Health loss

Grief and mourning are intense experiences that we will encounter on our paths at some stage in our lives. The loss of a beloved one or something important to us can bring forth intense feelings of sadness, emptiness, anger, incredulity, guilt or a mix of these emotions. We all have our own very personal rhythm when going through the stages of loss and the most wanted outcome is to deal with what happened, by accepting and adapting to the big change.

A particularly tough kind of grief is the one linked with the loss of physical or mental health.

Developing specific diseases may be more understandable and slightly easier to accept depending on our personal resources, age, familiarity and the period of life that we are going through. Unfortunately it can happen, that some diagnoses suddenly come up with no preliminary warnings, maybe at an early stage of our life, by bringing severe limitations to our lifestyle.

Accepting to be ill, can be a particularly tough one. Indeed, the discovery of a severe diagnosis brings us back with unexpected violence to the reality of our limits, transience and to the fact that we are indeed human beings. In our daily life, our brain usually works pretty well in keeping these awarenesses far away from our conscience, but getting sick is quite a reality check.

The loss of our idea of health is an intense life-changing element, that we may undergo facing exactly the same struggles as we do when losing a beloved person. It compels us to face our limits and deal with the restrictions imposed by illness. We may realise that our desired future will be different from the expectations we had and that some of our long-term goals may not be easily reachable any more. We may find ourselves forced to change habits, routines and lifestyle, to even take strong medications and potentially experience undesired side effects. We may feel overwhelmed and powerless, as nothing of all this has been directly chosen by us.

Losing our expected future and our expected self, can be a source of intense depressive feelings and it calls forth all our strength and resources to deal with, reset our expectations and mindset in order to accept our new reality and move on to the best of our ability. Dealing with health loss by ourselves can be particularly daunting and overwhelming.

Remember that you are not alone, seek out for help, ask for support from the people who surround you and when this is still not enough, reach out for specialistic help. Psychotherapy can help you deal with this burden and move towards acceptance.

Depression false myths

Despite the fact that depression will be the second most disabling illness by 2020 (WHO, 2012), it still causes wrong beliefs and false myths, interfering with the act of seeking and receiving appropriate treatment.

Let’s look at a few of them.

1. Depression doesn’t exist, we are all a bit depressed 

Many people think that depression is nothing but sadness and that everybody can experience it every once in a while.

Well, this is definitely false. Depression and sadness are very different in terms of intensity, duration and the impact they have on our daily lives. While sadness is a temporary feeling, as it doesn’t prevent us from experiencing positive emotions nor has it a significant impact on our daily life, depression can significantly account for changes in functioning and mood.

To be diagnosed with depression, the symptoms must be present for at least two weeks, most days and for most of the time.

Sadness and low mood are only some of the symptoms experienced by depressed people (beside lack of interest in the usual activities, diminished energy, feelings of worthlessness or guilt, change in sleep patterns and appetite, thoughts of death and difficulty concentrating).

2. Depression is all in our head and it does not have any biological root

Once again, false: nature and nurture interact to trigger and cause depression.

Genetic liability and life events play a role in this. As far as biology is concerned, a specific variation of a serotonin transporter gene seems to increase susceptibility to depression.

Besides, depression doesn’t only affect our thinking, but our body as well. Depressed people can experience different changes in their physical habits: some may experience a significantly increased or decreased appetite; some may have trouble sleeping while others may oversleep; some may go through motor retardation as opposed to agitation. This means that depression comes with a varied constellation of several different symptoms.

3. Depression is related to creativity and sensitivity

Since many gifted artists, scientists and musicians of the past suffered from mental disorders, one may tend to believe that suffering from a mental condition relates to being creative and sensitive. Well, this doesn’t apply to depression as a condition. There are so many creatives who have never suffered from depression and conversely, lots of depressed people whose nature is not particularly creative.

 4. Depression is always triggered by specific events

Specific events may sometimes trigger depression, such as the loss of a beloved one or a trauma.
As previously mentioned though, nature and nurture intimately intertwine and it’s not possible to pinpoint a single cause of depression.

5. If I start using antidepressants, I’ll be hooked forever

Taking medication for mental health treatment may be scary, because of the possible side effects as well as the fact itself of being on medication.

In the case of depression, depending on the severity of the specific case, a psychiatrist may deem clinically appropriate to prescribe medication. A combination of medication and psychotherapy is often recommended, especially in severe cases.

