the generic is able to show that the way that that drug is disposed of, or handled in your body, is between 80 and 125 per cent similar to the brand name drug,” he says. Health Canada also mandates that the generic drug must also be manufactured in the same way, and must have the same amount of active ingredient.

Sarah, however, says that her experience at CAPS was “wildly unhelpful.” She did not feel that she could wait the estimated three months for her appointment. She says that the fact that the interviewing clinician suggested that she take group therapy in the interim period for her appointment suggested that her comorbid social anxiety was not being adequately considered.

McIntyre prefers prescribing brand-name medication for this reason.

The fear of adverse side effects is especially troublesome for those with bipolar disorder, since their treatment necessarily depends on medication. Aaron said that the quality of his experiences while on medication was compromised: “[The pills] take the edge off of things. I’d rather be really, really happy or really, really sad than feel nothing at all.”

Second-year student Camille Angelo, who was diagnosed with bipolar II disorder in 2012, has also experienced adverse side effects from previous medications, but her current ones are working well for her.

“For me, [the most successful treatment choice] was a combination of the right cocktail of meds, my cognitive-behavioural therapist, and having friends and family around me who were able to help me work through some of it,” she says.

 

“The feeling of being something else”

One of the most feared side effects among patients with mood disorders is that the medication will alter their feelings of being authentically themselves.

“Definitely one of the reasons why I was scared of going on meds was because I felt it would change who I was as a person…and [the wrong meds] can change people a lot. That being said, I think medication is really, really useful to a lot of people, and helps them with their lives… Unfortunately, even when it is necessary, it can still change people, but I guess that’s a necessary evil to a certain extent,” says Sarah on her refusal to accept psychopharmacological treatment when it was previously suggested to her.

Aaron has experienced this sentiment firsthand, as he explains: “I did have the feeling of being something else, something other. Even if me was going to be dark and brooding all the time, then that was who I was gonna be, and I would prefer that than not feeling like anything.”

While Angelo also experienced a feeling of disconnectedness, she says that this feeling only occurred when the medications given to her were not right for her. “When I was being treated, and I felt like [disconnected], it made me really question if I made the right decision to get treated. But now that I’m on meds for bipolar — and definitely the right meds – I feel 100 per cent myself. As you have more and more experience on meds and more experience with your disorder, you become more sensitive to it, and you can say, ‘Oh, maybe I’m being overmedicated right now.’”

 

Practical considerations

Dr. Marcia Zemans, a child and adolescent psychiatrist at the Centre for Addiction and Mental Health (CAMH), suggests that the decision of when to prescribe medication, and how much to prescribe, is a complex relationship between the doctor’s administration and the patient’s own preference and specific situation. Some key factors include the nature of the illness; the patient’s financial means; the success of other treatments; and, ultimately, the decision of the patient or his/her power of attorney.

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Zemans outlines several situations in which medication may be preferable to psychotherapy for those with depression. For example, the expensiveness of CBT makes it a non-feasible option for many patients. On average, a patient can expect to spend approximately $200 per CBT session with a registered cognitive-behavioural therapist, as the Ontario Health Insurance Plan (OHIP) does not extend to psychotherapy. Even at one session per week, yearly expenditure could total around $10,400.

In contrast, OHIP covers many psychotherapeutic treatments; yet, as McIntyre explains, even these treatments are not always cost-free. “Some of the medications in this province to treat depression are not covered by the ODB, which is part of the Ontario Government. Many patients have private healthcare plans. There are many antidepressants that are not covered by the government, and there are many that are not covered by private plans, so you pay out of your pocket,” he says.

The effectiveness of psychotherapy also necessarily depends on an individual’s regular attendance at therapy and cooperation in doing “homework” assignments outside of therapy. This work may be especially trying for individuals with a mood disorder, as a lack of motivation is a key symptom of major depressive episodes.

According to Zemans, the speed and efficiency with which psychotherapeutic treatments affect individuals are some of the most attractive features of these treatments.

“I think that there are certainly doctors who are overmedicating; but I’ve also seen family doctors who, I think, don’t prescribe quickly enough. I think each situation is different …Therapy won’t work if someone won’t do it…One of the biggest things is motivation. If [an individual] is not motivated to do therapy, and doesn’t want to come to therapy at all, that is probably one of the biggest barriers [to their treatment],” she says, adding: “[Medication] can be the quickest option. And sometimes individuals or families say that that’s what they want, in which case, there’s really nothing you can do.”

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