The length of antidepressant treatment usually depends on the case severity and the number of depressive episodes experienced.

Despite the abundance of false myths, depression is a severe and disabling condition that should never be underestimated.

If you think you are suffering from a depressive episode, consider talking to a specialist to receive appropriate treatment as soon as possible.

References:
World Health Organisation, http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf

“False beliefs: the current treatment of patients with depression”, Lecrubier Y; Current Psychiatry Reports 2003, vol 5(6): 419-422.

Caregiver

No one is born as a caregiver, although it is a role that life obliges us to fulfil.

Being a caregiver means being a family member (or a paid helper) who regularly looks after a sick, elderly or disabled person (Oxford Dictionaries).

It seems that on average caregivers are women, in their mid 40s, who spend about 20 hours per week (or more) taking care of another person, usually their mother or a young family member or their own partner.

Being a caregiver implies a direct contact with different types of diseases, from dementia to physical illnesses and mental problems. Another responsibility is usually helping the person carrying out different daily tasks: from assuring the compliance to pharmacological and non-pharmacological treatments to monitoring the general health of the assisted person and helping in daily routines…

The list is potentially very long, depending on the severity and type of disability.

The sure thing is that being a caregiver can become a full-time job and it can involve great responsibilities, a considerable amount of stress and very often putting the other person’s needs first with the consequent risk of disregarding our own personal needs.

Caregivers and mental health

In particular, if the assisted person suffers from a mental health condition the scenario may get even more distressful and complexed.

Mental health problems are unfortunately still marked by stigma and prejudice and the general information about them is still not sufficient. As a consequence the emotional burden of the caregivers may be even heavier and it is not uncommon for caregivers to experience anxiety and/or depressive symptoms. Scientific research shows that family members of schizophrenic and bipolar patients are particularly affected by the issue, with between 30 to 60% experiencing depressive symptoms (NAC, 1997; Heru et al, 2005).

Given this delicate and complex background, being a caregiver or living with a person suffering from a psychiatric disorder, is doubtless a tough job that implies many challenges and that can sometimes make us feel isolated and not supported enough.

If you are a caregiver

If you find yourself in a similar situation, keep in mind that your health (also your mental health) should come first, as it allows you to better take care of the other person. Plus, a very important tool is information: getting to know the specific illness that the person you are taking care of is suffering from may give you better tools to deal with it as well as foresee any possible complication.

If you feel too burdened don’t be ashamed to ask for help and cooperation to your close family and your closest friends and use the services provided by your community; very often hospitals and clinics organise support or self-help groups specifically for caregivers. Even if often we may feel lonely and not fully understood by the people who surround us, reality is different: there are many caregivers who experience the same feelings and sharing can bring a powerful relief.

On the contrary, if you are experiencing intense symptoms of anxiety or prolonged sadness you may start thinking about seeking a more specialised help and perhaps beginning psychotherapy to better deal with the whole situation.

Remember that it is not possible to take care of everything on your own; sometimes a little help could really bring much more relief than you may think.

Seasonal Sadness

The temperature goes down, days get shorter, you wake up in the morning and outside it is already dark … you get out from work and outside it is still dark. You hope that the day will pass as fast as possible so that you can go directly back home, sleep and wait for spring to come back. You have the feeling of having become like a bear in hibernation: you have interest in doing nothing, you are only very tired, irritable and maybe more hungry than usual.

Why is this happening?

The change of season, in particular the shift from summer to autumn/winter in northern Europe, can be tough especially in countries situated far from the equator, where the amount of light is significantly different among the seasons.

Researchers have found that light has a significant impact on our circadian rhythms and on the production of some hormones; in particular, the most affected hormones seem to be melatonin, responsible for sleep patterns, and serotonin, a hormone linked to mood.

Therefore it seems normal to experience a slight effect of the lack of light on our mood, the so-called seasonal sadness, but usually this effect doesn’t have a significant impact on our daily life and it doesn’t prevent us to efficiently carry out our daily duties and activities.

On the contrary, for around the 2-3% of the adult european population autumn blues take the form of a real psychiatric disorder: the Seasonal Affective Disorder (SAD). Very often SAD symptoms show up in autumn, they worsen in January – February and tend to disappear with the arrival of spring.

SAD implies severe depressive symptoms such as a persistent low mood, loss of interest/pleasure in everyday activities, lack of energy, sleeping and eating more than usual, feelings of guilt or despair.

To diagnose SAD these symptoms must begin and end always in the same seasons and must be experienced for at least two consecutive years. Interestingly women are six times more at risk to developing SAD then men.

What to do

In general if you are experiencing a slight seasonal sadness, then taking care of yourself, your habits and your relationships can be a good start in dealing with it and feeling better.

Taking care of ourselves implies caring for our body as well: having a good and healthy diet and physical exercise are recommended. At the same time taking care of our relationships is important: researchers showed that perceiving a good social support is a protective factor for many psychological difficulties.

Another good way of taking care of our seasonal sadness is stimulating emotions that are opposite to the problematic ones; if you feel down you may try to work on your everyday life to improve the amount of positive events that can foster a better mood. A way of tracking this exercise is keeping a diary of pleasurable activities so that you can monitor your progress and the impact that these activities have on your mood.

If you think that you may be suffering from SAD then seeking help to your GP is recommended. Psychotherapy can help you out as well in dealing with these seasonal sadness. Cognitive behavioural psychotherapy is indeed very recommended by NICE for the treatment of mild and moderate depressive states.

Women and Depression

Depression is a severe condition characterised by a significant change in mood, pleasure and motivation regarding our usual activities. Researchers have highlighted that women and depression are particularly linked: women are from two to three times more at risk to developing a depressive disorder during adolescence and adult life then men.

This data highlights the importance of spreading information and knowledge of this problem and promoting access to effective treatments.

Why are women more at risk? 

Many factors seem to contribute in increasing this risk.

First of all, biology plays an important role: there is a huge hormonal difference between men and women.

Sexual hormones have a direct impact on our psychological life and in particular on our emotions and motivational systems. Women experience very different fluctuations of these hormones during their life; specifically there are three periods in women’s life that involve intense hormonal fluctuations (and therefore a higher risk): puberty, puerperium and menopause. Indeed in pre-puberty and post-menopause, the risk for depression seems to be equal between genders.

Another important role is played by cultural and social factors.

Different specific social factors have been identified as contributing to an increased risk, such as taking on multiple roles, being mother of two or more kids under 14, experiencing a lack of social support, having a poor relationship with the partner, retirement, having experienced bereavement during infancy and being a caregiver.

In particular, the caregiver role is culturally more linked to women than men; interestingly, it seems that in Scandinavian countries, where gender equality is more acknowledged, the incidence of depression in women is lower.

Risky moments in a woman’s life

As written above, puberty, puerperium and menopause involve deep hormonal fluctuations in women and at the same time significant changes in roles and identities. These changes might not be so easy for every woman to adapt to; some of them, because of personal and genetical predisposition, may experience some difficulties and stress in dealing with these changes, thus bringing an impact on an already particular biological substrate.

Specifically, puberty implies deep biological, physical and psychological changes, with the girl experiencing more and more autonomy and responsibilities for the first time. Furthermore, a specific kind of depression is linked to the menstrual cycle, called premenstrual dysphoric disorder.

Puerperium and the first year of motherhood are also very delicate moments in a woman’s life.
Indeed pregnancy can be associated with physical and psychological stress, and becoming a mother for some of them may bring not only joy and happiness but also feelings of loss of independence, extreme responsibilities and sometimes very high expectations about themselves.

In these instances, experiencing depressive symptoms is normal and transient (the so-called baby blues); but for about 10% of women these symptoms may turn into a postpartum depression. This kind of depression has a particular importance, as it might prevent the new mom to fully fulfil her new role and it might impact on the quality of the attachment bonding with the baby.

Menopause is also a very risky moment, in particular the pre-menopause period. This life moment is characterised by an irregular cycle, muscle and articular pains, sleep problems and endocrine changes. Furthermore, beyond these physical changes, menopause may be difficult to deal with because of its own personal meaning and other significant events may contribute in a negative way, as not having satisfactory working activities, friendships or relationships.

How to use this information

The recognition of the link among women and depression represents an important tool. Knowing that women have a higher risk of developing a depressive disorder and that there are defined moments in a woman’s life that specifically raise this risk, should allow us to keep an eye particularly open and to promptly react if depressive signs show up in order to receive appropriate treatment.

At the same time, if you have a previous history of depression and you are about to go through one of these delicate moments mentioned above, keeping both eyes open is important.

In either circumstance, depression can be faced and managed with an appropriate support. Depending on the symptom’s severity, psychotherapy and/or psychiatric support are highly recommended.

Sadness or depression?

Nowadays the word ‘depression’ has been so fully absorbed into our daily language that it is often incorrectly used to describe normal sadness.

Sometimes it may occur that intense sadness makes us wonder whether it is a normal and transitory feeling or there is more about what is perceived as sorrow, such as real depression. In this instance, it is important to be aware of it and in case the boundary is crossed, seek appropriate help as depression is an actual disease which should be dealt with as soon as possible.

Let’s have a look then at the differences between sadness and depression.

The differences between sadness and depression

Sadness is an emotion that we often experience in our everyday life and that is usually categorised as a ‘negative’ and ‘unwanted’ feeling. Sadness is generally caused by missing out on our aims or goals which seem no longer achievable. Depending on how important the goal is and its specific meaning to us, we may experience a more or less intense feeling of sadness. For example, the intensity of the sense of sadness will be very different if applied to an unsuccessful application for a temporary and maybe not-so-wanted job as opposed to the instance of not getting our dream-life position.

Usually sadness is linked to specific events or thoughts, is time-limited and doesn’t prevent us from experiencing positive feelings if happy and joyous events occur. Furthermore, it doesn’t have a significant influence on our biological rhythms and daily functioning.

On the contrary, depression brings consistent and identifiable changes and symptoms in our habits and lasts for longer. First of all, a wake-up call related to a depressive episode occurs if the symptoms and low mood persist for at least a period of two weeks, in which they manifest most of the time and most of the days.

The core symptoms are severely low mood and lack of interest in the activities that used to stir up a positive response within ourselves, such as a sense of interest and engagement. When depressed, we are no longer interested in and motivated to undertake activities or hobbies as they no longer bring us any sense of pleasure. We may also feel like we have no energy for them at all. We may not care at all about going out, hanging out with friends, spending time with our partner (engaging in sexual activity as well), going to work, playing our favourite sport, etc. It may even occur that we neglect self-caring tasks. Low mood and a lack of interest will make us perceive the world as emotionally dull and grey, as though colours no longer exist.

As mentioned above, depression brings changes in our biological rhythms as well.

Different types of change in sleep habits, appetite and motor activity are reported. As a matter of fact, sleep problems or a tendency to sleep in can be observed as well as significantly increased or reduced appetite (and therefore weight gain or weight loss) and retardation or agitation related to motor activity.
Cognitively speaking, we may suffer from concentration problems, have trouble making decisions and often feel guilty, unworthy and hopeless about the future. In particular, the future may be perceived as an infinite extension of a worthless today. Several cognitive biases tend to maintain this hopelessness-related point of view.

As you can see, depression manifests in different ways with different symptoms, but the common denominator is a significant change in the functioning of the person, intense, strong and long-lasting symptoms and a significant impact on everyday life.

What to do

If you have the feeling that your low mood may not be linked to momentary sadness, keep an eye on it and if you recognise yourself in the aforementioned symptoms, consult a specialist. A psychotherapist, and in mild or severe cases a psychiatrist, can help you understand and tackle the issue.

Bereavement

Bereavement is an extremely touching experience, difficult to articulate in words. The normal reaction to losing a beloved person implies a mix of feelings that can vary from deep sadness to guilt, anger or emptiness. Usually the person experiences the tendency of spending some time by himself/herself in order to cry for the loss, remember the memories, realise what has happened and “adjust” his/her life with the absence of the departed one.

The five stages of grief

Even if psychologists support the theory of the Five Stages of Grief theorised by Elizabeth Kubler Ross, everyone has its own specific pattern of reaction. Usually we need a variable amount of time in order to cope with a loss and it is proportional to the intimate meaning and role that the departed person represented to us.

Often, the very first reaction to some shocking sad news is denial. Many times people remember that their first thoughts were: Are you serious? What are you talking about? That is not possible! Denial is a primitive and protective reaction and it can manifest in different forms: for someone denial can last only few minutes, for others it can last few hours or even days; the person can feel shocked, stunned, turned upside down without realising what is going on and without feeling the relative emotions yet. Denial can then be followed by anger: Why is this happening to me? Why him/her? It is not fair! Why did he/she leave? Anger is a protective reaction as well; our anger can be addressed to different objects or persons, even the beloved one.

After anger, the person usually enters the bargaining stage, when he/she starts to look for explanations and faults about what happened. The universal and most known stage is then the depressive one, when sadness and regrets are dominant. On the contrary, the last stage is characterised by acceptance: realising and accepting the death of the loved person is the first step to go back to reality.

Not everybody is able to reach the acceptance stage: it can happen, for many different reasons, that a person gets stuck in one of the previous stages and needs a little help to elaborate the loss.

What to do

If we have trouble in elaborating bereavement, time is not healing our wounds and we have the feeling of being trapped by intense and sometimes contradictory emotions, psychotherapy can be a useful tool to get past this.

This is for example what happened to one of my first patients and how therapy worked for her.

Maria’s experience

She was a lovely and smart lady over 80 years old, who I will call Maria here; she lost her husband a few years earlier and she was stuck in the depressive stage. Actually Maria didn’t just lose her husband, she had lost her unique, special and long-lasting love after 60 years of marriage, the person she totally relied on for almost all of her life. And she was not able even to think about her life without this precious man by her side. Maria was very depressed and felt lost; no antidepressant was helping her so she decided to start psychotherapy.

Psychotherapy supported her while going through almost all the stages of loss. Indeed she was not alone while she was crying all her tears, expressing all her anger towards her condition and her dead husband who left her alone, while passing through guilt and every regret and remorse. In the end psychotherapy helped her searching and strengthening her personal dispositions that could help her in coping with that difficult period. Little by little, Maria started reorganising her life, finding new ways, new goals and new meanings. After two years of therapy, Maria decided that it was time to end psychotherapy: she realised that she will always be missing her husband, that she could never forget him, but that she could focus on her nephews, her family and friends to feel better. And in that moment she felt that she could do it by herself.

This is a good example of how a psychotherapist can indeed help you express and understand your feelings, realise what is keeping you stuck in a particular stage of grief and prevent you from coping with your loss.

Bipolar Disorder

As the former quote says, mood swings are the core feature of people with bipolar disorder.

As a matter of fact, events can trigger the mood swings, making the person feel the related excitement or sadness in such a deep way.

Bipolar disorder is an affective disorder that implies strong mood swings, from mania or hypomania to deep depression, alternating with periods of time with mood in a normale range.

There are two types of bipolar disorders:

• Type I: periods of intense activation and excessive mood elevation alternates with periods of deep depression. During mood elevation, the person doesn’t need to sleep as much as usual, acts in a different way from how he normally does, has an extreme self-confidence that could bring him to get involved into potentially dangerous situations (excessive speed driving, gambling, not safe and/or promiscuous sexual activity, …). This elevation is so intense that it gets very difficult to handle and potentially dangerous for the person himself or the people who surround him, requiring then a hospitalisation. Sometimes mixed states can be present: the person can experience symptoms of mania and depression at the same time.

• Type II: periods of time with hypomania alternate with periods of depression. Hypomania means having a less intense mood elevation, that never requires a hospitalisation. Even if the mood swings are less intense, their impact and consequences are anyway impressive.

Bipolar disorder treatment?

Bipolar disorder can be managed with an appropriate pharmacotherapy with mood stabilisers prescribed by a specialised psychiatrist, that will help you in controlling these swing and that should be very regularly taken.

Cognitive Behavioural psychotherapy is a parallel tool that is highly recommended by NICE guidelines (National Institute of Health and Care Excellence) in the treatment of bipolar disorder.

As a matter of fact, psychotherapy can be very helpful to better cope with the consequences of the swings and to adjust your lifestyle to prevent mood changes and to better cope with them. The best ways to prevent mood changes are indeed pharmacotherapy and adopting a very stable and healthy lifestyle.

As Sun Tzu said, “keep your friends close, but your enemies closer”. Cognitive Behavioural Psychotherapy can help you in getting to know bipolar disorder, in having a better awareness of it and in early recognising when the mood is changing so that you will be better prepared to deal with it before it gets worse.

Bipolar disorder can be a heavy burden; but with a good specialised help, you can arrange the best solution for you to cope with it.

Related articles:

“Life on a swing: sharing life with the bipolar disorder” by Ilaria Tedeschi.

Suggested links:

www.bipolaruk.org.uk

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/bipolardisorder.aspx

http://www.isbd.org

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